IRT - Woonona Residential Care Facility · installation (Ribbonwood Lodge), emergency lighting and...

IRT - Woonona Residential Care Facility

RACS ID 2663 6-8 Popes Road

WOONONA NSW 2516

Approved provider: Illawarra Retirement Trust

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 09 February 2018.

We made our decision on 16 December 2014.

The audit was conducted on 17 November 2014 to 21 November 2014. The assessment team’s report is attached.

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

Home name: IRT - Woonona Residential Care Facility RACS ID: 2663 2 Dates of audit: 17 November 2014 to 21 November 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

IRT - Woonona Residential Care Facility 2663


Introduction

This is the report of a re-accreditation audit from 17 November 2014 to 21 November 2014 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 17 November 2014 to 21 November 2014.

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: Kathryn Mulligan

Team member/s: Jennifer Woodman

Approved provider details


Details of home

Name of home: IRT - Woonona Residential Care Facility

RACS ID: 2663

Total number of allocated places:

160

Number of care recipients during audit:

148

Number of care recipients receiving high care during audit:

140

Special needs catered for: Care recipients living with dementia

Street/PO Box: 6-8 Popes Road

City/Town: WOONONA

State: NSW

Postcode: 2516

Phone number: 02 4251 5688

Facsimile: 02 4251 5675

E-mail address: Nil

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


Audit trail

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

Interviews

Category Number

Area manager 1

Care, lifestyle and hospitality managers 3

Education coordinator 1

Care coordinators 2

Registered/enrolled nurses 6

Care staff 13

Lifestyle officers 4

Physiotherapy aides 3

Welfare officer 1

Infection control committee member 1

Administration assistant 3

Care recipients 13

Representatives 8

Catering staff 4

Cleaning staff 5

Laundry staff 2

Fire officers 3

Maintenance staff 2

Roster clerk 1

Sales consultant 1

Site safety officer/WHS chairperson 1

Maintenance staff 2


Sampled documents

Category Number

Care recipients’ files including assessments, care plans, progress notes, medicalofficers notes, referrals, alliedhealth and associated documentation, pathology, various charts and forms

16

Wardrobe/quick reference care plans 16

Medication charts 20

Personnel files 10

Resident agreements 5

Other documents reviewed

The team also reviewed:

Continuous improvement plan, comments forms, clinical indicator reports, internal and external audits, call bell alarm summary reports, peer review audits, strategic planning towards 2020 vision

Contractors electronic data base, contract suppliers police check database, products and service agreements

Corporate intranet: manuals, policy and practice manuals, forms, news, employee resources,

Diet, meal preferences and drink lists, menu item definitions (allergy notations)

Education: calendars, attendance records, orientation, database annual mandatory training, mandatory training records, orientation training

Fire safety: annual fire safety statements, technical service reports, sprinkler system maintenance record and report (Flametree Lodge), emails and quote re sprinkler system installation (Ribbonwood Lodge), emergency lighting and fire door maintenance logs, internal fire audit, evacuation folders, fire officer certificates, emergency procedure manuals and flip charts

Hospitality services: NSW Food Authority License, food handling booklet, menus, menu feedback sheets, food storage and regeneration temperature records, dishwasher temperature records, approved food suppliers lists, instrument calibration certificates, audits, equipment service reports, housekeeping procedures manual, cleaning schedules, goods supply ordering records, laundry procedure handbook

Infection control: clinical indicator data, benchmarking performance data, infection lists and monitoring, antibiotic usage

Maintenance: contractor handbook, preventative maintenance work order schedule, work orders, service reports, legionella testing, mixing valve temperature records, pest control records

Mandatory consolidated register elder abuse


Medication documentation including, medication charts, profiles, medication refrigerator temperature records, medication incident forms, drugs of addiction (S8) register, pharmacy reviews of resident medications, medication competency for resident’s self- administration of medication and insulin, nurse initiated medication forms

Meeting minutes: management, staff and residents/representatives, memorandum, newsletters, email communication, electronic handover reports, communication diaries

Policy and practice manuals

Professional registrations, police clearance records, insurance, volunteer recruitment

Resident clinical care documentation including accident/incident reports, allied health records, behaviour monitoring, bowel, blood glucose level monitoring , care conferences, care histories, care directives, complex health directives, dietary needs/preferences, handover staff and management, pain monitoring, pain treatments, personal care records, observation charts, resident/client risk forms, restraint authority forms, risk assessment for bed rail usage, skin integrity issue form, resident surveillance/ monitoring, weight monitoring, wound charts

Resident handbook, employee handbook, IRT care centre resident guide

Resident lifestyle documentation including activity calendars, daily participation ‘statistical’ sheets’, venue risk assessments, evaluations of activities

Security patrol reports

Smart hoist pilot study documentation and staff training records

Staffing: ‘In charge’ operation manuals, rosters, disposition sheets, position descriptions, routines, duty lists, collective agreement, police clearance system, professional registrations, buddy shift assessment forms, weekly call bell response monitoring, sick leave monitoring, availability for casual shifts, employee assistance program information

The Flametree Project philosophy of care, staff training records, letters to representatives

Vision, Mission, Philosophy

Work health and safety: site safety officer training, hazard risk register, hazard logs and risk assessments, newsletter, legislation, incident monitoring, workplace inspection audits, external audits, statistics and targets.

