Published_decision_(SA_and_RA) · Web view2.5Specialised nursing care needsMet 2.6Other health...

Calvary Cooinda Retirement CommunityRACS ID: 0150

Approved provider: Calvary Retirement Communities Hunter-Manning Ltd

Home address: 42 Bathurst Street SINGLETON NSW 2330

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 04 April 2021.

We made our decision on 31 January 2018.

The audit was conducted on 03 January 2018 to 04 January 2018. 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: Calvary Cooinda Retirement Community Date/s of audit: 03 January 2018 to 04 January 2018RACS ID: 0150 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: Calvary Cooinda Retirement Community Date/s of audit: 03 January 2018 to 04 January 2018RACS ID: 0150 3

Audit ReportName of home: Calvary Cooinda Retirement Community

RACS ID: 0150

Approved provider: Calvary Retirement Communities Hunter-Manning Ltd

IntroductionThis is the report of a Re-accreditation Audit from 03 January 2018 to 04 January 2018 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 03 January 2018 to 04 January 2018.

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: 34

Number of care recipients during audit: 34

Number of care recipients receiving high care during audit: 31

Special needs catered for: N/A


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

Interviews

Position title Number

Facility manager 1

Care co-ordinator 1

Registered nurse 1

Continuous improvement and systems coordinator

1

Work health and safety coordinator 1

Care staff 9

Administration assistant 2

Catering staff 2

Care recipients and/or representatives 9

Leisure and lifestyle 1

Cleaning staff 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files 7

Wound charts 6

Medication charts 10

Accidents and incidents charts 8

Personnel files 6

Care recipient agreements 3

Other documents reviewedThe team also reviewed:

Accident, incident and hazard reports documentation

Archive register


Audit schedule and audit and survey reports

Behaviour management: monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports

Care recipient handbook

Care recipient outing register, visitor and contractor sign in and out register

Care recipient room listing

Cleaning and laundry manuals and schedules

Clinical care: bowel charts, blood glucose level monitoring, continence management, meals and drinks, weight monitoring, wound management/dressings, pain charts, incident reports, medical officers directives of care, electronic and paper based care recipients’ files

Comments and complaints reports

Corrective and preventative maintenance documentation

Data safety sheets

Fire and emergency plan and manual and emergency equipment inspection, testing and maintenance records

Food and catering equipment temperature records

Food authority licence and Foodsafe manual

Mandatory reporting documentation

Medication management: medication advisory committee terms of reference and meeting minutes, ward registers of drugs of addiction, refrigerated medication storage records, medication management - principles of safe medication management, medication policies and procedures, emergency and PRN medications

Menus and list of care recipient food allergies

Nutrition and hydration: food preference lists, specialised dietary requirements, seasonal menus, dietician reviews, nutritional supplement charts

Performance appraisal, professional registration, police certificate registers and records

Pest control records

Plan for continuous improvement

Risk assessment documentation

Rosters

Self-assessment report for re-accreditation and associated documentation

Staff and care recipient vaccination registers

Staff education calendar, training register and training records

Staff handbook, position descriptions and duty statements

Supplier/contractor database and records of induction, qualifications and police certificates

Training needs analysis

Work health and safety documentation


ObservationsThe team observed the following:

Activities in progress and associated resources and notices

Archived record storage

Care recipients utilising pressure relieving and hip and limb protection equipment

Charter of Care Recipients' Rights and Responsibilities displayed

Clinical information noticeboards in nurses station

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

Electronic and hardcopy documentation systems

Equipment and supply storage areas

Fire and emergency equipment, evacuation register and disaster box

Infection control resources including hand washing facilities, hand sanitising gel, colour coded and personal protective equipment, sharps containers, spills kits,

Information noticeboards: posters, notices, brochures and forms displayed for care recipients, representatives and staff

Interactions between staff, care recipients and representatives

Internal and external complaint mechanisms and feedback processes, feedback form box

Laundry and chemical storage area

Leisure and lifestyle program displayed

Living environment

Locations of clinical and sharps waste containers

Medication administration and storage

Menu on display

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

Notice boards and displayed information

Nurse call system in operation and timely response by staff

Photographs of care recipients participating in exercise and lifestyle programs

Re-accreditation audit notices on display.

