Annie Green Court - Aged Care Quality · Chef/catering staff 2 Cleaning staff 3 Sampled documents...

Annie Green Court

RACS ID 1004 47 Redfern Street

Redfern NSW 2016

Approved provider: Mission Australia

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 26 November 2019.

We made our decision on 24 October 2016.

The audit was conducted on 13 September 2016 to 14 September 2016. The assessment team’s report is attached.

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

Home name: Annie Green Court RACS ID: 1004 2 Dates of audit: 13 September 2016 to 14 September 2016

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 care recipients, 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:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Care recipient lifestyle

Principle:

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

Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 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

Annie Green Court 1004


Introduction

This is the report of a re-accreditation audit from 13 September 2016 to 14 September 2016 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 13 September 2016 to 14 September 2016.

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: Jane Satterford

Team member/s: Veronica Hunter

Approved provider details


Details of home

Name of home: Annie Green Court

RACS ID: 1004

Total number of allocated places:

73

Number of care recipients during audit:

72

Number of care recipients receiving high care during audit:

24

Special needs catered for: Homeless and disadvantaged care recipients

Street/PO Box: 47 Redfern Street

City/Town: Redfern

State: NSW

Postcode: 2016

Phone number: 02 9305 9100

Facsimile: 02 9698 4052

E-mail address: Nil


Audit trail

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

Interviews

Category Number

Director of care 1

General manager 1

Quality and compliance manager 1

Registered nurse 1

Care staff 8

Nurse educator 1

Pastoral care coordinator 1

Business manager 1

Care recipients/representatives 11

Aged care liaison officer 1

Leisure and lifestyle staff 2

Volunteer 1

Building manager 1

Chef/catering staff 2

Cleaning staff 3

Sampled documents

Category Number

Care recipients’ files including assessments, care plans, progress notes (nursing and medical), pathology results, referrals and consultations and associated documentation, hospital discharge and associated documentation, funeral arrangements, individual clinical monitoring charts

7

Interim care plans 7

Wound charts 5

Medication charts 23

Personnel files 6


Other documents reviewed

The team also reviewed:

Allied health folder, physiotherapist consultant register, care recipients who attend walking and gentle exercise classes

Care recipient information pack, handbook, care recipient agreement

Care recipient room listing

Cleaners’ manual, rosters, sign off sheets

Clinical documentation: dressing chart and treatment register, observation and skin integrity chart, treatment chart folder, bowel management chart, clinical equipment checks folder, oxygen concentrator nasal prong change records, treatment chart folders, toileting charts, behaviour observation logs, palliative care register, clinical handover sheets

Comments and complaints register

Continuous improvement documentation: continuous quality improvement (CQI) action plans and documentation, audit schedule and results, monthly incident summaries and trend analysis

External contractors: contractor/supplier service agreements and contracts, preferred contractor/service supplier list, equipment service reports

Fire security and other emergencies: fire safety equipment and sprinkler system service records, fire safety inspections, emergency evacuation procedures and emergency plan, care recipient evacuation information, annual fire safety statement, chemical register

Food safety program: kitchen cleaning logs, food and equipment temperature monitoring, NSW food authority audit result, kitchen staff competency assessments

Human resource management: new staff pack, orientation program and checklist, staff handbook, signed privacy and confidentiality of information agreement, position descriptions, duty statements, statutory declarations, visa status, rosters, performance appraisal register

Infection control information: infection control guidelines, infection control manual, care recipient vaccination records, surveillance data, audits, monthly reports and trend analysis, pest control records

Information systems: policies and procedures, newsletters, care recipient and staff satisfaction surveys, committee meeting agendas and minutes - CQI, staff, kitchen, care recipients, WH&S

Inventory and equipment: maintenance request logs, preventative maintenance schedule, thermostatic mixing valve records, electrical test tagging records, Legionella testing reports


Laundry manual

Leisure and lifestyle documentation: social history profile, overview folder, activities calendar folder, resident activities assessment folder, resident authority and outing consent forms, birthday list, schedule for updating leisure and lifestyle care plans, leisure and lifestyle activities 2016, community visitors program.

