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Uniting Banks Lodge PeakhurstRACS ID: 0232

Approved provider: The Uniting Church in Australia Property Trust (NSW)

Home address: 93 Baumans Road Peakhurst NSW 2210

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 22 December 2020.

We made our decision on 08 November 2017.

The audit was conducted on 27 September 2017 to 29 September 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: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 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 carePrinciple: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 MetHome name: Uniting Banks Lodge Peakhurst Date/s of audit: 27 September 2017 to 29 September 2017RACS ID: 0232 2

Standard 3: Care recipient lifestylePrinciple: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 services 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 systemsPrinciple: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

Home name: Uniting Banks Lodge Peakhurst Date/s of audit: 27 September 2017 to 29 September 2017RACS ID: 0232 3

Audit ReportName of home: Uniting Banks Lodge Peakhurst

RACS ID: 0232

Approved provider: The Uniting Church in Australia Property Trust (NSW)

IntroductionThis is the report of a Re-accreditation Audit from 27 September 2017 to 29 September 2017 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 27 September 2017 to 29 September 2017.

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.

Details of homeTotal number of allocated places: 114

Number of care recipients during audit: 106

Number of care recipients receiving high care during audit: 88

Special needs catered for: Memory support unit accommodating 27 care recipients living with dementia.


Audit trailThe assessment team spent three days on site and gathered information from the following:

Interviews

Position title Number

Care recipients 21

Representatives 5

Head of residential operations Sydney South Regional Hub

1

Service manager 1

Deputy service manager 1

Quality improvement manager learning and development (Regional hub)

1

Clinical nurse educator 1

Residential business lead manager (Regional hub)

1

Business services officer 1

Registered nurses 4

Endorsed enrolled nurse 1

Care staff 10

Physiotherapists 2

Memory and lifestyle support officer (Regional hub)

1

Recreational activities officers 2

Transport manager (Regional hub) 1

Chaplains (Regional hub) 2

Pastoral care staff 2

Beautician 1

Volunteers 2

Administration assistant 1

Client admission officer 1


Position title Number

Assets officer 1

Chef 1

Catering staff 2

Laundry staff 1

Cleaning coordinator and rosters officer 1

Cleaning staff 1

Area maintenance supervisor 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files (assessments, progress notes, care and lifestyle plans and associated documentation)

12

Medication charts 10

Other documents reviewedThe team also reviewed:

Accident and incident reports

Behaviour management: behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, wandering ‘resident’ check list

Catering, cleaning and laundry: food safety records, cleaning schedules (including laundry and kitchen)

Clinical monitoring records: care plan review schedule, clinical care needs spreadsheet, care and clinical admission and review procedure, anticoagulant therapy, blood glucose levels, blood pressure, neurological observations, pain, hygiene and pressure relief turning charts, clinical indicator monitoring data, case conference records

Comments, complaints and compliments register (electronic)

Continence management: continence assessments, continence management plans, toileting schedules, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care

Continuous improvement: audits, continuous improvement plan and outcomes

Emergency plan


Human resources: job descriptions, electronic personnel files, recruitment policies and procedures, rosters, education records (mandatory and professional development), education matrix, learning and development calendar and learning campus (electronic)

Infection control: staff and care recipient fluvax register, outbreak management guidelines, Public Health Unit line listings, infection incident reports, infection surveillance monitoring data

Information management: communication diaries, memoranda, minutes of meetings, care recipient, staff and volunteers information handbooks, policies and procedures, care recipients’ information package, surveys and agreements

Lifestyle management: lifestyle past history , leisure and spiritual assessments, activity plans, attendance records, activity evaluations, newsletters, consent forms, communication cue cards

Maintenance records: maintenance plans (preventative and reactive), contractors folder and handbook, assets register

Medication management: medication administration plans, signing sheets, PRN medication (whenever necessary) evaluations, clinical refrigerator temperature monitoring records, therapeutic monitoring guidelines and anti-coagulant therapy care plans, oxygen therapy care plans, medication incident reports, nurse initiated medication forms, drugs of addiction registers, complex health care directives diabetic management, professional signatures register, self-medication assessments/authorisations

Mobility: mobility assessments, physiotherapy care plans, individual exercise, massage, heat pack therapy and transcutaneous electrical nerve stimulation attendance records, hip protector list, safe footwear checklist