Secure suggestion box and displayed comments and complaints brochures and forms

Short group observation in the dining room

Sign in/out registers, keypad access

Staff handover

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


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

Cooinda Aged Care Facility uses an organisational quality framework to actively pursue continuous improvement across the four Accreditation Standards. The continuous improvement program includes processes for identifying areas for improvement, implementing change and generally monitoring and evaluating the effectiveness of improvements. Feedback is sought from care recipients, representatives, staff and other stakeholders to direct improvement activities. Continuous improvement activities are generally documented on the plan for continuous improvement. Management uses a range of monitoring processes such as audits, surveys and quality indicators to monitor the performance of the home's quality management systems. Care recipients and representatives reported they are aware of the feedback system and are satisfied with improvements made at the home and the feedback received when they make suggestions. During this accreditation period, the organisation has implemented initiatives to improve the quality of care and services it provides.

Recent examples of improvements in Standard 1 Management systems, staffing and organisational development are:

In response to a care recipient reporting they felt unsafe and uncomfortable in a single bed, management purchased a bariatric bed. Staff reported the bariatric bed makes it easier to attend to the care recipient’s activities of daily living, and the care recipient is more relaxed during these procedures.

Management identified care recipient assessment and observation charts were located in several different locations which resulted in observations being overlooked by care staff. The charts are now stored in a single file in each wing (Waratah and Jacaranda). Staff interviewed reported the single file streamlines observation monitoring and recording processes.

In consultation with staff, management updated the staff handbook to ensure staff are provided with appropriate information regarding the home and the wider organisation. New staff interviewed reported the handbook is informative and provides an overview of the home’s human resource policies.

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 home has a system to identify relevant legislation, regulatory requirements and guidelines, and for monitoring these in relation to the Accreditation Standards. The organisation's management has established links with external organisations to ensure they are informed about changes to regulatory requirements. Where changes occur, the organisation takes action to update policies and procedures and communicate the changes to Cooinda’s management, staff, care recipients and their representatives as appropriate. A range of systems and processes have been established by management to ensure compliance with regulatory requirements. Staff have an awareness of legislation, regulatory requirements, professional standards and guidelines relevant to their roles.

Relevant to Standard 1 Management systems, management is aware of the regulatory responsibilities in relation to police certificates and the requirement to provide advice to care recipients and their representatives about changes to basic daily fees, complaints mechanisms and advocacy services and re-accreditation site audits; there are processes to ensure these responsibilities are met.

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


The organisation's learning and development framework consists of programs and guidelines for staff orientation, mandatory training, performance development and review. The home's processes support the recruitment of staff with the required knowledge and skills to perform their roles. New staff participate in an orientation program that provides them with information about the organisation, key policies and procedures and equips them with mandatory skills for their role. Staff are scheduled to attend regular mandatory training; attendance is monitored and a process available to address non-attendance. The effectiveness of the education program is monitored through attendance records, evaluation records and observation of staff practice. Staff reported they are encouraged to attend regular education to assist them to perform their roles effectively. Care recipients and representatives reported staff have adequate skills and knowledge for their role.

Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include:

Understanding accreditation

Using the lifter

Induction training for new staff.

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".


There are processes to ensure care recipients, their representatives and others are provided with information about how to access complaint mechanisms. Care recipients and others are supported to access these mechanisms. Facilities are available to enable the submission of confidential complaints and ensure privacy of those using complaints mechanisms. Complaints processes link with the home's continuous improvement system and where


appropriate, complaints trigger reviews of and changes to the home's procedures and practices. Management monitors and evaluates the effectiveness of the comments and complaints system on an ongoing basis. Results show complaints are considered and feedback is provided to complainants, unless they decline follow-up contact. Management and staff have an understanding of the complaints process and how they can assist care recipients and representatives with access. Care recipients and representatives interviewed have an awareness of the complaints mechanisms available to them and are satisfied they can access these without fear of reprisal.