Observations

The team observed the following:

Activities in progress

Archiving room and storage of records

Charter residents’ rights and responsibilities displayed

Comments forms, suggestion boxes, poster and brochures external advocacy services


Emergency evacuation boxes, first aid boxes, emergency torches

Equipment and supply storage areas, smart hoist

Cleaning equipment colour coded, chemicals in use and storage

Fire safety equipment, fire boards and mimic panels, exit lights, fire procedures on the back of resident doors, evacuation plans and emergency signage

Flag pole, pathway and cement surround, men’s shed foundations

Interactions between staff and residents

Laundry equipment including new trolleys for clean clothing, labelling equipment, soiled linen and clothing bins, automated chemical dispensing

Living environment

Meal serving and staff providing assistance for residents to eat and drink

Medication rounds and storage

Noticeboards and notices on display including re-accreditation audit notices; aged care complaints scheme and advocacy brochures; Charter of residents’ rights and responsibilities; menus, and mission and values statement

Outbreak supplies, outbreak management kits and handbooks

Palliative care kit and supplies

Personal protective equipment (PPE)

Quiet room

Safety data sheets

Short group observation in the dementia specific unit

Spills kits

Staff implementing hot weather safety strategies

Video monitoring of external and internal areas

Waste collection and disposal equipment, locked confidential waste bins, shredder

Work health and safety: IRT injury management toolkit

Wound care products and equipment.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

IRT Woonona residential care facility pursues continuous improvement across the four Accreditation Standards through implementation of a quality framework which is resident and achievement focused. The continuous improvement system includes regular internal and external audits, resident and staff surveys, comments and complaints processes, verbal feedback, incident reporting, peer review and monitoring of key performance data.

Opportunities for improvement are discussed during meetings and added to the continuous improvement plan as appropriate. Monitoring of improvements to completion and evaluation of outcomes shows ongoing improvements to the quality of care and services provided for residents. Staff say they understand and are involved in continuous improvement and residents/representatives say they are satisfied with improvements at the home.

Improvement initiatives implemented by the home in relation to Standard One Management systems, staffing and organisation development include:

Management identified the separate lines of reporting for care, hospitality and lifestyle staff on each floor to department heads led to inefficiencies and loss of information. In consultation with staff a new structure now requires staff of all streams to report direct to the ‘in charge’ on each floor who is empowered to deal directly with issues as they arise. Computer and email access along with training assist the ‘in charge’ in their new role. The result is improved quality control of individual floors, less interruption of managers with day to day issues, and improved efficiency and team work.

The organisation identified the recruitment process for new staff was slow. In response a new organisation wide recruiting process has commenced where initial documentation is completed through the corporate office including police clearances, reference checks and administration paperwork. Prospective staff who successfully complete the initial process then present at the home for the interview and selection process. The result is a decrease in the amount of documentation completed on site and improved efficiency in recruiting staff.

Management identified the archiving system required improvement due to the difficulty locating information and storage was at capacity. Funding was sourced for a new storage system which was implemented by corporate office staff. The result is a system


which allows ample room for storage and faster retrieval of information. Security of resident personal information has also improved due the larger storage capacity with one central lock.

Management identified staff access to electronic information and communication could be improved. Computer terminals have now been installed across the home which improves efficiency and staff access to policy and practice manuals, forms, department manuals and general information. In addition the ‘in charge’ on each floor now has email access which is used for regulation updates, clinical handover documents and information exchange. This has improved the timeliness of information exchange especially in relation to resident clinical care.

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 corporate office monitors legislation, regulations, professional standards and guidelines and provides the home with updated information as relevant. Once change is identified advice is provided to appropriate managers and staff through meetings, emails, education, memorandum and the intranet. Policies and practices are updated, discussed during meetings and available for staff on the intranet. The management team monitor implementation of policies and compliance with legislation and regulations through observation of staff practices, review of key performance indicators, audit results and feedback from residents/representatives.