Medication documentation: system for warfarin administration and diabetic management plans, medication self-administration assessments and authority, schedule eight (S8) drugs of addiction register, medication and specimen refrigerator temperature charts

Nutrition and hydration: care recipient dietary analysis forms, special diets, nutritional supplement requirements, weight monitoring, menu with dietician review

Regulatory compliance: information folder, mandatory reporting register, unexplained care recipient absences, staff police check certificates, professional registrations - registered nurses and allied health

Self-assessment report for re-accreditation and associated documentation

Staff education: training needs analysis, calendars, mandatory and non-mandatory education attendance records, education resources, annual competency assessments including hand washing and medication administration

Workplace health and safety (WH&S) information: risk management action plan, hazard report forms, audits and inspections

Observations

The team observed the following:

Activities calendar and activities in progress

Aged Care Complaints Commissioner and Seniors Rights Service information on display

Cleaning in progress, trolleys and supplies, wet floor signage in use

Comments/compliments forms, locked suggestion box

Dining environment during midday meal services, chef serving/supervising

Displayed notices: Quality Agency re-accreditation audit notices, Charter of care recipients’ rights and responsibilities, Mission Australia Our Values statement

Domestic laundries

Equipment and supply storage areas

Firefighting equipment checked and tagged, fire indicator panel, sprinkler system, evacuation diagrams, evacuation pack, identification lanyards


Infection control resources including hand washing facilities, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, waste management

Information noticeboards

Interactions between staff and care recipients/visitors

Kitchen and serveries, NSW food authority licence on display

Living environment internal and external

Medication round, secure storage of medications and medication trolleys

Menu for the day displayed in dining areas

Mobility equipment in use

Nurse call bell system

Safe chemical and oxygen storage, safety data sheets (SDS) at point of use

Secure storage of care recipients’ clinical files and staff personnel files

Short group observation in activities room

Sign in/out registers, security cameras

Specimen refrigerator and two medication refrigerators

Staff work practices and work areas

Whiteboards in treatment rooms displaying clinical information


Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service,

management systems are responsive to the needs of care recipients, their representatives,

staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous

improvement”.

Team’s findings

The home meets this expected outcome

Management at Annie Green Court actively pursues continuous improvement across the four Accreditation Standards. The home identifies improvement opportunities from a range of sources that includes results from a comprehensive suite of audits; surveys; clinical indicator and incident reporting; requests and feedback mechanisms. Continuous improvement activities are discussed and monitored at the home’s monthly continuous quality improvement committee meetings. The committee has representation from across the home and a rotating chairperson. Management develops continuous quality improvement action plans to prioritise, action and evaluate identified opportunities for improvement. Care recipients/representatives and staff are encouraged to make improvement suggestions and they are kept informed regarding improvements undertaken in the home. Examples of recent improvements implemented in relation to Accreditation Standard One include:

An aged care funding instrument (ACFI) registered nurse was appointed three days a week in April 2015. This was previously a shared role with the sister home within the organisation. This dedicated role provides improved staff education in regard to completion of accurate ACFI assessment documentation which impacts ongoing funding to the home.

Management identified due to increasing care recipient care needs, the two afternoon staff rostered would benefit from additional assistance. Organisational approval has been given for a new four hour afternoon shift from 4.00pm to 8.00pm. Recruitment is underway to fill this position.

Management have introduced initiatives to show appreciation for staff achievements. A feel good “brag board” to post positive comments regarding staff from their peers and care recipients has recently been established in the staff room. A Christmas in July staff lunch was held in 2016 to encourage and celebrate cultural diversity. The lunch was such a success staff have agreed to hold further events every three months. Feedback from staff is they are well supported by management and “wouldn’t want to work anywhere else”.


1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place

to identify and ensure compliance with all relevant legislation, regulatory requirements,

professional standards and guidelines”.

Team’s findings


The home has systems overseen by the general manager to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines applicable to aged care. This is achieved through access to a variety of authoritative sources including a peak body. Policies and procedures are developed with reference to industry guidelines and legislation. Management at the home is informed by the general manager of relevant changes and updates. Management notifies staff of changes to policies, procedures and regulations through meetings, at handover and by providing education. Updated policies, procedures and information manuals are readily available for staff. The system for monitoring compliance with obligations under the Aged Care Act 1997 and other relevant legislation includes audits; surveys; competency assessments; performance appraisals; observation of staff practices and feedback. Examples of regulatory compliance with Accreditation Standard One include:

Care recipients, any involved representatives and staff were informed of the upcoming Quality Agency re-accreditation audit by notices, mail out and at meetings.

There is a system to monitor currency of staff criminal history certificates.

There is a system to monitor and record professional registrations and authorities to practice for clinical staff.

Management ensures care recipients, staff and visitors to the home have access to internal and external comments and complaints mechanisms.