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 organisation has documented the home's vision, vision, values, objectives and commitment to quality. This information is communicated to care recipients, representatives, staff and others through a range of documents.

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".


There are systems and processes to ensure there are sufficient skilled and qualified staff to deliver services that meet the Accreditation Standards and the home's philosophy and objectives. Recruitment, selection and orientation processes ensure staff have the required knowledge and skills to deliver services. Staffing levels and skill mix are reviewed in response to changes in care recipients' needs and there are processes to address planned and unplanned leave. Registered nurses are available Monday to Friday and are on-call after hours to direct care staff and manage specialised nursing care needs. Care staff undertake training and competencies to provide them with appropriate skills to manage care recipients’ care needs under the direction of qualified staff. The home's monitoring, human resource and feedback processes identify opportunities for improvement in relation to human resource management. Staff are satisfied they have sufficient time to complete their work and meet care recipients' needs. Care recipients and representatives interviewed are satisfied with the availability of skilled and qualified staff and the quality of care and services provided.

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


The home has processes to monitor stock levels, order goods and maintain equipment to ensure delivery of quality services. Goods and equipment are securely stored and, where appropriate, stock rotation occurs. Preventative maintenance and cleaning schedules ensure equipment is monitored for operation and safety. The home purchases equipment to meet care recipients' needs and maintains appropriate stocks of required supplies. Staff interviewed stated they are satisfied they have sufficient stocks of appropriate goods and


equipment to care for care recipients and are aware of procedures to obtain additional supplies when needed. Care recipients and representatives interviewed stated they are satisfied with the supply and quality of goods and equipment available at the home.

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


The home has systems to provide all stakeholders with access to current and accurate information. Management and staff have access to information that assists them in providing care and services. Electronic and hard copy information is stored securely and processes are in place for backup, archive and destruction of obsolete records, in keeping with legislative requirements. Key information is collected, analysed, revised and updated on an ongoing basis. Data obtained through information management systems is used to identify opportunities for improvement. Information is disseminated to staff and care recipients through verbal systems as well as through other mechanisms such as newsletters, memoranda, meetings and informal discussion. The home regularly reviews its information management systems to ensure they are effective. Staff interviewed stated they are satisfied they have access to current and accurate information. Care recipients and representatives interviewed are satisfied the information provided is appropriate to their needs, and supports them in their decision-making.

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 mechanisms to identify external service needs and quality goals. The organisation's expectations in relation to service and quality is specified and communicated to the external providers. The organisation has agreements with external service providers which outline minimum performance, staffing and regulatory requirements. Administration staff monitor contractors attending the home to ensure they have appropriate qualifications and police clearances. There are processes to review the quality of external services provided at both organisational and site levels. Where a deficit is identified, action is taken to ensure the needs of care recipients and the home are met. Management and staff are able to provide feedback on external service providers. Care recipients, representatives and staff interviewed stated they are satisfied with the quality of externally sourced 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 information about the home's systems to identify and implement improvements.

Recent examples of improvements in Standard 2 Health and personal care are:

To improve care recipients’ access to optometry and dental services, management organised these services be provided on-site by visiting specialists. An optometrist is currently visiting the home fortnightly to conduct initial assessments for care recipients wishing to access the service. When initial assessments are completed, the optometrist will visit the home annually. A dentist visits the home bi-annually and as required to assess care recipients’ dental needs and, where appropriate, provide on-site treatment. Care recipients and representatives interviewed reported they are happy with care recipients’ access to optometry and dental services.