Nutrition and hydration: nutritional preferences assessments, weight monitoring records, dietitian reviews/management plans, speech pathologist reviews/reports, nutrition and hydration list and supplements list

Pain management and palliative care: pain assessments, pain management plans, advanced care plan directives, palliative specialised nursing care plans, end of life clinical pathways

Regulatory compliance: police certificates and statutory declarations register, professional registrations, consolidated register and incident and hazards reporting records

Self-assessment report for reaccreditation and associated documentation

Skin integrity: wound assessments and management plans, weekly photographic wound monitoring records, pressure care directives, podiatry assessments and reports

Work, Health and Safety materials

ObservationsThe team observed the following:

Activities in progress

Care recipients utilising pressure relieving and hip and limb protection equipment

Chemicals storage and safety system including safety data sheets

Complaints (internal and external) forms, materials and brochures

Dining environment during midday meal service and morning and afternoon teas including staff serving meals, supervision and assisting care recipients

Equipment and supply storage areas


Fire certificate, fire equipment, exits and evacuation plans

Hairdresser and beautician in attendance

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

Information noticeboards including Work, Health and Safety

Interactions between staff, care recipients and representatives

Living environment

Menu and menu boards (including electronic in foyer)

Mobility equipment in use including mechanical lifters, walk belts, wheel chairs, shower chairs, low-low beds, hand rails in corridors and internal lift access

NSW Food Safety certificate A rating

Pampering room and memory areas/boxes

Re-accreditation audit notice on display

Secure storage of care recipients' clinical files and confidential staff handover

Secure storage of medications and oxygen; medication administration

Short group observation in memory support unit lounge

Sign in/out registers, internal swipe and key pad access, closed circuit television monitoring systems

Staff work practices and work areas including administrative, clinical, lifestyle, physiotherapy, catering, cleaning, laundry and maintenance

Vision, Mission and Philosophy statements and Charter of Care Recipients' Rights and Responsibilities displayed

Wound management trolley and resources


Assessment informationThis 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 developmentPrinciple:Within the philosophy and level of care offered in the residential care services, 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 improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The home demonstrated it has a robust continuous improvement system with a range of continuous activities across the Accreditation Standards. Uniting, the organisation, has developed consistent systems and processes designed to capture and analyse information relevant to continuous improvement activities. The home’s management demonstrated it applies these to its continuous improvement program. Staff, care recipients, representatives and other stake holders are actively encouraged to contribute to continuous improvement. Improvements are also drawn from analysis of information such as clinical and incident data, audits, surveys, meeting minutes, comments, complaints and compliments. The organisation’s Practice and Quality team work closely with the home’s management to support continuous improvement. Improvements are evaluated for effectiveness. Care recipients and staff were able to describe a range of recent improvements and their satisfaction with these.

Continuous improvements related to Standard One include the following:

Following care recipient feedback regarding staff sufficiency, management conducted a review of staffing numbers across the home. The review identified an increase in care recipient needs leading to a targeted increase in staffing levels. This included a registered nurse position being introduced overnight. A floating care staff position has been added to both the morning and afternoon shifts. Further to this a leisure and lifestyle office was introduced on weekends in the memory support unit to better support the management of behaviours. The service manager and deputy acknowledged these changes have been successful and they are continuing to monitor the sufficiency of staff. Including the plan to introduce an additional floater position to assist with strategies in fall prevention.

Uniting has recently undergone a major review and restructure. Building on its model of inspired care it is rolling out in residential care a first person/household model. This will lead to creating smaller clusters (or households) within the home; each with its own kitchen, dining room, activity area and small, cosy, homely spaces. The home’s management is beginning to integrate this approach into Banks Lodge. Key staff have attended training on applying the model and recent refurbishments within the home reflect this (see Continuous improvement Standard Three for more information on this). Management recognise the need to change the work culture to achieve this outcome and provide person first care and services and are actively applying this to their current recruitment requirements. Management are actively working to empower staff to be a


self-led team and make work decisions appropriate to their designation. Solution orientated community circles are being used for care recipients/representatives and staff to discuss and problem solve issues and concerns. Care recipients and staff said they are inspired by the changes that are taking place through this improvement.

