bernard chan nursing home - aged care quality · 2018-12-14 · bernard chan nursing home racs id...

Bernard Chan Nursing Home

RACS ID 2826 58 Weldon Street

BURWOOD NSW 2134

Approved provider: Australian Nursing Home Foundation Limited

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 18 August 2018.

We made our decision on 30 June 2015.

The audit was conducted on 02 June 2015 to 03 June 2015. The assessment team’s report is attached.

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

Home name: Bernard Chan Nursing Home RACS ID: 2826 2 Dates of audit: 02 June 2015 to 03 June 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Bernard Chan Nursing Home 2826


Introduction

This is the report of a re-accreditation audit from 02 June 2015 to 03 June 2015 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 02 June 2015 to 03 June 2015.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: Sue Kelly

Team member/s: Kate Gatwood

Approved provider details


Details of home

Name of home: Bernard Chan Nursing Home

RACS ID: 2826

Total number of allocated places:

45

Number of care recipients during audit:

45

Number of care recipients receiving high care during audit:

45

Special needs catered for: Chinese specific

Street/PO Box: 58 Weldon Street

City/Town: BURWOOD

State: NSW

Postcode: 2134

Phone number: 02 8741 0210

Facsimile: n/a

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Director of nursing 1

Deputy director of nursing 1

Registered nurses 2

System coordinator 1

General manager residential care 1

Training and development manager 1

Human resources officer 1

Care staff 4

Assets and property officer 1

Office administrator 1

Care recipients/representatives 7

Lifestyle Coordinator/physiotherapist 1

Recreation activity staff 2

Catering staff 3

Laundry staff 1

Cleaning staff 2

Handyman 1

WHS coordinator 1

IC officer 2

Sampled documents

Category Number

Care recipients’ files, including care plans and medical progress notes

7

Summary/quick reference care plans 4

Medication charts 6

Personnel files 6


Other documents reviewed

The team also reviewed:

Accident/incident reports including care recipient, clinical and staff, monthly clinical indicator reports, trend analysis and benchmarking reports

Activity calendar

Activity program summaries and evaluations

Admission procedures checklist

Care recipient information package in English and Chinese, resident and accommodation agreement, resident handbook

Care review schedule for RNs

Cleaning and laundry manuals and schedules

Clinical care documentation; assessments including nutrition, falls risk, continence, skin integrity, physiotherapy, behaviour, pain and personal care, Interim care plans, Observation charts, Wound assessments and care charts and wound care resources, Care conference documents

Clinical policies and procedure manuals

Comments and complaints including feedback register

Communication books and diaries; staff, physiotherapy, RAO and medical officers

Continuous improvement documentation including continuous quality improvement plans, improvement logs, internal and external audit schedule and results, trend analysis, external benchmarking reports

Diversional therapy reports

External services information including contact lists, contractor/supplier service agreements, preferred contractor/supplier listing, contractors handbook and orientation checklist

Fire security and other emergencies including fire safety equipment service records, audits, inspections, emergency flip charts, care recipient photographic evacuation information, disaster management plan, fire safety statement

Food safety program including manual, kitchen cleaning logs, food and equipment temperature monitoring records, NSW food authority audit result

Human resource management including staff handbook, statutory declarations, visa status, position descriptions, duties lists, signed code of conduct and confidentiality of information statements, performance appraisals, rosters

Infection control information including manual, outbreak management information, care recipient and staff vaccination programs, monthly infection control reports and trend analysis, pest control reports, Medication fridge temperature records


Information systems including electronic information, organisational intranet, organisational chart, strategic plan, policies and procedures, meeting schedule, agendas and minutes, newsletters, memoranda, surveys, communication diaries, handover sheets

Inventory and equipment including maintenance request books, planned preventative maintenance schedule, equipment service reports, electrical testing and tagging, thermostatic mixing valve records, call bell audit, repair and maintenance register

RAO resource folder

Regulatory compliance information including mandatory reporting register, privacy agreement, criminal history certificates and alert system, professional registrations, fire safety statement

Restraint authorisations

Self-assessment report for re-accreditation and associated documentation

Staff education including training calendar, orientation program and checklist, mandatory and non-mandatory education attendance, education evaluations, competencies, resources