The manager identified the need to improve support provided to family members of care recipients in their final palliation phase. Comfort Bags have been introduced for family members, containing a pen, notepad, word puzzle, tissues etc. A booklet explaining the palliation journey, ‘When Someone You Love is Dying’, is included in the bag. Management advised family members reported the booklet assisted them to understand the dying process and their role is supporting the care recipient. Comfort bags have been introduced in all homes in the Calvary Retirement Communities Hunter region. The manager recently received a community award for this initiative.

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 information about the home's systems to identify and ensure compliance with relevant regulatory requirements.

Relevant to Standard 2 Health and personal care, management is aware of the regulatory responsibilities in relation to specified care and services, professional registrations and medication management. There are systems to ensure these responsibilities are met.




The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to health and personal care. Refer to Expected outcome 1.3 Education and staff development for more information.

Examples of education and training provided in relation to Standard 2 Health and personalcare include:

Responding to challenging behaviours

Continence management

Falls risk education

Medication management

Nutrition and hydration, and texture-modified diet

Palliative care

Skin care, including wound management.

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

Team's findingsThe home meets this expected outcome

The home provides care recipients with appropriate clinical care through initial and ongoing assessments, care planning and evaluation processes. The home has systems that enable care recipients and representatives to exercise control over the care they receive and to provide input into care recipients' care planning. The care co-ordinator/registered nurses review and evaluate care recipients’ individual plans of care every three months or when required. Relevant staff are informed of any alterations/exceptions to the usual care required by the care recipient through handovers, progress notes, meetings, communication diaries and verbally. Generally, care recipients’ weights, vital signs and urinalysis results are recorded monthly or as ordered by the medical officer. An accident and incident reporting system is in place for the reporting of incidents such as falls, skin tears and behaviours of concern. Staff demonstrate knowledge of care recipients’ care needs ensuring that care recipients’ clinical care is being met. All care recipients and representatives interviewed are satisfied with the timely and appropriate assistance given to care recipients by care staff.

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”.


Care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officer input when required. This includes registered nurse input into assessment, management and care planning for care recipients. The home currently provides specialised nursing care for care recipients living with dementia, diabetic management, catheter care, oxygen therapy, wound care and pain management. Staff are provided with education in specialised nursing procedures. Staff confirmed they have access to adequate supplies of equipment for the provision of care recipients’ specialised nursing care needs. Care recipients and representatives are satisfied with the level of specialised


nursing care offered to care recipients by nursing, medical and/or other health professionals and related service teams.

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”.


Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates timely referrals for care recipients are arranged with appropriate health specialists as required. The registered nurse has regular access to a physiotherapist, podiatrist, speech pathologist, optometrist and community clinical nurse consultants. Regular review and evaluation of care recipients’ health and well-being and referrals are carried out by the care co-ordinator/registered nurse in collaboration with care staff and medical officers. Effective monitoring is achieved through the handover of key care recipient information to relevant staff. When required, care recipients’ medical officers are alerted and consulted. Care recipients and representatives stated referrals are made to the appropriate health specialists in accordance with care recipients’ needs and preferences.

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


Generally, the home follows a process to ensure care recipients’ medication is managed safely and correctly. These include policies and procedures, regular pharmacy deliveries, the secure storage of medications and internal/external audits. Staff administer medication using a prepacked system and the registered nurse oversees the home’s medication management system and processes. Review of care recipients’ medication profiles show generally medical officers’ orders are current, recorded and information includes medication identification sheets, care recipients’ photographic identification and medication allergy status. All staff who administer medications are assessed according to the home’s medication policy through annual skills based assessments or as required. Care recipients and representatives said they are satisfied with the home’s management of care recipients’ medication.

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


All care recipients are assessed to identify their pain history on entry to the home with medical officer input in determining the effectiveness of interventions. A multidisciplinary approach involving the care recipient’s medical officer, nursing staff and recreational activity officers supports the care recipient’s pain management program. Staff are knowledgeable about the many ways of identifying care recipients who are experiencing pain. Pain management strategies include pharmacological reviews, various non-pharmacological interventions and treatment in liaison with care recipients’ medical officers. Care recipients are repositioned, assisted with movement and exercise, given gentle heat therapy, massage and are involved in distraction therapy. Care recipients said the care provided at the home relieves their pain or it is managed so they are comfortable.