1.2 Regulatory complianceThis 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”.


The organisation and home’s management has a range of policies, systems and processes to identify and ensure compliance with all relevant legislation, regulation, professional standards and guidelines. The organisation monitors industry standards and guidelines and subscribes to a range of organisations and agencies that provide current and updated regulatory information. This includes a peak body, Department of Health, legal services, local authorities and Australian Aged Care Quality Agency. The electronic intranet site ensures information populates relevant policy and documentation and sends electronic alerts and circulars as and when required. Homes are provided with information, training and education to ensure compliance is maintained across all Standards. Regulatory compliance under Standard One includes maintaining privacy requirements, ensuring currency of police certificates and that staff on restricted work visa conditions meet all required criteria of such visas.

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


Staff and management were able to demonstrate they have the appropriate knowledge and skills to effectively perform their roles. The organisation has a consistent structure of education which includes both mandatory training and professional development. Staff receive an orientation at the commencement of employment and there is a system to ensure all staff complete mandatory required education. The organisation actively encourages professional development and has a comprehensive electronic learning campus accessible to all staff. Staff have individual service learning plans. Staff and care recipient surveys also identify areas for further learning development and this can result in live training and tool box talks. Staff said they are very satisfied with their education and professional development opportunities. Management said they see improvement in practices where learning is directed. Care recipients said staff are competent in their work roles. Education provided under Standard One includes: Person centred care, new equipment training, Senior Rights Service and Code of Conduct.

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


The organisation and home actively support care recipients and their representatives to access internal and external complaints processes. The home maintains a register of


comments, complaints and compliments and uses this to initiate change as and where appropriate. The home’s management ensure complaints can be made confidentiality and there is a process to ensure these are responded to in a timely and effective manner. The service manager was seen to operate an open door policy. Regular case conferencing allows concerns to be addressed and solutions developed as part of ongoing care and services delivery. Comments and complaints were seen to be discussed at care recipient, representative and staff meetings. Care recipients and staff were provided education in using the Senior Rights Service. Care recipients and their representatives were familiar with the complaints processes available in the home and confident that if they did raise concerns these would be addressed.

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


The home has documented it and the organisation’s vision, values and philosophy throughout the service. This includes how these support the delivery of care and services. Staff awards were seen in meeting these objectives and discussing inspired care is part of the standing agenda at meetings. Care recipients, representatives and staff commented on their satisfaction with the home’s leadership team.

1.6 Human resource managementThis 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".


The organisation’s People, Learning and Culture model delivers on workplace strategies, a range of employment related programs and supports policies and procedures to attract and retain committed and skilled staff. A comprehensive system is in place to support recruitment based on meeting the needs of care recipients. Reference checks and police certificate clearance are attended prior to employment. New staff receive comprehensive organisational and workplace orientation and complete ‘buddy’ shifts and a period of probation. Position descriptions and work schedules support delivery of care and services. Management regularly review rosters and staff numbers to ensure care and service needs are being met. The home rarely uses agency staff but has a pool of staff to draw on for sudden absences or leave requirements. Staff have at least an annual appraisal and are actively encouraged to pursue professional development. Staff said they have sufficient time and skills to complete their duties. Overall care recipients and representatives said there are sufficient and appropriately skilled staff available to meet their requirements.

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


The home demonstrated there is a system for ordering all appropriate goods and equipment. This is monitored by the organisation’s asset team who also ensure currency and


replacement of equipment. Auditing processes ensure all ordered stock is appropriate for use, is useable and matches what was ordered. Systems were seen to be used to return goods which were unsuitable, faulty or below the required standard (such as fresh food supply). A review of inventory and equipment showed adequate supplies and appropriate storage including a system, where required, of stock rotation and when goods needed to be replenished. An assets register is maintained. The home is in process of replacing a range of equipment including lifters, beds, mattresses and furnishings. Care recipients expressed their satisfaction with the sufficiency of and access to appropriate goods and equipment.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The organisation has a comprehensive and effective information management system. This is both electronic and hard copy and supports a consistent approach to use of documentation and procedures. Staff and management in the home demonstrated they apply these systems in the delivery of care and services. Management and staff have access to accurate and controlled information sufficient to help them perform their roles. These include care plans, clinical documentation, work schedules, position descriptions and the intranet. Care recipients and representatives have access to information appropriate to their needs. This includes agreements, handbooks, newsletters, brochures, meeting minutes, and noticeboard information. Information was seen to be stored in a way which was secure, such as password protected and accessible to only those with authority to do so. The computer system is backed up. Staff and care recipients said they are satisfied with the information available to them.