Staff handbook

Workplace, health and safety (WH&S) information including environmental audits, workplace inspections, hazard identification and risk assessments

Observations

The team observed the following:

Activities program and information for residents/representatives (displayed on notice boards), activities in progress, including Karaoke ,mah-jong and craft

Aged care complaints scheme, advocacy, feedback forms, posters and other information on display in English and Chinese, locked suggestion box

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

Communication methods including meeting minutes displayed, newsletters and noticeboards for staff and families

Dining environments during lunch and beverage services with staff assistance, morning and afternoon tea, including care recipients seating, use of assistive devices for meals and care recipients being assisted with meals in their rooms

Notices displayed in English and Chinese including Quality Agency re-accreditation audit notices; activity programs; Charter of residents’ rights and responsibilities

Equipment and supply storage areas including supplies of clinical stock, continence aids, linen stock in sufficient quantities and lifting equipment.

Evacuation egresses unobstructed, emergency evacuation packs, identification wrist bands


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

Indoor and outdoor living environment

Infection control resources including hand washing facilities and instructions, hand sanitising cleanser dispensers, spill kits, sharps waste disposal containers, outbreak resources, personal protective and colour coded equipment, waste management

Interactions between staff and care recipients

Key pad locks, nurse call system and staff response, security cameras

Kitchen environment, NSW Food Authority licence on display

Laundry with chute, delivery system of personal clothing

Medication round

Medication trolleys

Mission and values statements on display

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

Secure storage of confidential care recipient and staff information and medications, including emergency stock

Short structured observation in lounge/dining area

Sign in and out registers - residents, visitors and contractors

Staff work areas including nurses’ stations, treatment/utility rooms, staff room, reception and offices

Staff work practices


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

Management at Bernard Chan Nursing Home actively pursue continuous improvement across the four Accreditation Standards. The quality system to identify improvement opportunities includes comment and complaint mechanisms, surveys, scheduled audits, incident and clinical indicator reporting and feedback from meetings. Management maintains a continuous quality improvement plan for prioritising, implementing, actioning and evaluating identified opportunities for improvement. The effectiveness of the continuous improvement system is monitored through the home’s quality assurance and other committee meetings.

Residents/representatives and staff are encouraged to make improvement suggestions and are kept informed of improvements undertaken in the home.

Examples of recent improvements implemented in relation to Accreditation Standard One include:

The quarterly newsletter had been published in a combination of English and Chinese articles. None of the articles were written in both English and Chinese. This led to not all residents/representatives being able to read the whole newsletter. Management have arranged that from the June 2015 edition of the newsletter all articles will be written in both English and Chinese.

The registered nurses advised management that, due to needing to be available for resident care, they could not always attend education sessions. Management agreed that all staff would be paid for 12 hours of education each year. This has enabled the registered nurses to attend appropriate education throughout the year.

Management identified the need to have alerts for a number of events including annual police checks. It was noted that a software program already in use at the home had this capability. The function for alerts was activated and management now receive alerts for annual and more frequent events. The director of nursing noted that this has increased the ease of ensuring all annual events are managed appropriately.


1.2 Regulatory compliance

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

Team’s findings


The home has systems with corporate support to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines applicable to aged care. This is achieved through access to a variety of authoritative sources including peak bodies. Management is informed of changes and updates to policy, procedures and practices by the organisation’s corporate services. Updates are communicated through the intranet, by e-mail and discussed through management forums. Management has responsibility to notify staff at the home of changes to regulations through meetings, memoranda and providing education. Updated policies, procedures and manuals are readily available for staff on the organisation’s intranet. The system for monitoring compliance with obligations relevant legislation includes audits, benchmarking, observation of staff practices and feedback.

Examples of regulatory compliance with Accreditation Standard One include:

Residents/representatives and staff were informed of the upcoming Quality Agency re- accreditation audit by notices, mail out and at meetings.

There is a system to monitor currency of staff, volunteer and contractor criminal history certificates.

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

Management ensures residents, staff and visitors to the home have access to internal and external comments and complaints mechanisms in both English and Chinese.