Examples of regulatory compliance in relation to Standard One Management systems, staffing and organisational development include:

The organisation implements an electronic system which monitors the currency of management, staff and volunteers police clearances.

Information on the re-accreditation assessment was provided to residents/representatives.

The home has systems to ensure documents are securely stored, computers are password protected, and appropriate archiving and destruction of documents is undertaken.

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 home implements systems to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. Management uses resident care needs,


resident/representative feedback, observation of staff practices, key performance data, results of audits and discussion during staff performance reviews to identify training needs. Education calendars are planned in advance and include mandatory training and topics related to resident care and service provision. New staff complete a full day of orientation training, relevant assessments and buddy shifts prior to commencing work.

Annual mandatory education includes fire safety, manual handling, infection control, reporting of elder abuse and privacy. The IRT College provides opportunities for staff to further their education with the support of management. Residents/representatives say staff are competent and caring, and staff say they have opportunities for education.

Examples of education and staff development relevant to Standard One Management systems and organisational development include: orientation, comments and complaints, documentation, information systems, and archiving and storage of documents.

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


Residents/representatives, staff and visitors to the home are able to freely access information on internal and external mechanisms for providing suggestions, comments and complaints. Management actively encourages feedback and regards this as an opportunity to improve service delivery. All issues raised are dealt with promptly, fairly, confidentially and without retribution. The resident handbook includes information on how to provide feedback to the home or external advocacy services. Posters are on display and brochures are available which provide additional information on ways to provide comments or raise concerns. There are locked suggestion boxes in each area of the home for confidential feedback which are regularly cleared by management. Residents/representatives say they feel comfortable raising issues and generally have no complaints.

1.5 Planning and leadership

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

Team’s findings


IRT Woonona residential care facility displays the Vision and Mission prominently around the home and the Vision, Mission, Values and Philosophy are clearly written in key documents. The Vision and Mission include ‘excellence in care and service through continuous improvement; efficient management of resources and innovation; and high quality supportive care and services to meet the needs of our ageing population’. The organisation philosophy is one of integrated communities and ‘a home for life’. Interviews, review of documentation and our observations show management and staff provide care and services consistent with the organisation’s Vision, Mission, Values and Philosophy.


1.6 Human resource management

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

Team’s findings


Management ensures there are sufficient numbers of appropriately skilled and qualified staff to meet the care and service needs of residents. Policy and practice manuals, position descriptions, routines and duty lists guide management and staff in day to day care and service provision. Recruitment processes include advertising, applications, interview, reference checks and police clearances. An orientation process for new staff includes mandatory training as well as buddy shifts prior to commencing shift work. Casual staff availability is identified on a weekly basis to cover after business hours and weekends. The home values staff contributions through an employee recognition process. Management monitor staff numbers and skill mix and adjust staffing according to resident care needs. The monitoring of staff practices is achieved through observation, competency assessment and the performance management system. Staff say they enjoy working at the home and residents say staff are polite and caring.

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


Management and staff implement effective systems to ensure stocks of appropriate goods and equipment are available as needed for quality service delivery. Service contracts provide guidelines for contractors and approved suppliers. Key staff monitor stock levels and prepare orders for approval by management. Management and staff review the quality of goods and services, and ensure return of unsatisfactory goods. The maintenance system includes regular servicing of all equipment through a work order system monitored by the corporate office. Inventory and equipment are monitored through regular audits, observation, hazard reports, meeting discussion and feedback from residents/representatives, management and staff. Staff say there are sufficient supplies of goods and equipment.

1.8 Information systems

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

Team’s findings


Effective information management and dissemination of information processes ensure residents/representatives, management, staff and other interested people are provided with relevant, appropriate and timely information. Systems include those to manage the creation, distribution, storage, archiving and appropriate destruction of information. Electronic information is backed up regularly, password protected and restricted to authorised personnel.


Forms of communication include email, reports, memorandum, meeting minutes, newsletters, communication diaries/books, handover reports and noticeboards.

Residents/representatives sign consent for exchange of information to appropriate persons. Confidential information is stored securely and staff sign confidentiality agreements.

Residents say they know what is happening around the home and representatives say 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


Management monitor external goods and service providers to ensure the standard provided meets the needs and service quality goals of the home. A range of contractors, goods providers and external service providers operate within contracts and agreements covering for example resident care related services, the fire safety system, plumbing and food products. The corporate office monitors providers and maintains a database to ensure contracts and required documentation such as police clearances if appropriate and insurance are current. Providers who do not meet the home’s requirements are reviewed by corporate management and other options sourced if required. Feedback on external providers is sourced from residents/representatives via meetings, surveys and verbally. Other feedback is sourced from staff, through audits and observation. Residents/representatives and staff say they are satisfied with the goods provided and external services available.