1.9 External servicesThis 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".


The organisation has preferred contractors used by the home to ensure external services are provided in a way which meets the needs of the service and care recipients. Contractors are used to support maintenance, catering, clinical supplies and services and chemical supplies. The organisation’s residential business lead manager monitors contracts to ensure currency and that they meet required legislative requirements such as police certificates, insurances, qualifications and registrations. Key staff in the home provide feedback around satisfaction with the quality and standard of services provided. There is also a system for gathering care recipient feedback on this. The home demonstrated there is a system to monitor contractors when they are on site and to evaluate completed work. Recent changes in contractors to the home include linen supplies and podiatrist. Staff and care recipients said they are confident in raising any concerns regarding the quality of the external services.


Standard 2 – Health and personal carePrinciple: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.



Refer to expected outcome 1.1 Continuous improvement for further information regarding the home’s system of continuous improvement.

Continuous improvements related to Standard Two include the following:

In early 2017 the organisation reviewed pressure care. Management said clinical indicators at Uniting Banks Lodge showed there was a need to look at wound care in the home. The organisation had recruited a clinical nurse consultant (CNC) in wound care who reviewed the home’s registered nurse understanding and practices in this area. This resulted in all registered nurses attending further education and the development of wound care champions. As a result the home’s registered nurses are better able to identify those care recipients at risk of developing pressure injuries; care staff are informing registered nurses of changes to skin integrity earlier. Likewise through the CNC the home has more scope in sourcing skin care products and this has led to the purchase of air mattresses, pressure injury boots and wedges. The home has also reviewed its use of nutrition to support skin integrity care and a number of care recipients were observed drinking more fluids. As a result of this initiative, management said pressure injuries and wounds have dropped. Including one care recipient with a stage four pressure wound having their wound resolve with more targeted care. Pressure care equipment was seen in use and a care recipient commented on the comfort of their new air mattress which gave them a “Good night’s sleep!”

It was identified through concerns raised that continence management in the home’s memory unit was not optimum. This was discussed at a care staff community circle and a staff member suggested a more effective system of tracking and recording individual care recipients’ toileting schedules in this area. This includes a signing sheet and every shift working as a team to ensure the interventions are effective. The management team said this has improved continence management in this area and reduced behaviours which may have resulted from unmet continence needs.

The management team decided on reviewing care recipient falls to implement a falls management plan. This included initiating care recipient and staff falls education provided by the physiotherapist. As a result exercise classes were reviewed and improved to focus on strengthening gait, mobility and balance. Equipment such as non-slip socks, hi-lo beds and bedside mats were introduced for those care recipients identified as being high falls risk. Staff were encouraged to be more vigilant in monitoring care recipient mobility. Management said incidents of falls resulting in injury have significantly reduced. Care recipients commented on how much they enjoy the exercise class and we observed many care recipients in non-slip socks and being assisted by staff to mobilise.


2.2 Regulatory complianceThis 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”.


Refer to expected outcome 1.2 Regulatory compliance for further information regarding the home’s system in this area.

The home demonstrated it has systems to ensure the currency of professional registrations. Meeting minutes showed the home was following safe systems for the delivery and storage of S8 medications.



Refer to expected outcome 1.3 Education and staff development for further information regarding the home’s system in this area.

Education provided under Standard Two includes: wound care, continence management, sensory loss, nutrition, Schedule 8 restricted drugs of addiction register, catheter care, oral and dental care and pain management.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


There are systems and processes to ensure care recipients receive appropriate clinical care and policies and procedures to guide staff practice. The deputy service manager oversees clinical care at the home. Twenty four hour registered nursing care is provided and a comprehensive program of assessments is completed on entry. Individualised care plans are formulated, regularly reviewed and monitored by registered nurses. Care is planned in consultation with the care recipient and/or their representative, the care recipient’s medical practitioner and allied health professionals. Staff have a sound understanding of the clinical care process. The home has appropriate supplies of equipment and resources maintained in good working order to meet the ongoing and changing needs of care recipients. Care recipients and representatives state they are satisfied with the clinical care provided and representatives say they are informed of changes in the care recipient’s condition and care needs.

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


There are systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Documentation and discussions with staff show care recipients’ specialised nursing care needs are identified when they move into the home and


are addressed in the care planning process. Registered nurses coordinate assessments on the care recipients’ specialised care needs. The home liaises with external health professionals including the local Area Health Service to ensure care recipients’ specialised nursing care needs are met. Staff access internal and external education programs and there are appropriate resources and well maintained equipment to provide specialised nursing care. Care recipients and representatives are satisfied with the specialised nursing care provided.