1.3 Education and staff development

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

Team’s findings


The education and training program incorporates a range of topics across the four Accreditation Standards. This assists staff develop appropriate knowledge and skills to perform their roles effectively. The organisation’s training and development manager develops the education program through information acquired from review of clinical indicators, legislative changes, audits, staff requests and performance appraisals. Staff are required to complete a range of mandatory education topics during orientation and then annually. Education and training is provided on-site and from external sources. The home also subscribes to an aged care specific electronic education program. The training requirements and skills of staff are evaluated on an ongoing basis through competency assessments, performance appraisal, the changing needs of residents and feedback.

Education attendance records are maintained by the home to monitor staff attendance at mandatory and non-mandatory education. Staff stated the education program offered is comprehensive and relevant.

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

Frontline management; staff orientation; customer service – FISH Philosophy; code of conduct; basis of Office 365 and how to use SharePoint; grievance procedures; bullying and harassment; training on new equipment.

1.4 Comments and complaints

This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings


The home has a policy and procedures for complaints management. There are internal and external mechanisms for residents, representatives and other interested parties to provide feedback about comments and complaints. All stakeholders are encouraged to provide feedback on the services provided through meetings, newsletters, brochures and notices. Residents/representatives are informed of the internal and external complaints mechanisms on entry to the home. This is documented in the handbook. Feedback forms and a locked suggestion box for confidential feedback are accessible for stakeholders. Information on the external complaints scheme in English and Chinese and advocacy services are on display. Any comments and complaints received are logged and responded to and actioned by the director of nursing and are monitored at a corporate level. Complaints are evaluated through quality assurance and other committee meetings. Residents/representatives and staff stated in general they have few complaints. They said management is responsive regarding any issues or concerns.


1.5 Planning and leadership

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

Team’s findings


Bernard Chan Nursing Home’s vision, values, objectives and philosophy are communicated to all stakeholders. These statements are published in the staff and resident handbooks and are on display in the home. A five year strategic plan has been developed to document the organisation’s future objectives. The home’s commitment to quality is demonstrated in the pursuit of continuous improvement activities. The philosophy of care is promoted through staff orientation and education processes.

1.6 Human resource management

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

Team’s findings


The home has corporate policies, procedures and support to facilitate recruitment to ensure selected staff meet the requirements of their roles. Human resource management is implemented through an orientation program, provision of a handbook, position descriptions, duties lists and a performance appraisal system. Management ensures sufficient skilled and qualified culturally appropriate staff are rostered to meet the needs of residents and legislated requirements. Personnel files are securely stored at the home and contain a code of conduct and confidentiality of information statement signed by staff. Human resource management is monitored through meeting feedback, results of clinical indicator reports, audits, surveys and benchmarking. Staff stated they are able to complete their duties on shift. Registers are maintained to monitor staff criminal history checks as well as staff professional registrations. Staff stated that they enjoy working at the home and they express a commitment to residents. Residents and representatives stated staff are knowledgeable, are responsive to residents’ needs and have a helpful and caring attitude.


1.7 Inventory and equipment

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

Team’s findings


The home has systems and processes to ensure that stocks of appropriate goods and equipment is available. Input from residents and staff through meetings are included in the processes of maintaining and introducing new equipment as is organisational inputs. Storage for equipment and goods is available at the home with staff able to access storage areas.

Stock levels are ordered and monitored by key personnel and are rotated and monitored for expiry dates. Preventative maintenance schedules monitor equipment useability and this is documented by the maintenance officer. Corrective maintenance requests are reported to the maintenance officer through the completion of “pink slips”. These were noted to be followed up in a timely manner. Faulty equipment is identified, removed from service and replaced or returned to suppliers for replacement. Staff are satisfied with the stocks of appropriate goods and equipment.

1.8 Information systems

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

Team’s findings


The home has processes and procedures to ensure information is managed in a secure and confidential manner, including restricted access to service information, resident and personnel files, locking of storage areas and offices and restricted password access to computers. Clinical information is updated to guide care delivery needs of residents with back-up systems in place to prevent loss of information. Information is communicated to staff through meetings, memoranda, notice boards, handover processes and residents’ clinical files. Staff have position limited access to electronic information. Management communicate with residents/representatives via newsletters, resident meetings, suggestion box and one– to-one discussions. Residents/representatives and staff are satisfied with information which management provides.