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


The home has a suitable environment and culture to ensure the comfort and dignity of terminally ill care recipients is maintained. Where possible, care recipients' end of life wishes are identified and documented on entry to the home or at an appropriate time thereafter, through the assessment process. The home has specialised clinical and comfort devices to ensure and maintain care recipients palliation needs and preferences. The local clergy visit and are available to provide emotional and spiritual support. The home has a variety of resources and equipment that families, friends and staff can use for the benefit of the care recipient. Care recipients and representatives said the home’s practices maintain the comfort of terminally-ill care recipients.

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


The home has processes to provide care recipients with adequate nourishment and hydration. Care recipients are assessed for swallowing deficits and other medical disorders, allergies, intolerances, food likes and dislikes, as well as cultural or religious aspects relating to diet. Provision is made for care recipients who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information is recorded on a care recipient’s nutrition and hydration form and sent to the kitchen. Care recipients are provided with assistance at meal times and assistive cutlery and crockery are available. The home monitors nutrition and hydration status through staff observations and recording of care recipients’ weights with variations assessed, actioned and monitored. Care recipients are referred to their medical officer and, where appropriate, referrals are made to a dietician and/or speech pathologist when problems arise with nutrition. Care recipients and representatives are satisfied they are able to have input into menus and care recipients’ meals.

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


The home has a system to ensure care recipients’ skin integrity is consistent with their general health. Initial assessment of the care recipient’s skin condition is carried out along with other assessments relating to and influencing skin integrity. Care recipients have access to nutritional support, podiatry, hairdressing and nail care according to their individual needs and choices. Maintenance of skin tears, skin breakdown and required treatments are documented, reviewed and noted on electronic wound care charts. The home’s reporting system for accidents and incidents affecting skin integrity is monitored monthly and is included in clinical indicator data collection. The home has a range of equipment in use to maintain care recipients’ skin integrity. Care staff help to maintain care recipients’ skin integrity by providing regular pressure care, by applying skin guards and by using correct manual handling practices. Care recipients and representatives are satisfied with the skin


care provided to care recipients and report that staff are careful when assisting them with their personal care activities.

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


The home has a system for identifying, assessing, monitoring and evaluating care recipients’ continence needs to ensure their continence is managed effectively. Processes are in place for the distribution of care recipients’ continence aids and informing staff of care recipients’ continence aid needs. Care recipients are assisted and encouraged to maintain or improve their continence level in a dignified and supportive manner. Care staff have access to adequate supplies of continence aids to meet care recipients’ needs and they provide care recipients with individualised toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies. For example: regular drinks, aperient medications if necessary and a menu that contains high fibre foods such as fresh fruit and vegetables and a variety of fruit juices. Infection data, including urinary tract infections, is regularly collected, collated and analysed. The home’s continence supplier provides ongoing advice and education for staff and care recipients. Feedback from care recipients and representatives shows satisfaction with the continence care provided to care recipients.

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


The needs of care recipients with challenging behaviours are managed through consultation between the care recipient and representative, staff, medical officers and allied health professionals. Care staff and recreational activity officers implement a range of strategies to effectively manage care recipients with challenging behaviours. The care recipients’ challenging behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate. Staff are able to recognise the triggers and early warning signs exhibited by some care recipients and put in place appropriate strategies to manage behaviours. The team observed the environment to be calm and care recipients well groomed. Care recipients and representatives said staff manage care recipients’ challenging behaviours well.

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


Care recipients are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by care recipients for transferring and mobility. A care recipient’s mobility status and falls risk are assessed by a registered nurse when the care recipient moves into the home and as their needs change. This is followed by a referral to the medical officer and/or physiotherapy review if necessary. Individual treatments include massage, heat treatments and exercises. Falls prevention strategies include the completion of risk assessments. Interventions noted


include the provision of specialised equipment such as mobility aids, ramps and handrails. Staff are able to discuss an individual care recipient’s needs and were seen assisting care recipients to mobilise within the home. Care recipients said they are satisfied with the program and assistance they receive from staff.