1.3 Education and staff development:

This expected outcome requires that “management and staff have appropriate knowledge

and skills to perform their roles effectively”.

Team’s findings


The staff education and training program incorporates a range of topics across the four Accreditation Standards from both internal and external sources. The education calendar is developed by the home’s nurse educator with staff input. Program development is based on information acquired through an annual training needs analysis; staff performance appraisals; review of clinical indicators; feedback mechanisms; legislative changes and audits. Staff are required to complete orientation and induction programs, annual competency assessments and mandatory education topics. The training requirements and skills of staff are evaluated on an ongoing basis through performance appraisals; the changing needs of care recipients and verbal feedback. Education attendance records are maintained to monitor staff attendance at mandatory and non-mandatory education. Staff stated the education program offered is comprehensive and assists them to develop the skills required for the specialised nature of their work. Examples of education and


development attended by management and staff in relation to Accreditation Standard One include:

Management attendance at industry forums; staff orientation; aged care funding instrument (ACFI) training; effective communication; comments/complaints; Mission Australia - domestic family violence.

1.4 Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and

other interested parties have access to internal and external complaints mechanisms".

Team’s findings


The home has a policy and procedures for feedback management. All stakeholders are encouraged to provide feedback on the services provided through meetings, newsletters, brochures and notices. Care recipients are informed of the internal and external complaints mechanisms on entry to the home. This is provided in the care recipient information pack and agreement. Feedback forms and a locked suggestion box are accessible for all stakeholders. Information on the external complaints scheme and advocacy services is readily available.

Management stated they have an “open door” policy and care recipients generally prefer to feedback in person. Any written comments and complaints received are logged, responded to and actioned by management in a timely manner. Feedback, complaints and compliments are discussed at the home’s meetings. Care recipients/representatives and staff stated management is readily available if they need to discuss their concerns.

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


Mission Australia has a vision, mission and values statement that is communicated to all stakeholders. “Our values in action” statement is included in Annie Green Court’s publications and is on display in the foyer along with the Charter of care recipients’ rights and responsibilities. The home’s commitment to quality is demonstrated in the pursuit of continuous improvement activities. Mission Australia’s philosophy of care is promoted through staff orientation and education processes.


1.6 Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff

sufficient to ensure that services are delivered in accordance with these standards and the

residential care service’s philosophy and objectives".

Team’s findings


The home has policies and procedures with corporate support to facilitate recruitment to ensure selected staff meet the requirements of their roles at the home. Human resource management is implemented through position descriptions; provision of a handbook; orientation and induction programs; ‘buddy shifts’; duty statements and performance appraisals. Management at Annie Green Court ensures sufficient skilled and qualified staff are rostered to meet the specific needs of care recipients and legislated requirements. There is a pool of casual staff to fill vacant shifts and agency staff are not utilised. Personnel files are maintained at the home and contain a signed privacy and confidentiality of information agreement. Human resource management is monitored through meeting feedback; surveys; audits and results of clinical indicator reports. There is a high level of staff retention at the home and staff stated they are well supported by management. Care recipients said the staff are very good - “like family”.

1.7 Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for

quality service delivery are available".

Team’s findings


The home has purchasing systems and available stocks of goods and equipment appropriate for quality service delivery. Purchase of major items is subject to senior management approval. Goods in regular use are ordered through established approved service suppliers. Stock levels are managed and maintained by designated staff at the home. Management monitors the inventory and equipment system through inspections; audits; review of incident and hazard forms and feedback. Preventative and corrective maintenance of equipment is carried out by external contractors and the on-site building manager. Care recipients/ representatives and staff stated and observations indicated there are supplies of goods and equipment available as required.

1.8 Information systems

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

place".

Team’s findings


The home has effective information management systems. Care recipients are provided with information prior to entry; in an agreement; a handbook; by newsletters; notices and at meetings. Ongoing consultation is undertaken with care recipients and/or their representative regarding meeting their care needs. The organisation’s information


technology systems, documentation and publications ensure management and staff have access to current policies, procedures and information relevant to their role in the home. Orientation and induction of new staff; a handbook; handover; education and meetings are also mechanisms to ensure current information is available for staff. Electronic information is backed up, password protected and key personnel have access appropriate to their position. There is an archiving procedure to ensure confidentiality of care recipient information. Management monitors the effectiveness of the information system through meetings; audits; surveys and verbal feedback. Care recipients/representatives and staff stated there is good communication throughout the home and they are kept well informed.