1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings


There are systems and processes to ensure external services are provided to meet the home’s care and service needs and quality goals. Management has access to an organisational approved supplier/contractor listing. Service agreements with a range of external providers and service suppliers are established at corporate level and are reviewed regularly. External suppliers of goods and services are required to provide evidence of their insurance, workplace health and safety obligations, license or business registration details and criminal history


certificate as required. Contractors sign a register when working at the home. All work performed is monitored for quality and effectiveness of service through inspection, audits and feedback. A range of allied health professionals and a hairdresser provide on-site care and services for residents. Residents/representatives and staff are satisfied with external services provided.


Standard 2 – Health and personal care

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

Examples of recent improvements implemented in relation to Accreditation Standard Two include:

To improve general resident care, including continence and personal hygiene, management have increased the number of care service employees (CSE) staff hours in each morning shift. Staff noted they are able to provide more person centred care and one resident has commented to management that they are able to be attended to with less waiting time than previously.

The registered nurses identified that some injectable medication was not labelled individually by the pharmacy. This system has been altered to include a label for each vial of the medication leading to a more accurate system for medication management.


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

Team’s findings


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

Examples of regulatory compliance with Accreditation Standard Two include:

Initial and on-going assessments, planning, management and evaluation of care for residents are undertaken by a registered nurse.

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

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




Team’s finding


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

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

Medication management competencies; first aid certificate; dementia care; continence management; catheter care; wound care; falls prevention; pain management; diabetes; palliative care.

2.4 Clinical care

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

Team’s findings


There are systems and processes in place to ensure residents receive appropriate clinical care. Residents’ care needs are identified on entry to the home through a comprehensive range of clinical and lifestyle assessments. Care plans are developed and documentation reviewed confirmed ongoing reviews by appropriate staff are in place. Care conferences with families usually occur annually or whenever there is a demonstrated need. Documentation also confirmed residents are regularly reviewed by medical officers of their choice. Changes in care requirements are communicated to staff during handovers and in communication diaries. Clinical performance is monitored through regular audits and an incident reporting system is in place. Staff interviews confirm they are aware of the care needs of the residents and observations of staff interactions with the residents confirm they are treated in a warm and caring manner. Residents and their representatives expressed satisfaction with the staff and the care provided by the home.

2.5 Specialised nursing care needs

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

Team’s findings


The home has systems to ensure residents’ specialised nursing care needs are identified and met by appropriately qualified staff. Examples of specialised care the home currently provides are wound care, diabetes with blood glucose monitoring, automated peritoneal dialysis, stoma care and management of urinary catheters. Registered nurses are responsible for the ongoing management of all wound care. A review of clinical documentation confirms wounds are


regularly reviewed and a digital camera is available to visually document wounds when necessary. Staff reported they have access to ongoing education to maintain their skills in the provision of specialised care and there is adequate equipment, stock and support available to them. External health professionals, including wound and continence nurse consultants and the Renal Dialysis unit from the local health district are available to staff to provide advice on specialised nursing care as required. Interviews with residents and their representatives confirm they are satisfied with the way staff provide specialised nursing care to residents.

2.6 Other health and related services

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

Team’s findings


The home has systems to ensure residents are referred to appropriate health specialists as required. Ongoing assessments and regular reviews of residents’ care needs help to identify those requiring referral to other health and related services. Some of the services being accessed by the home include optometry, podiatry, dentistry, audiology, geriatric services and physiotherapy. A review of residents’ care documentation confirms referrals and outcomes of the consultation are evident with appropriate changes made in the care plans as required. The home is able to assist residents with travel arrangements to external appointments when this is required. Interviews with residents and their representatives confirm they are consulted when referrals to health specialists are required and are happy with the support provided by the home in accessing these services.