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


Documentation shows the home refers care recipients to external health professionals and any changes to care following specialist visits are implemented in a timely manner. The physiotherapist manages a pain program four days a week, an additional physiotherapist and an exercise physiologist are both on site two days each week. Several allied health professionals visit the home on a regular basis including pathology services, the podiatrist, the dietitian, speech pathologist, optometrist and the Area Health Service Mental Health team. Representatives report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care are implemented.

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


Management demonstrates care recipients’ medication is managed safely and correctly. Registered nurses and medication endorsed care staff administer medications via a sachet packaging system. A current pharmacy contract and locked storage of medication promotes safe and correct management of medication to care recipients. The electronic medication system includes photographic identification of each care recipient with their date of birth and clearly defined allergies. Pharmacy and medical practitioner protocols have been established in the home and staff practices are consistent with policy and procedures as evidenced through audits and training. The medical advisory committee review legislation changes, medication and pharmacy issues. Regular medication reviews are completed by a consultant pharmacist. Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned by the deputy service manager. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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


There are systems to ensure all care recipients are as free as possible from pain. Initial assessments identify any pain a care recipient may have and individual pain management plans are developed. Staff are trained in pain prevention and management and use verbal and non-verbal pain assessment tools to identify, monitor and evaluate the effectiveness of


pain management strategies. Documentation shows strategies to prevent and manage care recipients’ pain include attendance to clinical and emotional needs, medication and alternative approaches including heat, massage, transcutaneous electrical nerve stimulation (TENS) and pressure relieving devices. Pain management measures are followed up for effectiveness and referral to the care recipient’s medical practitioner and other services is organised as needed. Staff regularly liaise with medical practitioners and allied health personnel to ensure effective holistic care planning. Care recipients and representatives report care recipients are as free as possible from pain and staff respond in a timely manner to their requests for pain control.

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


There are systems to ensure the comfort and dignity of terminally ill care recipients and support for their families and those involved in their care. Documentation and staff discussions show the spiritual, cultural, psychological and emotional needs of care recipients are considered in care planning and ongoing pastoral care and emotional support is provided. Representatives are informed of the palliation process and the home is in regular communication with representatives, medical practitioners and specialists throughout the palliative care process.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Documentation demonstrates care recipients’ nutrition and hydration status is assessed on entry to the home and individual needs including swallowing difficulties, sensory loss, special diets and individual preferences are identified and included in care planning. Appropriate referrals to the speech pathologist, dietitian and dentist are made in consultation with the care recipient/representative and others involved in their care. The seasonal menu is reviewed by a dietitian and provides care recipients with an alternative for the midday and evening meal. Care recipients are weighed monthly or more often if indicated and weight loss/gain monitored with referral to medical practitioners or allied health for investigation and treatment as necessary. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements including thickened fluids, pureed and soft food. Care recipients and representatives are satisfied with the frequency and variety of food and drinks supplied.

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


Care recipients’ skin integrity is assessed through the initial assessment process. Staff monitor care recipients’ skin care as part of daily care and report any changes in skin integrity to the registered nurse for assessment, review and referral to their medical


practitioner as needed. Staff have access to sufficient supplies of appropriate equipment and resources to meet the needs of care recipients. Staff receive ongoing training and supervision in skin care and the use of specialist equipment such as lifting devices used to maintain care recipients’ skin integrity. The home’s reporting system for accidents and incidents includes skin integrity and is monitored monthly and included in the quality clinical indicators. Care recipients have access to the physiotherapist and other external health professionals. Care recipients and representatives report staff pay careful attention to care recipients’ individual needs and preferences for skin care. Observation confirms the use of pressure relieving and limb protecting equipment.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