Standard 2 – Health and personal care

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




Team’s findings


Refer to expected outcome 1.1 Continuous improvement for a description of the overall system of continuous improvement. In relation to Accreditation Standard Two - Health and personal care the system is monitored through audits, clinical indicator results and feedback from residents/representatives, health professionals and staff.

The home has implemented improvements in Accreditation Standard Two - Health and personal care including:

Resident life management agreements have been reviewed across the home in response to a comment received from a relative. Life management agreements are now included in the pack provided to new residents when the discussion about end of life preferences is commenced. During case conferences life management agreements are discussed and updated as necessary according to the wishes of the resident. The result is up to date information readily available in relation to resident choice and wishes for their care if they become terminally ill.

Management identified refusals by female residents for physiotherapy treatment was high, 30 in the month of August 2014. This led to the commencement of a pain clinic where female residents gather in a lounge area for social interaction, coffee, music and therapies including heat packs, massage and electrical nerve stimulation therapy. The pain clinics run by a registered nurse and physiotherapy aides twice a week have seen refusals drop to only seven in October 2014. The result is a significant decrease in refusals of treatments, improved pain management and a social opportunity enjoyed by the residents.

Management and staff identified hand writing of clinical handover information was cumbersome and difficult to distribute across the home especially to night staff. Electronic handovers sheets are now in use, which are updated in the afternoons and again in the late evening. Registered nurses access email and print current handover sheets at the beginning of their shift which supplement verbal handovers. This has improved the clinical information exchange from shift to shift thus improving efficiency and resident care.

To improve the provision of appropriate meals for residents who require special diets or have particular food allergies a meal definition system has been introduced. All meals now have allergy symbols in the form of coloured dots. For example gluten/green, egg/yellow, nuts/brown, soy/orange, peanuts/pink and crustaceans/red. The result is an easy to use system which has improved the safety of meal delivery to residents with allergies and those who require special diets.

In response to the increasing clinical information required by ambulance officers and hospital staff when a resident is transferred to hospital an ‘In charge’ operations manual was developed. The manual details clinical assessments required to ensure detailed information is quickly available to ready a resident for transfer. In addition a pulse oximeter equipment has been purchased for all floors to assist in clinical assessment


prior to transfer. These improvements have resulted in improved quality of care for residents.


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

Team’s findings


The home has systems to manage regulatory compliance relating to health and personal care. For the description of the system refer to the expected outcome 1.2 Regulatory compliance. Examples of regulatory compliance in relation to Standard Two Health and personal care include:

Management implements a system to ensure all professional registrations remain current.

The home stores and administers schedule eight medications in accordance legislation.

Resident medication management regime reviews are conducted by a pharmacist.



Team’s findings


The home has education and staff development systems which provide management and staff with appropriate knowledge and skills to perform their roles effectively. For a description of these systems please refer to expected outcome 1.3 Education and staff development.

Examples of recent education and staff development in relation to Standard Two Health and personal care include: dementia training, nutrition and hydration, oral and dental, texture modified diets and thickened fluids, wound care, medication management and skin care.

2.4 Clinical care

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

Team’s findings


IRT Woonona residential care facility has systems to ensure residents receive appropriate clinical care. The overall clinical care system is monitored by the care manager. The registered nurses assess, document and review resident care needs when residents enter the home and on an ongoing basis. The care co-ordinators support the registered nurses in the clinical care processes ensuring residents’ clinical care needs are met. The resident’s medical officer is notified of resident incidents either via facsimile or telephone. Case conferencing supports


consultation with residents/ representatives in relation to all aspects of care. Care staff demonstrated an understanding of residents’ individual needs.

Residents/representatives say they are satisfied with the clinical care received by residents.

2.5 Specialised nursing care needs

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

Team’s findings


There are systems to ensure appropriately trained staff are utilised to meet the needs of residents who require specialised nursing care. Registered nurses undertake clinical assessments of residents requiring specialised nursing care. Care plans are in place and evaluated every three months and as needed. There is documentation relating to consultation with other health care specialists regarding resident care needs. Care staff demonstrated awareness of residents’ individualised specialised nursing care needs.

Residents/representatives say they are satisfied with the level of specialised nursing care provided for residents.

2.6 Other health and related services

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

Team’s findings


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


2.7 Medication management

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

Team’s findings


IRT Woonona residential care facility has systems and processes to ensure residents’ medication is managed safely and correctly. A medication incident reporting and auditing process forms part of the home’s safe system. Medication administration is administered via a blister pack system by staff who have a current medication competency and appropriate qualifications. Residents who wish to self-administer their medication are assessed by the medical officer and registered nurse for their ability to safely manage their medications.