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


The home has systems to ensure care recipients’ oral and dental health is maintained. Care recipients’ dental needs are identified through assessment and consultation with the care recipient and representative on a care recipient’s entry to the home and as their needs change. Appropriate dental health is planned and staff are informed of the care recipients’ needs. The care recipient’s medical officer is consulted if there are any needs and a referral may be made to a specialist and/or a dentist for further assessment or treatment. Ongoing care needs are identified through care recipients’ feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Care recipients are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Care recipients and representatives said they are satisfied with the oral and dental care provided to them.

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


The home assesses care recipients’ vision and hearing initially on entry and on an ongoing basis. Other sensory assessments for touch, smell and taste are undertaken when assessing care recipients’ nutritional needs, dexterity and interest in activities. These are documented on care recipients’ care plans to prompt and instruct staff on how to care for and engage care recipients appropriately. The home’s activity program features activities to stimulate care recipients’ sensory functions. Staff described types of group and individual activities which encourage active participation from care recipients with sensory deficits. Staff said they employ various strategies to assist care recipients with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance care recipients’ participation, adapting the environment to ensure it is conducive to maximising care recipients’ enjoyment and participation in the chosen activity. Care recipients and representatives said they are satisfied with the home’s approach to managing care recipients’ sensory losses.

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


The home assists care recipients to achieve natural sleep patterns through a sleep assessment, care planning, choice of time for going to bed and rising, and staff support at night. Staff are able to explain the various strategies used to support care recipients’ sleep. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, repositioning and night sedation if ordered by the medical officer. Care


recipients can use the nurse call system to alert the night staff if they have difficulties in sleeping. Care recipients stated they sleep well at night. Care recipients and representatives said they are satisfied with the home’s approach to care recipients’ sleep management.


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.




Recent examples of improvements in Standard 3 Care recipient lifestyle are:

To assist a care recipient who damaged their hearing aid to continue to participate in bingo, management purchased large bingo cards. The cards enable care recipients with reduced hearing to view the numbers called. While the care recipient’s hearing aid is now working effectively, lifestyle staff reported the cards are useful for other care recipients with a hearing deficit.

In response to a family’s feedback regarding a care recipient wearing the same clothing for a number of days, management implemented a clothing log. Staff complete the log each day when assisting the care recipient to dress or prepare for bed. The family reported they are happy with the response to their feedback, and are confident the care recipient is appropriately dressed at all times and their dignity is maintained.

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”.



Relevant to Standard 3 Care recipient lifestyle, management is aware of the regulatory responsibilities in relation to compulsory reporting, user rights, security of tenure and care recipient agreements. There are systems to ensure these responsibilities are met.



The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to care recipient lifestyle. Refer to Expected outcome 1.3 Education and staff development for more information.

Examples of education and training provided in relation to Standard 3 Care recipient lifestyle include:


Mandatory reporting

Standard 3 training delivered at induction.

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


Care recipients and representatives expressed appreciation to staff for the support and assistance staff provide during their entry to the home, the subsequent settling in period and on an ongoing basis. An assessment of care recipients’ specific needs and preferences is undertaken on entry to the home including their social history and backgrounds. Care recipients are orientated to the home and staff spend extra one-on-one time with care recipients during the settling in period and as required. Care recipients and representatives said care recipients are provided with appropriate emotional support and feel the staff are supportive in helping them to adjust to their new life within the home.

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".


Care recipients are assisted in joining group activities at the home, as well as being encouraged to attend bus trips and outings. Individual and group activity plans, monthly programs and diversional therapy assessments provide opportunity for care recipients to achieve maximum independence. Individual engagement between care recipients, visitors and staff are encouraged and was observed during the re-accreditation audit. The activities plan shows regular access to outdoor community venues is a significant part of the care recipients’ lifestyle plan and much enjoyed. Care recipients and representatives advised they are satisfied care recipients’ independence is supported by the home as much as possible.