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


There are systems and processes to ensure external services are provided to meet the home’s care and service needs and quality goals. Service contracts/agreements with external providers and service suppliers are established and managed at the home and are reviewed regularly. External suppliers of goods and services are required to provide evidence of their insurance, license or business registration details and criminal history certificate as required. The home has an established approved contractor/service provider listing. Contractors are overseen by the on-site building manager when working at the home. All work performed is monitored for quality and effectiveness of service through inspection, audits and feedback. A range of specialist and allied health professionals also provide on-site care and services for care recipients. Care recipients/representatives and staff are satisfied with 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.



improvement”.

Team’s findings


Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Two include:

Staff identified although hearing and vision assessments were being undertaken when new care recipients entered the home, there was no adequate assessment for the senses of touch, taste and smell. As a result a sensory box was developed in October 2015. Sensory assessment for the five senses is now routinely undertaken for all new care recipients resulting in an improved clinical outcome.

In January 2016 the home was able to engage the funded services of a visiting clinical psychologist. Individual or group sessions can be conducted. The psychologist is in addition to the psychiatrist who regularly attends care recipients at the home. This team of visiting specialist services provides improved monitoring of care recipient mental health issues.





professional standards and guidelines about health and personal care”.

Team’s findings


The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Two include:

Initial and on-going assessments, planning, management and evaluation of care for care recipients are undertaken by a registered nurse as per the Quality of Care Principles 2014.

The home has a system to manage unexplained care recipient absences in accordance with regulatory requirements.

An accredited pharmacist undertakes care recipients’ medication management reviews for the home.

2.3 Education and staff development



Team’s finding


The home has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home uses these systems to identify and implement a range of educational measures relevant to Accreditation Standard Two. Care staff have achieved a minimum requirement of certificate III in aged care.

Examples of recent education and training attended by staff in relation to Accreditation Standard Two include:

Medication administration competencies; medication best practice; national residential medication chart; first aid; certificate IV mental health training module; managing challenging behaviours; working with people with mental health issues; schizophrenia; sensory loss; palliative approach; falls prevention; diabetes management; wound care.


2.4 Clinical care

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

Team’s findings


Care recipients/representatives reported quality clinical care is provided at the home and individual needs and preferences are respected. A program of assessments is undertaken when a care recipient moves into the home and a care plan is developed from information from the assessments. Care plans are regularly evaluated in consultation with the care recipient, their representative and the health care team. Medical officers review care recipients regularly and as requested and referrals to specialist medical and allied health services are arranged as required. A range of care based audits, clinical indicators, care recipient surveys, meetings and staff handovers are used to monitor the quality of care. As required, care conferences and conversations are undertaken with the care recipient/ representative to ensure satisfaction with care. Staff receive clinical care training, supervision and have access to appropriate supplies of equipment to ensure quality clinical care is provided for all 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/representatives are satisfied with specialised nursing care at the home. There are systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Specialised nursing care needs are assessed and documented in care plans when a care recipient moves into the home. A review of documentation shows changes are documented in progress notes, clinical charts, specialist forms and charts and in care plans. Care plans are regularly evaluated in consultation with the care recipient/representative and the health care team. Registered nurses attend care recipients’ specialised care and equipment is supplied as needed to meet individual need. Staff said they receive training in specialised nursing care and the use of equipment.

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/representatives said they are consulted when a referral is required and they are assisted to attend specialist appointments as needed. A review of documentation including care recipients’ files and interviews with staff show care recipients are referred to medical specialists and other allied health professionals such as physiotherapist, podiatrist, speech therapist, occupational therapist, audiologist and optometrist in a timely manner and any changes are incorporated into care planning. Some external providers of


specialist services visit care recipients in the home. Care recipients expressed satisfaction with services provided by health specialists.

2.7 Medication management

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

correctly”.

Team’s findings


There are policies and processes to ensure all care recipients’ medication is managed safely and correctly. These include regular pharmacy deliveries, the secure storage of medications and internal and external audits. Care staff administer medication using a prepacked medication system and the registered nurse oversees the home’s medication management system processes. All prescribed medications are recorded in the paper based medication charts. Review of care recipients’ medication profiles show current medical officers’ orders are recorded and information includes medication identification sheets, photographic identification, care recipient allergies and medication allergy status. Care recipients who self- administer medications are assessed for capability and safety. All staff administering medications are assessed according to the home’s medication policy through initial skills based assessments, then annually or as required. Care recipients/representatives are satisfied with the home’s management of care recipients’ medication.