Medications administered by staff are locked in medication trolleys and stored in a locked treatment room when not in use. Residents say they receive their medication in a timely manner.

2.8 Pain management

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

Team’s findings


The home has a system for assessing, monitoring and treating residents’ pain when they enter the home and as needed. Care plans are formulated with individual pain management strategies. A multidisciplinary approach involving medical, nursing, physiotherapy and physiotherapy assistants supports a resident’s pain management program. The home offers treatment at either the home’s pain clinic or in the resident’s room. A combination of treatment options is available to manage residents’ pain which includes heat, massage, the use of electronic nerve stimulation and pain relieving medication. Referral to specialists is in line with residents’ needs. Staff demonstrated knowledge of the processes required to effectively manage residents’ pain. Residents/representatives say they are satisfied with their pain management treatments and with staff responses to their needs.

2.9 Palliative care

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

Team’s findings


There is a system for palliative care to ensure the comfort and dignity of terminally ill residents is maintained. Consultation and communication processes are used in order to ensure residents, representatives, medical officers, care staff and all other health professionals are aware of the individual needs of the resident. The local community based palliative care team is available to support the home’s staff in providing appropriate individualised palliative care as needed. Care staff are aware of the processes to be used when a resident is requiring end of life care.


2.10 Nutrition and hydration

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

Team’s findings


IRT Woonona residential care facility has a system to ensure each resident receives adequate nourishment and hydration. When a resident enters the home an assessment is completed and the information is provided to the hotel services manager. Resident’s weights are recorded by care staff monthly and in line with their individual assessed need. Nutritional supplements are available for residents who require extra nutritional support. Specialised eating equipment is used on an individual basis to help promote independence.

Documentation indicates and staff said residents receive appropriate special diets, dietary supplements, extra fluids and allied health referrals. Residents/representatives say they are generally satisfied with the meals and drinks provided at the home.

2.11 Skin care

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

Team’s findings


The home has systems to assess and monitor residents’ skin integrity. Residents’ skin care needs are assessed on their entry to the home by a registered nurse and monitored daily by care staff. The home uses a skin integrity issue reporting system to report any breaches in skin integrity. A registered nurse is responsible for the overall wound management procedures within the home. Residents/representatives say they are satisfied with the skin care provided by staff.

2.12 Continence management

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

Team’s findings


The home has systems to ensure residents’ continence needs are managed effectively. Continence management strategies are developed for each resident following an initial assessment of urinary and bowel patterns. Care staff assist residents with their continence programs as required and residents’ bowel management programs are monitored daily.

Registered nurses/team leaders liaise with all care staff in relation to the individual continence needs of residents. Care staff said there is a sufficient supply of continence aids to meet residents’ needs. Residents / representatives say they are generally satisfied with the continence care provided to residents.


2.13 Behavioural management

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

Team’s findings


IRT Woonona residential care facility has a system to ensure the needs of residents with challenging behaviours are managed effectively. All residents are assessed on their entry to the home, behaviours identified and strategies to manage the behaviour/s are developed by registered nurses. All episodes of challenging behaviours are recorded in the resident’s progress notes and the resident is monitored closely. Registered nurses investigate the presence of infection or constipation if a resident’s challenging behaviour escalates. Referral to behaviour management specialists is available to assist staff manage behaviours of concern. There are two specific secure units for residents who are living with dementia. Care staff are aware of residents’ individual behavioural needs and management strategies.

Residents/representatives say they are satisfied with the manner in which staff manage residents’ behaviours.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


The home has processes to optimise residents’ levels of mobility and dexterity. Residents’ mobility and dexterity is assessed by the physiotherapist and/or registered nurse on their arrival at the home and on a needs basis. The physiotherapist and physiotherapy assistants provide individual and group exercise programs for residents. The accident and incident reporting system includes analysis of incidents to identify trends and strategies are implemented to reduce the number of resident falls. The home has a range of mobility equipment available for the use of residents. Care staff showed an understanding of their responsibilities in relation to optimising residents’ mobility and dexterity.

Residents/representatives say they are satisfied with the home’s resident mobility program.

2.15 Oral and dental care

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

Team’s findings


IRT Woonona residential care facility has a system to ensure residents’ oral and dental health is maintained. This includes initial and ongoing assessment of residents’ oral and dental needs by a registered nurse. Residents’ day-to-day oral care is attended in line with individual care plans and referral to specialists is arranged according to residents’ needs and preferences. Care staff demonstrated an understanding of oral and dental care practices used in resident


care. Residents/representatives say they are satisfied with the way in which residents’ oral health is maintained.