There are systems to ensure care recipients’ continence is managed effectively. The deputy service manager and the registered nurses oversee continence management at the home. Clinical documentation and discussions with staff show continence management strategies are developed for each care recipient following initial assessment. Care staff report they assist care recipients with their continence programs regularly and monitor care recipients’ skin integrity. Staff are trained in continence management including scheduled toileting, the use of continence aids and the assessment and management of urinary tract infections. Bowel management strategies include daily monitoring. Staff ensure care recipients have access to regular fluids, appropriate diet and medications as ordered to assist continence. There are appropriate supplies of continence aids to meet the individual care recipient’s needs. Care recipients and representatives state they are satisfied with the continence care provided to the care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behavioural management needs are identified by initial assessments and behaviour care plans formulated. Behaviour management strategies include one-on-one and group activities which are regularly reviewed in consultation with the care recipient and/or representatives and other specialist services. There is an evening lifestyle program from 3.30pm until 7.30 pm in the memory support unit; management and staff confirm this has been instrumental in minimising incidents of aggression. Staff confirm they have received education in managing challenging behaviours and work as a team to provide care. The home has access to other health professionals including the Area Health Service Mental Health Team and the organisational dementia clinical nurse consultant. Staff were observed to use a variety of management strategies and resources to effectively manage care recipients with challenging behaviours and to ensure the care recipients’ dignity and individual needs were respected at all times. Care recipients and representatives are satisfied with how challenging behaviours are managed at the home.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.



There are systems to ensure optimum levels of mobility and dexterity are achieved for each care recipient. Systems include comprehensive assessments, the development of mobility and dexterity plans and mobility programs. There is one physiotherapist on site four days and one two days each week. Daily exercise classes are held and the exercise physiologist is on site twice weekly. Individual programs are designed to promote optimum levels of mobility and dexterity for all care recipients. Falls incidents are analysed and are monitored in the quality clinical indicators. Care recipients and representatives report appropriate referrals to the physiotherapist are made in a timely manner. The falls prevention committee meet monthly and review all falls; the committee actively promote falls prevention strategies including safe footwear, non-slip socks, and hip protectors. Staff are trained in falls prevention, manual handling and the use of specialist equipment. Assistive devices such as mobile frames, walk belts, mechanical lifters and wheelchairs are available.

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


There are systems to ensure care recipients’ oral and dental health is maintained. Oral and dental health is assessed on entry to the home and documented on care plans. Staff state they receive education in oral and dental care and assist care recipients to maintain daily dental and oral health. Swallowing difficulties and pain are referred to the medical practitioner or allied health services for assessment and review. Care recipients and representatives state care recipients are provided with appropriate diets, fluids, referral and equipment to ensure their oral and dental health is maintained.

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


Sensory loss is assessed on entry to the home and appropriate referrals are made to ensure care recipients’ care needs are managed effectively. Specialist equipment is maintained in good working order and staff are trained in sensory loss. Staff have implemented programs to assist care recipients with sensory stimulation including of taste, touch and smell. Care recipients and representatives report staff are supportive of care recipients with sensory loss and promote independence and choice as part of daily care.

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


Care recipients’ sleep patterns including a history of night sedation are assessed on entry and sleep care plans are formulated. Lighting and noise is subdued at night. Care recipients’ ongoing sleep patterns are reviewed and sleep disturbances monitored and appropriate interventions put in place to assist care recipients to achieve natural sleep. Staff report care recipients who experience sleep disturbances are assisted with toileting, repositioning,


snacks and fluids as requested and assessed as needed. Care recipients and representatives are satisfied with the way care recipients’ sleep is managed.


Standard 3 – Care recipient lifestylePrinciple: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.




Continuous improvements related to Standard Three include the following:

As part of the development of a first person/household model of care and services the home has reviewed the living environment to consider ways in which public areas can be made more homely and interesting. This has led to the development of ‘feature’ areas. On the first floor, a room has been transformed into a pampering area. This is richly styled with ‘baroque’ furnishings and décor including chandeliers, gilt mirrors, luxurious rugs and red satiny seating (all sourced by the service manager on line). Once a week this area is also used by a beautician and staff said care recipients line up to use it. Care recipients described the room as beautiful with one saying when they have their nails done they “Feel like a queen!” Care recipients and their visitors were seen enjoying sitting in this area during this visit. Another area has been filled with objects such as fine china, older style cabinets, an old Singer sewing machine and vintage books and pictures. Staff said care recipients will often reminisce in this area as a lot of the objects remind them of their earlier life.

Following a review of meaningful engagement within the memory support unit it was decided to create a special high tea event for the care recipients in this area. The home purchased vintage fine bone china crockery. Tables were dressed in linen and lace, with flower arrangements and special cake plates. Cakes were purchased and high tea served. Care recipients enjoy sitting at the tables conversing as they have high tea. The management said a result of this, care recipients do not get up from the table and wander off as they do during meals but enjoy the companionship and sense of occasion the high tea provides.