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


The home works to support each care recipient’s right to privacy, confidentiality and dignity. Care recipients are accommodated in single rooms with ensuites. The assessment process identifies any care recipients’ specific needs and preferences relating to privacy and dignity. Information about care recipients is securely stored and only accessible to authorised personnel. All staff sign confidentiality agreements as part of their employment and are bound by the code of conduct. Care recipients were observed to be appropriately dressed and well presented. Care recipients and their representatives said that care recipients are treated with respect.

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 home offers a wide range of activities of interest to care recipients. The assessment of care recipients’ needs is overseen by the diversional therapist and put in place by the team of recreational lifestyle officers. There is a weekly and monthly program in place however staff advise this is a guide and activities are conducted in accordance with the care recipients’ day to day wishes. A review of care recipient records show the home is conducting engaging activities and outings in consultation with care recipients and representatives. Feedback from care recipients and representatives shows satisfaction with the range of activities offered and the access to outside community visits.

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


The home ensures care recipients’ cultural and spiritual needs are valued and the home provides opportunities to fulfil these needs. The individual requirements of care recipients to continue their beliefs and customs are identified in the assessment process by the diversional therapist on entry. Provision is made for the celebration of special cultural and religious days such as Easter, Christmas, Australia Day and ANZAC Day as well as other celebrations of diverse cultures. Church services are a regular occurrence at the home. Care recipients and representatives reported they are satisfied with the support provided for their cultural and spiritual needs.

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".


Care recipients and representatives are supported by the home to decide on their lifestyle and choice of services and activities through initial assessment, recording of their preferences and feedback through surveys, meetings and suggestions to staff. The alternate decision maker for the care recipient is established during the admission process for those care recipients who are unable to make decisions for themselves. A sound understanding and knowledge of the care recipients means staff can gauge and interpret the choices made by care recipients who are not able to easily express themselves through verbal communication. Care recipients are enabled to exercise choice about their daily preferences for meals, attendance at social activities and rest periods. Care recipients representatives stated they make decisions for the care.

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".


Care recipients and their representatives are provided with information about care recipients' rights and responsibilities, the terms and conditions of their tenure, any limitations to care


provision within the home, fees and charges and information about complaints, when they enter the home. Changes to care recipients' security of tenure or rights and responsibilities are communicated to care recipients and/or their representative. If a change in care recipient health requires a room change or transfer to another home, this is discussed with the care recipient and/or their representative. The home's monitoring processes, including feedback, meetings and care reviews, identify opportunities for improvement in relation to care recipient rights, responsibilities and security of tenure. Staff demonstrate an understanding of care recipient rights. Care recipients and representatives interviewed are satisfied care recipients have secure tenure within the home and understand their rights and responsibilities.


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.




Recent examples of improvements in Standard 4 Physical environment and safe systems are:

The identification of structural damage to some care recipient bathrooms initiated an upgrade of all ensuite bathrooms. To date, five bathrooms have been renovated and care recipients reported they are very happy with their upgraded facilities. Care recipients waiting for bathroom renovations stated they are looking forward to the work being completed. This initiative will be formally evaluated when all bathroom renovations are completed.

Ongoing damage to the doors of care recipients’ rooms caused by wheelchairs and walking frames was addressed by installing kick plates at the bottom of the doors. Management confirmed, and we observed, the kick plates have prevented further damage occurring. Care recipients interviewed stated they are happy with the kick plates which improve the ambience of the home. The initiative was formally evaluated at the September 2017 care recipient meeting.

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”.



Relevant to Standard 4 environment and safe systems, management is aware of the regulatory responsibilities in relation to work, health and safety, fire systems and food safety. There are systems to ensure these responsibilities are met.