2.16 Sensory loss

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

Team’s findings


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

2.17 Sleep

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

Team’s findings


The home has systems in place to assist care recipients achieve their natural sleep patterns. On their entry to the home, a residents’ sleep pattern is assessed and strategies implemented. Residents are encouraged to settle quietly in their rooms at night and staff can offer snacks and drinks during the night when required. The home ensures residents who are accommodated in shared rooms are able to achieve natural sleep patterns. This is by use of bed screens and effective management of both care recipients in the shared room.

Residents say they are generally able to have a good night’s sleep and the night staff are attentive to their needs.


Standard 3 – Care recipient lifestyle

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard Three Resident lifestyle: resident meetings, the comment and complaint system, verbal comments and surveys are used to gather suggestions and feedback on the lifestyle systems of the home.

The home has implemented improvements in relation to Standard Three Resident lifestyle including:

The home in conjunction with the University of Wollongong as part of the Flametree Project identified residents with cognitive impairment required new ways to add meaning to their lives. Project ideas were discussed during meetings and with representatives resulting in a list of tasks residents may like to be involved in doing around the home. Residents of the dementia secure unit guided by lifestyle staff now enjoy participating in day to day tasks they have done throughout their lives such as sweeping, dusting, applying boot polish, setting tables and folding napkins. This has added meaning to their lives and their feeling of usefulness.

Staff identified that it was unsafe for residents to access the flag pole to raise or lower the Australian flag as it was located in a grassed area. Approval was gained for a path and cement area around the flag to facilitate access. The result is residents, especially those in wheelchairs are now able to raise and lower the flag which is particularly important for Remembrance Day.

Residents raised a suggestion during a meeting for development of the men’s group further through regular meetings and the building of a men’s shed. Male residents across the site now meet formally fortnightly and informally on the intervening week, attend monthly lunch outings and visit men’s sheds in the district. A men’s shed on the site has been approved with the foundation laid, internal plans drawn and the shed ordered. The men enjoy the socialisation during meetings, attendance is increasing and they are enjoying being involved in the development of their own men’s shed.

Management identified that the home has culturally diverse residents and staff members so in order to celebrate the diversity of people living and working at the home an International Day was celebrated. A lunch with meal contributions from staff of many different nationalities was attended by residents, representatives and staff. The event was deemed a success with residents, visitors and staff enjoying the many different foods and socialising. The home plans to implement similar events as part of the social program.



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

Team’s findings


The home has systems to manage regulatory compliance relating to resident lifestyle. For the description of the system refer to the expected outcome 1.2 Regulatory compliance.

Examples of regulatory compliance in relation to Standard Three resident lifestyle include:

Management provides information on residents’ rights and responsibilities during the moving in process, in key documents and residents’ rights and responsibilities is displayed on the wall of the home.

Residents sign consent for exchange of appropriate information with other health related services and use of their photograph.

The privacy of resident personal information is reinforced through staff ‘sign off’ on confidentiality agreements.



Team’s findings



Examples of education and staff development in relation to Standard Three resident lifestyle include: reporting elder abuse, privacy and dignity, independence, emotional support, and leisure interests and activities.

3.4 Emotional support

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

Team’s findings


Residents/representatives reported that emotional support is given by staff to residents when they first arrive and that support is ongoing. New residents are supported by staff through introductions to other residents and to the activities in the home. Assessments and a lifestyle profile assist in identifying any specific needs relating to emotional support for individual residents. Residents are encouraged to bring personal items such as photographs and


mementoes into the home and representatives are welcome to visit frequently. Additional emotional support is provided by the welfare officer who provides various services including individual visits and support.

3.5 Independence

This expected outcome requires that "residents 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


IRT Woonona residential care facility has processes which encourage residents’ independence and participation in community life. Each resident’s level of independence and their need for assistance are assessed on entry to the home and reviewed as needed.

Exercise programs are provided to optimise residents’ mobility and dexterity. The home promotes resident links with the community through bus trips, voting and in providing opportunities for residents to interact with volunteers and other visitors. Resident’s friends and families are encouraged to share special events with residents and to participate in their life within the home. Residents/representatives say they are satisfied with the home’s processes to maximise care recipients’ community involvement and independence.

3.6 Privacy and dignity

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

Team’s findings


Residents’ right to privacy, dignity and confidentiality is recognised and respected by staff at the home. Information on residents’ rights and responsibilities is included in documentation provided to all residents/ representatives when residents first enter the home. Staff demonstrated an awareness of practices which promote the privacy and dignity of residents. These include closing resident doors, window curtains and bed screens when providing personal care. Residents’ personal information is stored securely with access by authorised staff only. Residents have access to a confidential process for reporting comments and complaints. Residents/representatives say they are satisfied with the way staff respect their privacy and maintain residents’ dignity and confidentiality.