2.8 Pain management

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

Team’s findings


Care recipients are assessed on entry and monitored on an ongoing basis to ensure they are as free as possible from pain. Any care recipient identified with pain, including those at risk of pain, is monitored via the use of a pain management log. The use of analgesia is regularly evaluated for effectiveness by the care staff and registered nurse in consultation with the care recipient and healthcare team. Medication and alternative approaches to manage pain are used including emotional and spiritual support, balms and creams, exercise and diversion are provided by all staff including recreational activities staff. Staff receive education in pain management and staff practice is closely monitored by management. Care recipients/representatives are satisfied with the way their pain is managed.


2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill care recipients

is maintained”.

Team’s findings


Management has practices in place to ensure the comfort and dignity of terminally ill care recipients is provided. The home does not provide end stage of life care but will provide and maintain care recipients with a terminal illness as long as possible with assistance from specialist palliative support services. Care recipients are made aware of this condition on entry to the home. Close links are maintained with homes that provide end of life care and care recipients are transferred if and when the need arises. The director of care and registered nurse ensure pastoral and spiritual care is available to care recipients and their representatives as required and requested. Staff practice is monitored to ensure it is consistent with needs and preferences of care recipients and staff have access to training in palliative care. Care recipients/representatives commented on the caring nature of the management and staff.

2.10 Nutrition and hydration

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

hydration”.

Team’s findings


The home has systems to ensure care recipients receive adequate nourishment and hydration including initial assessment and ongoing monitoring of care recipients’ needs and preferences. Care recipients have a choice of food from the four weekly dietician approved menu. Meals are prepared on-site and nutrition supplements and assistance with meals are provided as needed. The registered nurse identifies any care recipient at risk of weight loss and malnutrition or excessive weight gain by monitoring regular weight records. Care recipients of concern are reviewed by the local medical officer and/or referred to a dietician. Hydration is carefully monitored and extra fluids are encouraged and provided in hot weather. Care recipients are very satisfied with the catering services provided and any concerns they may have are discussed at relevant meetings and with staff to ensure their needs are met.

2.11 Skin care

This expected outcome requires that “care recipients’ skin integrity is consistent with their

general health”.

Team’s findings


Care recipients/representatives are satisfied with the way skin integrity is managed at the home. A review of documentation shows care recipients’ skin integrity is consistent with their general health. Care recipients’ skin integrity is assessed when they move into the home and care staff monitor skin integrity as part of daily care. Any changes are reported


to the registered nurse for review and referral as needed. Complex wound management is carried out by the registered nurses and skin tears and infections are recorded and monitored by the registered nurse and director of care. A podiatrist regularly visits the home, a range of skin protective devices such as skin emollients and protective bandaging are available. Staff receive education in skin care and the registered nurses receive education in complex wound management and refer to specialist services as needed.

2.12 Continence management

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

Team’s findings


Care recipients/representatives are satisfied with the way continence is managed at the home and said staff are respectful and ensure privacy and dignity is maintained. Care recipients are assessed for their needs immediately upon entry to the home to preserve dignity and comfort. A more thorough assessment and resulting care plan ensure individual strategies are developed and all care recipients’ needs and continence requirements are met. The home has sufficient stock of continence aids in appropriate sizes to meet individual need and education in continence management is provided for staff and care recipients as needed. Staff were observed being considerate of care recipients’ privacy and dignity at all times.

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/representatives said management and staff ensure a calm environment is maintained at the home and there are strategies to assist care recipients with challenging behaviours. The home specialises in behaviour management and all staff are carefully chosen for their aptitude for this specialisation. Assessment and monitoring of challenging behaviour is conducted on entry to the home. Triggers that may lead to challenging behaviours are identified and included in individual care plans. Care recipients with challenging behaviours are referred to appropriate specialist services as required including a psychiatrist and psychologist. Those exhibiting challenging behaviours are encouraged to participate in specific activities to engage and calm. Staff were observed respectfully and patiently working with care recipients to ensure their individual needs were met. The home is free of physical restraint. Staff are offered education in dementia care and management of challenging behaviours.


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


Care recipients/representatives are satisfied with the way mobility, dexterity and rehabilitation are achieved and maintained at the home. Care recipients are assessed before entry by the director of care and registered nurse for mobility levels. Care recipients are encouraged to walk and exercise as much as possible. Care recipients are often independent with mobility and can choose to go out when they like. Gentle exercise classes are held on a weekly basis and group walks to the park are conducted by the leisure and lifestyle staff. Care recipients have access to the physiotherapists at the local hospital if treatment is required. Interviews with staff and a review of documentation show accidents/incidents including falls are reviewed and discussed at appropriate meetings to ensure optimal levels of mobility and dexterity are achieved and appropriate referrals are made. Staff are educated in manual handling and the use of mobility and transfer equipment. Assistive devices such as mobile walking frames and wheelchairs are in use for care recipients.