The home has a system to monitor the knowledge and skills of staff members and enable them to effectively perform their role in relation to physical environment and safe systems. Refer to Expected outcome 1.3 Education and staff development for more information.


Examples of education and training provided in relation to Standard 4 Physical environment and safe systems include:

Chemical management

Food safety

Fire and emergency

Infection control

Outbreak management

Manual handling.

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 environment reflects the safety and comfort needs of care recipients, including comfortable temperatures, noise and light levels, sufficient and appropriate furniture and safe, easy access to internal and external areas. All care recipients are accommodated in single rooms with ensuite. Physical restraint is not used within the home. The safety and comfort of the living environment is assessed and monitored through feedback from meetings, surveys, incident and hazard reporting, audits and inspections. There are appropriate preventative and routine maintenance programs for buildings, furniture, equipment and fittings. Staff support a safe and comfortable environment through hazard, incident and maintenance reporting processes. Care recipients and representatives interviewed are satisfied the living environment is safe and comfortable.

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


There are processes to support the provision of a safe working environment, including policies and procedures, staff training, routine and preventative maintenance and incident and hazard reporting mechanisms. Opportunities for improvement in the work health and safety program are identified through audits, safety inspections, supervision of staff practice, and analysis of incident and hazard data. Sufficient goods and equipment are available to support staff in their work and minimise health and safety risks. Staff have an understanding of safe work practices and are provided with opportunities to have input to the home's work health and safety (WHS) program. Staff were observed attending to their work in a safe manner, and reported they are satisfied management is actively working to provide a safe working environment.

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".



Policies and procedures relating to fire, security and other emergencies are documented and accessible to staff, including an emergency evacuation plan. Staff are provided with education and training about fire, security and other emergencies when they commence work at the home and on an ongoing basis. Emergency equipment is inspected and maintained and the environment is monitored to minimise risks. Staff have an understanding of their roles and responsibilities in the event of a fire, security breach or other emergency and there are routine security measures. Fire procedures are posted on the internal doors of care recipients’ rooms. Care recipients and representatives interviewed are generally aware of what they should do on hearing an alarm and stated they feel safe and secure in the home.

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


The home has processes to support an effective infection control program. The infection control program includes regular assessment of care recipients' clinical care needs in relation to current infections, susceptibility to infections and prevention of infections. Staff and management follow required guidelines for reporting and managing notifiable diseases. Care plans describe specific prevention and management strategies. The home's monitoring processes identify opportunities for improvement in relation to infection control; this includes observation of staff practices, analysis of clinical and infection data and evaluation of results. Preventative measures used to minimise infection include staff training, a food safety program, cleaning regimes, vaccination programs, a pest control program, waste management and laundry processes. Staff are provided with information about infections at the home and have access to policies and procedures and specific equipment to assist in the prevention and management of an infection or outbreak. Care recipients, representatives and staff interviewed are satisfied with the prevention and management of infections.

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 identifies care recipients' needs and preferences relating to hospitality services on entry to the home through assessment processes and consultation with the care recipient and their representative. There are processes available that support care recipients to have input into the services provided and the manner of their provision. Special occasions and cultural/religious days are celebrated with special foods, and care recipients’ cultural menu preferences are respected and provided for as required. The cook visits each care recipient daily to discuss their menu choices for the day and receive feedback regarding the previous day’s menu. The home's monitoring processes identify opportunities for improvement in relation to the hospitality services provided; this includes feedback from care recipients and representatives and monitoring of staff practice. Hospitality staff interviewed said they have access to current information about care recipient needs and preferences, and receive feedback about services provided. Staff are satisfied the hospitality services enhance the working environment. Care recipients and representatives interviewed are generally satisfied the hospitality services meet their needs. Three respondents reported they liked the food ‘some of the time’. The reasons for dissatisfaction were: lack of choice, tough meat and not liking the curry. Each respondent reported they are offered alternative meals when they do not like the menu of the day. The care recipients also stated they are not losing weight.


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