3.7 Leisure interests and activities

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

Team’s findings


Residents at IRT Woonona residential care facility are encouraged and supported to participate in a wide range of interests and activities. An assessment of residents’ leisure preferences is conducted on their entry and reviewed as required. Lifestyle care plans based


on this information are prepared in conjunction with residents/representatives. The home’s leisure program has a variety of in-house and community based activities including exercises, bus outings, games, quizzes, craft and men’s shed activities. Residents in the dementia specific units have an activity program which includes reminiscing, games and music therapy, as well as participation in shared activities with other residents at the home. In addition to group activities, the home’s lifestyle staff spend one-on-one time with residents. The home’s activity program is evaluated using information from activity participation records, surveys and resident feedback to ensure the program continues to meet resident needs and preferences. Residents/representatives expressed satisfaction with the overall leisure program.

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


The home is able to demonstrate that residents’ individual interests, customs, beliefs and cultural backgrounds are valued and fostered. Assessment of residents’ specific needs, customs and beliefs is conducted on their entry to the home and reviewed on an ongoing basis. Residents are actively encouraged to maintain cultural and spiritual links in the community. Church services are held and days of cultural significance are celebrated.

Residents/representatives say they are satisfied with the support provided for residents’ cultural and spiritual needs.

3.9 Choice and decision-making

This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident 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 has processes to ensure that each resident (or their representative) participates in decisions about the services received by the resident. These processes uphold the resident’s right to exercise choice and control over his or her lifestyle. Residents are kept informed and given opportunities to provide input into the home through systems such as assessment and care planning processes, surveys and resident meetings. Where residents are unable to make choices for themselves, an authorised decision maker is identified for the resident.

Residents are provided with choices concerning their personal care regimes, cultural and spiritual choices, waking and sleeping times. Choices are also available regarding meals, participation in activities and choice of medical officer. Residents/representatives say they are satisfied the home’s staff actively support residents in making their own lifestyle choices and decisions.


3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Residents/representatives say they are satisfied with the information provided by the home in regard to their security of tenure and rights and responsibilities. Prospective residents meet with staff to discuss fees and charges, agreements, security of tenure and residents’ rights and responsibilities prior to moving into the home. A tour may also be arranged. An interim agreement is initially signed followed by a residential care agreement which residents/representatives are encouraged to take away and have reviewed by a professional if they wish. Once finalised a copy of the signed agreement is provided to the resident/representative. A resident information handbook provides additional day to day information about living at the home. Residents say they enjoy living at the home and feel secure in their residency.


Standard 4 – Physical environment and safe systems

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



Team’s findings


The home is actively pursuing continuous improvement in relation to physical environment and safe systems. This was confirmed through observations, interviews and review of documentation. For a description regarding the continuous improvement system see expected outcome 1.1 Continuous improvement.

Examples of improvement activities in relation to Accreditation Standard Four include:

The home is implementing ‘The Flametree Project’ in conjunction with the University of Wollongong supported by a grant from the IRT Research Foundation which aims to improve the living environment for residents with dementia. An environmental assessment and intensive staff training has been completed. Some initial changes have already occurred including lowering of the nurse station counters and installation of wall openings to improve sight lines for residents and staff. This has improved resident orientation from the hallway and provides greater reassurance as they can see staff, and staff can see them. The project is ongoing.

Management identified the time lost through workplace injuries required improving. A site safety officer who is also the chairperson of the work health and safety committee spreads the safety message to staff. He also develops and distributes a newsletter with current legislation information, reviews hazard reports and monitors data related to incidents/accidents. Staff know who their site safety officer is and say this position has improved their awareness of work safety. The result is a significant decrease in lost work time due to injury and a safer work environment for staff.

The home is participating in a research project in conjunction with the University of Technology Sydney which centres around development of assistive robotic devices. A smart hoist initially trialled at the home is now in regular use by staff. The hoist is a conventional lifter which is equipped with motors enabling it to move around and sensors to detect its surroundings to avoid collisions. Cameras, an interface touch screen, movement records and extensive data collection capabilities enables tracking of the lifter and monitoring of its use. The equipment is designed to address the high risk of injury to staff during care delivery. Over 60 staff received training in use of the smart hoist with positive feedback related to the ease of use and improved safety.

Management identified through a review the clean laundry delivery system was cumbersome and trolleys were difficult for staff to manoeuvre around the site leaving them at risk of injury. New trolleys were sourced which facilitate folded clothes for each resident in an individual section and room for hanging clothing. Clothes are now sorted direct to the trolley and delivered easily around the home. The system has significantly improved efficiency and the safety of staff.