2.15 Oral and dental care

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

Team’s findings


Care recipients’ oral and dental health is assessed on entry to the home. Individualised care plans are developed to ensure that care recipients’ oral and dental health is maintained. Staff monitor oral health during daily care and encourage and remind care recipients to maintain satisfactory oral health. Any changes are reported to the registered nurse for follow up.

Management monitor staff practice and care recipients expressed satisfaction with the oral and dental care. Care recipients are assisted to visit local dentists and a dental prosthetist will visit the home if necessary.

2.16 Sensory loss

This expected outcome requires that “care recipients’ sensory losses are identified and

managed effectively”.

Team’s findings


Each care recipient’s sensory loss is assessed using a variety of strategies on entry to the home. Any changes to sensory loss are communicated to staff via handover. Management monitors staff practice and staff are trained to report any change or sensory loss to the registered nurse for review. Care recipients are assisted to visit local audiologists or


optometrists when necessary. Information from referrals is followed up and included in monitoring processes. Touch, taste and smell are stimulated by active and often spontaneous recreational activities. Fresh cooked meals are prepared daily in the home. Care recipients participate in various leisure and lifestyle activities of their choice.

2.17 Sleep

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

patterns”.

Team’s findings


Consultation with care recipients/representatives is undertaken to identify care recipients’ ability to achieve natural sleep patterns. Preferred routines for daytime rests, their patterns for settling at night and any concerns or changes that may interfere with natural sleep patterns are investigated. Pain management is considered if sleep natural patterns are disturbed and care recipients referred to the medical officer if necessary. Care recipients are checked regularly throughout the night and those who do not wish to be disturbed can sign a waiver for staff not to check on them through the night.


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.



improvement”.

Team’s findings


Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Three include:

The home regularly receives donations from the community. For example a number of books were recently donated. New book cases were purchased for each level of the home to display a range of reading material. A number of care recipients commented on the increased accessibility of books.

Care recipients recently suggested a new physical movement activity of disco dancing to 1960’s and 1970’s music. Lifestyle staff organised this and the first session was held during the re-accreditation audit with prizes of chocolate for the best dancers. Care recipients and staff enjoyed the session and anticipate this will become a regular activity.




professional standards and guidelines, about care recipient lifestyle”.

Team’s findings


The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Three include:

An agreement is offered to care recipients to meet legislative requirements.

The home has systems to meet regulatory requirements regarding mandatory reporting.





Team’s findings


The home has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home uses these systems to identify and implement a range of educational measures relevant to Accreditation Standard Three. Examples of recent education and development attended by staff in relation to Accreditation Standard Three include:

Mandatory reporting; cultural diversity; sexuality in aged care; security of tenure; privacy dignity and confidentiality.

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


Annie Green Court endeavours to create a secure nurturing homelike environment for the care recipients who are mostly disadvantaged and unused to a nurturing environment.

Adjusting to life in the home sometimes requires time, care and patience. Management, staff and the pastoral care team all assist with the emotional support required for care recipients to begin to settle into the home and allow them their space and freedom. Care recipients are invited and encouraged to participate in lifestyle programs and maintain contact with friends. Management monitors staff practice to ensure staff are helpful and caring and are responsive to care recipients’ need for emotional support whenever it is required. Staff and management say they are dedicated to ensuring each care recipient is as happy as possible and care recipients/representatives are very satisfied with the emotional support they receive at 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


The home has systems to assist care recipients achieve maximum independence, maintain friendships and participation in the community. Annie Green Court’s environment provides opportunities for care recipients to exercise independence and choice on a daily basis.

Exercise and walking programs are held to assist with maintaining mobility. Leisure activities actively seek the involvement of care recipients and promote independence. Care recipients are encouraged to maintain independence and decision-making regarding personal hygiene, meal choice, voting in elections and attendance at activities. Social groups and entertainers regularly visit the home and family members are especially welcomed. Shopping trips enable care recipients to visit the local community. Care recipients/representatives are satisfied care recipients are encouraged and assisted to maintain their independence and friendships.