3.2 Regulatory complianceThis 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”.



As an example of meeting regulatory compliance under this Standard the home maintains a consolidated record. This shows incidents where mandatory reporting has occurred or discretion not to report has been used. All incidents are reported up through the organisation and decisions on appropriate action are made by the designated key person only. Staff demonstrated an understanding of how they would report alleged assaults and said they had


received mandatory education on reporting elder abuse. The home (through its organisation) has the link to the updated reporting form as is now required by the Department of Health for missing care recipients and the reporting of alleged assaults.




Education provided under Standard Three includes: Managing challenging behaviours, elder abuse, grief and loss, privacy and dignity and choice and decision making.

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the Chaplain and recreational activities officers, care recipient/representatives meetings and involvement of family in the activity program. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors including pets are encouraged. Care recipients and representatives are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive.

3.5 IndependenceThis 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".


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Community visitors, volunteers and entertainers are encouraged and arranged. The environment encourages care recipients, their representatives and their friends to participate in activities. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.

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



There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The 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 display of photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Care recipients’ rooms are managed so that privacy is not compromised; lockable storage is available to all care recipients. Staff handovers and confidential information is discussed in private and care recipients’ files securely stored. Staff practices respect privacy and dignity and care recipients and representatives are satisfied with how privacy and dignity is managed at the home.

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


The lifestyle program offers an extensive range of activities seven days a week. There are individual activities programs for both the mainstream and memory support units with many activities integrated. There is a specific afternoon program in the memory support unit with staff available to provide activities until 9pm. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. Lifestyle programs include concerts, bus outings, entertainers, bingo, quoits, happy hour, word games, pampering sessions, daily exercise classes, knitting groups and craft. Care recipients are given the choice of whether or not to take part in activities. The results of interviews and document review confirm care recipients and representatives are highly satisfied with the activities provided to the care recipients. During the three days of the re-accreditation site audit we observed meaningful engagement and obvious enjoyment of the lifestyle program.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients/representatives are asked about end of life wishes and this information is documented in their file. The home has a Chaplain and two pastoral care staff. Pastoral visitors of various denominations regularly visit and religious services are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met.

3.9 Choice and decision-makingThis 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".



Management demonstrates each care recipient participates in decisions about the services the home provides and is able to exercise choice and control over their lifestyle through consultation around their individual needs and preferences. Management has an open door policy and this promotes continuous and timely interactions between the management team, care recipients and/or representatives. Observation of staff practices and staff interviews show care recipients have choices available to them including waking and sleeping times, shower times, meals and activities. Care recipients/representatives meetings and surveys occur regularly to enable care recipients and representatives to discuss and provide feedback about the services provided. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


The home was able to demonstrate care recipients and their representatives have been provided with information about security of tenure and understand care recipient rights and responsibilities. The care recipient handbook and care recipient agreement outlines security of tenure and potential care recipients are supported to consider the contents of the agreement before signing and becoming a resident in the home. Any change of room is only done in consultation with the care recipient and/or their designated representative and seeking their agreement to the change. The Charter of Care Recipients’ Rights and Responsibilities was seen to be on display around the home. Care recipients said they feel secure in the home and understand their rights and responsibilities in living at Uniting Banks Lodge.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.




Examples of continuous improvements under Standard Four include the following:

Previously the home had a cook chill menu with food cooked off site. There were significant concerns raised by care recipients and representatives regarding the quality and variety of this menu. The home’s management reviewed these concerns and decided to introduce fresh cooking into the home. Initially this was through baking cakes and biscuits. Care recipients said they enjoyed the smell of baking and having baked goods for morning and afternoon teas. Staff were also trained in making a range of simple dishes such as sandwiches and salads to encourage care recipient appetites and provide additional variety to the menu. The decision was then made to refurbish the home’s kitchen, including new ovens and storage facilities and cook all meals fresh on site. A chef was recruited (who has worked in commercial catering settings) and they have worked closely with care recipients and their focus group to improve the dining experience and quality of meals. This included ensuring the quality of produce used in cooking was improved and that meals across the day had variety and were nourishing and tasty. The home has introduced a chef being on site seven days a week to ensure freshly cooked meals on the weekend. Although there has been significant changes to the menu and the home’s presentation of the dining experience, some care recipients and their representatives said they still have concerns at times with the meals served but that they can and do provide feedback regarding this. They acknowledged a change is that the “new” chef talks with them directly about the quality of the meals and any improvements that can be made. There are also feedback books in each of the dining areas. Overall, care recipients said there has been a significant improvement in meals. The chef said they welcome all feedback as it assists in the fine tuning of the next seasonal menu which is almost ready for release.