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

Team’s findings


The home has systems to manage regulatory compliance relating to Physical environment and safe systems. For the description of the system refer to the expected outcome 1.2 Regulatory compliance.

Examples of regulatory compliance relating to Accreditation Standard Four include:

There is a system for regularly checking and maintenance of fire safety equipment and current fire safety statements are on display. Flametree Lodge has a sprinkler system and the Ribbonwood Lodge quote has been accepted and work on site commenced.

The home has a current New South Wales (NSW) Food Authority license on display. The food safety system meets the legislated requirements for food safety.

Monitoring is carried out on thermostatic mixing valves for temperature safety and testing for legionella occurs.



Team’s findings



Examples of recent education activities relating specifically to Accreditation Standard Four Living environment include: fire safety, infection control, food handling, manual handling, chemical training and laundry equipment operation.

4.4 Living environment

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

Team’s findings


The IRT Woonona residential care facility is part of an integrated community where residents are able to age in place, ‘a home for life’. The home has multiple lounge areas and quiet rooms with comfortable seating, and tea or coffee facilities are freely available. Outdoor recreation


areas have well maintained lawns and landscaped gardens, and there is a spacious courtyard in front of Flametree Lodge. Accommodation is in single or double rooms with privacy curtains, and heating and cooling systems ensure residents remain comfortable all year round. There are special dedicated wings with a secure perimeter to cater for the needs of residents living with dementia who may wander. A preventative and corrective maintenance system is overseen by an onsite manager and implemented through work orders from the corporate office. Resident safety is monitored and maintained through incident and hazard reporting, environmental audits and efficient repairs by maintenance staff or external contractors. Residents say they are happy and enjoy living at the home.

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


Management and staff implement systems to actively ensure a safe working environment that meets regulatory requirements. A work health and safety committee with representatives from across departments meets regularly to review environmental audits, incidents/accidents, hazard reports and discuss issues related to safety. The site safety officer who chairs the committee encourages staff to be involved in work health and safety through being vigilant about hazards and a safe work place. A newsletter distributed by the site safety officer details new information relevant to staff and engenders enthusiasm through competitions. Policy and practice manuals guide staff on safe practices. New equipment is trialled in consultation with staff and training in the use of equipment ensures staff have the knowledge for safe use. A return to work program with support is available if required. Staff say management are proactive in ensuring their working environment is safe.

4.6 Fire, security and other emergencies

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

Team’s findings


Management and staff are proactive in ensuring the home provides a safe and secure environment for residents and the home is ready should an emergency occur. A senior fire officer oversees trained fire officers covering each area of the home who are specifically trained to lead staff in an emergency. All new and existing staff complete mandatory fire safety training annually. Regular monitoring and testing of fire emergency equipment and systems is carried out by external contractors. Emergency evacuation boxes with resident information and first aid kits are ready and plans for disaster management are in place. Staff lockdown the home at night, there is a video monitoring system and an external security company patrols overnight. Residents say they feel safe living at the home.


4.7 Infection control

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

Team’s findings


The infection control system is overseen by management, an infection control coordinator and a committee with representatives from departments across the site. Infection data is collected, analysed, monitored and followed up to ensure infections occurring are minimised. Staff complete mandatory annual training and are well conversed in infection control practices including procedures for managing outbreaks and chronic infections. Vaccination programs are implemented for residents and staff. There are outbreak kits and spills kits along with a waste management program which includes contaminated waste and sharps management. Residents/representatives say they are satisfied with the infection control practices implemented by staff.

4.8 Catering, cleaning and laundry services

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

Team’s findings


The home ensures hospitality services enhance the quality of life of residents and the working environment for staff. The hospitality manager oversees the catering, cleaning and laundry systems which are monitored closely. The menu is developed and adjusted in consultation with residents and a dietician, and daily feedback on resident satisfaction assists in monitoring the quality of meals. Residents/representatives say they are satisfied with the catering service provided. The cleaning system follows infection control guidelines including appropriate chemicals and colour coded equipment. Staff complete training and follow set schedules to ensure all areas of the home are cleaned regularly. Residents/representatives say they are satisfied with the cleaning program and the home always smells fresh. The laundry operates six days a week providing good turnaround times. Commercial washing machines with automated chemical dispensing ensure sanitisation of linen and residents personal items. There is a labelling system for residents clothing. Residents/representatives say they are satisfied with the laundering system and commented “no items had been lost”.

IRT - Woonona Residential Care Facility · installation (Ribbonwood Lodge), emergency lighting and...

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