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 systems to ensure privacy and dignity is respected in accordance with care recipients’ individual needs. The initial assessment process identifies each care recipient’s personal, cultural and spiritual needs, including the care recipient’s preferred name.

Permission is sought from care recipients for the disclosure of personal or clinical information or the right to refuse to be photographed or go on outings. Staff handovers and confidential, care recipient information is discussed in private and care recipients’ files are maintained securely. Staff assist and address care recipients in a manner that is both respectful and dignified. They maintain the individual’s privacy for example by knocking on a room door prior to entry. Care recipients who are reliant on staff for their dressing and grooming requirements are well presented and dressed appropriately for the weather. Care recipients/ representatives are satisfied with the way privacy, dignity and confidentiality are managed at the home.


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


Annie Green Court provides a varied lifestyle program which is developed in consultation with care recipients. A social profile is created on entry to the home with the input of the care recipient and/or representatives. Staff monitor and slowly get to know the care recipient and support them to come and join in whatever activities are offered on a daily basis. Any activities which care recipients request are tried and are mostly attended by others.

Information obtained from meetings, survey and one to one discussions is also used to plan suitable group and individual activities. Staff work as a team to provide a supportive environment surrounding the activities program. Often outings, from a walk in the park to a lunch outing, are very popular and all staff including management, will walk with care recipients. A weekly program of activities is offered and weekly calendars are displayed in the home. Staff maintain attendance records and evaluate activities to identify levels of interest in the program provided. Care recipients stated they enjoy the activities program and whilst they are encouraged to participate their decision not to do so is respected.

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’ spiritual and cultural needs are fostered through the identification and communication of their individual interests, customs, religions, and ethnic backgrounds during the home’s initial assessment processes. The home invites cultural visitors for any care recipients who do not speak English or are from a different cultural background. The newsletter can be written in languages as well as English and is currently published in Mandarin. Younger care recipients are supported by visitors from appropriate organisations. The pastoral carer works at the home three mornings per week and conducts a weekly prayer service for care recipients. Bible study is also held weekly and has a strong core group. Care recipients are encouraged to attend local churches if they wish and the pastoral carer will liaise with any religious group if requested by the care recipient. Special celebrations are held for cultural days and birthdays are celebrated on a special day each month for those who wish to attend. Staff recognise individual birthdays privately with a card on the day. Funerals and memorial services are organised by the home as many care recipients have no family. Care recipients are satisfied with the individualised attention they receive at the home.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative)

participates in decisions about the services the care recipient receives, and is enabled to


exercise choice and control over his or her lifestyle while not infringing on the rights of other

people".

Team’s findings


The home demonstrates each care recipient participates in decisions about the services the home provides. Care recipients are able to exercise choice and control over their lifestyle through consultation and assessment of their individual needs and preferences on entry to the home and monitoring on an ongoing basis. The Charter of care recipients’ rights and responsibilities is on display in the home and care recipients and their representatives participate in decisions about services including access to management, care recipient meetings, surveys and complaint mechanisms. Care recipients are encouraged to personalise their rooms with items of their choosing. Care recipients are very satisfied with the support of the home with regard to their choice and decision making processes.

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


Annie Green Court caters for disadvantaged care recipients many of whom are from a homeless or insecure housing background. All beds at the home are concessional with no bond payment required. Information is provided by the home to explain all aspects of care and services for new care recipients prior to entry. An agreement is offered to each care recipient to formalise occupancy arrangements. The care recipient agreement includes information about rights and responsibilities; services and facilities; complaints handling; temporary absences; their security of tenure and the process for the termination of the agreement. Care recipients’ rights and responsibilities and other relevant information are made available for care recipients in a handbook and are on display in the home.


Standard 4 – Physical environment and safe systems

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



improvement”.

Team’s findings


Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Four include:

Care recipients take an active interest in meals served at the home and are very complimentary of the chef’s skills. For improved consultation with care recipients the chef commenced an annual menu meeting in May 2016 with approximately 40 per cent of care recipients attending. One recent addition to the breakfast menu is an omelette which has been well received.

The quality and compliance manager has written a brochure for care recipients and visitors to stress the importance of hand hygiene. Brochures are available in the home’s foyer. This infection control initiative is to encourage improved personal hygiene of care recipients.

As a workplace health and safety initiative, staff at the home who work outdoors for maintenance or lifestyle activities have been issued with Mission Australia caps for sun safety.




professional standards and guidelines, about physical environment and safe systems”.

Team’s findings


The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Four include:

A current fire safety statement meets regulatory requirements.