As part of work, health and safety the management team identified there were a significant number of incidents of staff injury. It was identified these occurred in three main areas; as a consequence of care recipient aggression; slips/trips and falls; and hazardous tasks. As a result staff were provided with targeted education across these areas. Monthly education focused on one aspect was provided including in manual handling, managing challenging behaviours and identifying environmental hazards impacting on work roles. As a consequence of the education and staff community circles to discuss strategies to reduce risk in work practices the number of incidents of staff injury have dropped (from 27 last year to 12 this year). Findings have been discussed at staff meetings and staff spoke of being proactive in identifying work place hazards.


4.2 Regulatory complianceThis 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”.



The home has a current fire certificate and NSW Food authority certificate. The home has a work, health and safety committee. Catering staff have completed safe food handling training and all staff are on track to complete the mandatory 2017 fire and emergency training.




Education provided under Standard Four includes: Work, health and safety, outbreak management, manual handling, fire and emergency training, food hygiene and hand hygiene.

4.4 Living environmentThis 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".


The home’s management is actively working to ensure a safe and comfortable environment consistent with care recipient needs. The home has two residential floors and a basement area where kitchen, laundry, maintenance and car park are situated. Two lifts and stairs provide access between the floors. Care recipients have single rooms with ensuites and they are encouraged to make these homely with their own furnishings and decorations. There is a comprehensive maintenance program and electrical goods tagging occurs and is maintained. Outdoor areas include courtyard, flower and vegetable beds and there are a number of balcony areas with potted plants and seating arrangements. Regular environmental audits monitor the safety of the internal and external environments. The home is secured after hours and there is a system to ensure this is effective. Care recipients said the home is safe and comfortable and that they enjoy the many living environments available.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Health, safety and well-being policies and procedures ensure regulatory compliance for work, health and safety are maintained. The home has a work, health and safety committee and members have attended training as required to conduct their workplace role in this area.


Noticeboards showed work, health and safety issues are addressed in the workplace and work, health and safety is a standing item in meeting agendas. Staff described education such as hazard identification that assists to maintain a safe working environment. The home has a proactive return to work program and is actively working to reduce staff injury incidents.

4.6 Fire, security and other emergenciesThis 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".


The organisation has policies and procedures to manage fire, security and other emergencies including those that are site specific. Mandatory face-to-face education for fire safety awareness occurs annually for all staff. Chemicals are stored safely and all have current safety data sheets. Evacuation plans were seen in place, fire exits were lit, signed and free of obstruction. Monthly environmental audits are conducted and reported on. Fire equipment was seen to be regularly checked and maintained. CCTV cameras provide additional security in public areas. Care recipients were able to describe the home’s procedure for managing an emergency and these instructions were seen on the back of the door in care recipient rooms.

4.7 Infection controlThis expected outcome requires that "an effective infection control program".


There is an effective infection control and surveillance program. The home has an infection control coordinator and there is a system to document, monitor and review the level of infections within the home. Observations confirm consistent staff practice to reduce cross infection such as the use of hand washing facilities, personal protective and colour-coded equipment. The home has a food safety program, pest control and waste management systems; monitors laundry and cleaning practices and has an outbreak management plan. Preventative measures include education for all staff with specific education and training relevant to staff positions and roles. Care recipients and staff are offered vaccinations. Staff demonstrate an awareness of infection control relevant to their work area.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


The home demonstrated its hospitality services are provided in a manner which supports care recipient quality of life. Cleaners follow a schedule to ensure maximum cleaning coverage throughout the home using defined infection control practices. Care recipient rooms and public areas were observed to be clean and dust free. Laundry services are provided for personal items and linen is laundered commercially. All clothing is labelled and the laundry is divided into a section for soiled clothing and a clean area. The kitchen provides freshly cooked meals and these are served to the dining areas on the two floors. There is a seasonal rotating menu reviewed by a dietitian. Care recipients have a choice of meals. Catering staff have been trained in safe food handling. Overall, care recipients said they are very satisfied with the hospitality services saying their rooms are “spotless”, laundry is fresh


and delivered to their room. They said there has been a big improvement in the quality and presentation of meals and that they are encouraged to give ongoing feedback on food and drink.


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