The home has a food safety program audited by the NSW food authority. A current NSW food authority licence for vulnerable persons is on display.





Team’s findings


The home has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home uses these systems to identify and implement a range of educational measures relevant to Accreditation Standard Four. Examples of recent education attended by staff in relation to Accreditation Standard Four include:

Annual mandatory fire awareness, equipment and evacuation procedure; workplace health and safety; manual handling/competency; infection control/hand washing instruction; safe food handling; chemical safety.

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


Annie Green Court is a 72 bed home built in 2012 for care recipients at risk of homelessness and financially or socially disadvantaged. Accommodation is provided in a single room with an en-suite bathroom on four levels with interconnecting lifts. Rooms are fitted with call bells and lockable cupboard. Care recipient rooms have ducted air conditioning and all areas of the home are monitored to ensure comfortable temperature and lighting is maintained. There are communal and private areas, including a ground level and a rooftop garden. For safety and ease of mobility there are hand rails in corridors and grab rails in bathrooms. There are corrective and planned preventative maintenance programs and a regular cleaning schedule to maintain the home’s environment. This is monitored through feedback from meetings; surveys; incident and hazard reporting; audits and inspections. Care recipients/ representatives are very satisfied with all aspects of the home’s environment.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe

working environment that meets regulatory requirements".

Team’s findings


The home provides a safe working environment consistent with workplace health and safety (WH&S) policy and regulatory requirements. There is a system to record, analyse and review accidents and incidents and any identified hazards. The home’s workplace health and safety (WH&S) committee meets monthly with staff representation from across


the home. Any concerns raised are recorded on a risk management action plan. Staff undertake WH&S education and manual handling training on orientation and then annually. Management monitors WH&S through the audit program, inspections and feedback. The home has a return to work program if required following any staff injuries. Safe work practices were observed on-site and staff stated they receive relevant education.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to

provide an environment and safe systems of work that minimise fire, security and

emergency risks".

Team’s findings


The home has systems to promote the safety and security of care recipients, visitors and staff. These include emergency and fire evacuation policy and procedures as well as regular checks of the fire indicator panel, sprinkler system and other fire safety equipment by an authorised contractor. Staff attend annual mandatory fire safety and emergency evacuation training with an accredited training organisation. Fire emergency and evacuation diagrams are displayed. A number of care recipients are cigarette smokers and there is a smoking room located on each of the four accommodation levels of the home. Care recipients unable to understand staff directives to use the designated smoking rooms are placed on a supervised smoking program. The home has an emergency evacuation plan and procedures with care recipient photographic evacuation information. Safe storage of chemicals is maintained in all areas and safety data sheets are available at point of use. Safety and security measures include a lock-up procedure; sign in/out books; closed circuit television security (CCTV); a nurse call system and staff duress alarms. The fire safety and security system is monitored through regular services, audits and inspections. Staff stated they have received training and know how to respond in the event of the fire alarm sounding. Care recipients are generally aware to follow staff instructions.

4.7 Infection control

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

Team’s findings


The home has an infection control policy and program with infection control clinical indicators and antibiotic use collated monthly and monitored for any trends. Preventative measures include mandatory annual infection control education, hand washing instruction and facilities, a cleaning regime and a care recipient vaccination program. There is a food safety program in the kitchen to monitor food and equipment temperatures. Outbreak management information and resources are available. The home maintains a waste management system and a pest control program. Results of infection control audits and infection surveillance data are reviewed at the home’s committee meetings. Staff have access to personal protective clothing and colour coded equipment and have understanding of infection control measures relevant to their work area.


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


There are systems for all aspects of hospitality services to be conducted in accordance with infection control and WH&S guidelines. Fresh cooked meals are prepared in the home’s kitchen by the chef. Care recipients’ dietary preferences, changes in needs and special requirements, such as diabetic and culturally specific meals are identified and communicated to the chef by a registered nurse. The chef consults with care recipients regarding their meal preferences. The four weekly seasonal rotating menu is reviewed by a dietician and offers an alternative to the main meal served. Cleaning is provided by the home’s cleaning staff seven days a week according to set schedules or as needed. Care staff launder care recipients’ personal clothing individually in a domestic laundry on each of the four accommodation levels of the home. Laundering of flat linen is outsourced. Hospitality services are monitored through feedback, audits, surveys and meetings. Care recipients are very satisfied with the hospitality services offered by the home.

Annie Green Court - Aged Care Quality · Chef/catering staff 2 Cleaning staff 3 Sampled documents...

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