2.7 Medication management

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

Team’s findings


There are effective systems for the safe and correct management of residents’ medications in the home. Registered nurses and care staff who are deemed competent are responsible for the administration of all medications. Photo identification with clear information relating to known allergies and special requirements is evident on the residents’ medication identification charts. All medications are securely stored. The supplying pharmacy provides the home with a regular delivery service. A review of the home’s documentation confirms there are comprehensive policies and procedures and a medication incident reporting system is in place. Residents and their representatives interviewed report they are happy with the care provided in relation to the residents’ medication requirements.


2.8 Pain management

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

Team’s findings


The home has processes to ensure residents are as free as possible from pain. Pain is assessed on a resident’s entry to the home and on an ongoing regular basis. Care plans with individualised strategies are formulated for those residents who experience pain. Treatment of pain is attended in consultation with the resident and their representatives, staff and the medical officers. The home’s attending physiotherapist identifies options for non- pharmacological pain management such as massage, Transcutaneous electrical nerve stimulation (TENS), gentle exercises and appropriately qualified staff assist in the delivery of these treatments. Staff interviews confirm effective clinical knowledge to recognise and evaluate residents with pain and appropriate manual handling equipment is available. Observation and resident interviews confirm that residents’ pain is managed appropriately.

2.9 Palliative care

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

Team’s findings


Bernard Chan Nursing Home has a system to ensure terminally ill residents have their comfort and dignity maintained. This is undertaken in consultation with the resident, their representatives and attending medical officers. Families have opportunities to stay and spiritual support is available for those who request it. Advance care directives are discussed with families and documented in the resident’s file. The home has a range of pressure relieving mattresses available to assist with resident comfort. The home uses the consultative services of the local palliative care service who are able to offer advice and support in the management of residents’ palliative care needs.

2.10 Nutrition and hydration

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

Team’s findings


Residents’ nutritional and hydration needs and preferences are identified on entry to the home through the initial assessment and consultation and are regularly reviewed. Dietary preferences containing information identifying individual preferences, allergies, and special requirements such as modified textured meals are completed with a copy supplied to the kitchen. Nutritional status is monitored through staff observation of eating patterns and residents are weighed regularly. Special diets, modified crockery and nutritional supplements are provided when required. Observations of the staff during meal times identify supervision and assistance is provided as necessary. Residents and their representatives expressed satisfaction with the management of residents’ nutrition and hydration needs.


2.11 Skin care

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

Team’s findings


The home has systems and practices to ensure residents’ skin integrity is consistent with their general health. These include initial and ongoing assessments, care planning and reviews. Specific strategies are implemented dependent on the results of the assessments, including the use of emollients, the promotion of adequate hydration, regular repositioning and pressure relieving equipment. The majority of the beds in the home are electric for the comfort of the residents and to aid staff with the safe transfers and repositioning of residents. Skin tears, wounds and infections are all monitored and staff confirm residents’ skin integrity is checked daily with any changes reported to the registered nurses. A hairdresser visits regularly and podiatry services are regularly available to those requiring this service.

Residents and their representatives’ interviews demonstrate satisfaction with the skin care provided by the home.

2.12 Continence management

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

Team’s findings


Residents’ continence is managed effectively through the home’s initial and ongoing assessment processes and the development of care plans that identify the individual needs of each resident. Documentation shows continence management strategies are developed for those residents who require assistance. The home promotes continence with the provision of adequate nourishment and fluids, regular toileting regimes and the use of continence consumables. Staff have access to education through the home’s internal education program and observation of staff practices confirm assistance is provided to residents. The home was odour free during the team’s visit. Staff confirm and observation show there is a range of continence consumables available with adequate supplies maintained. Residents and their representatives confirm they are satisfied with the continence management provided by the home.

2.13 Behavioural management

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

Team’s findings


The home ensures the needs of residents with challenging behaviours are managed effectively. Through the home’s assessment and care planning processes residents with challenging behaviours are identified, assessed and individualised interventions documented in care plans. Staff interviewed described strategies used in managing challenging behaviours and reported education relating to dementia and challenging behaviours is available to them.


We observed staff interacting with residents in a calm, quiet and appropriate manner. Documentation reviews confirm referrals to specialist behaviour management services and geriatric services are made in consultation with the medical officers and recommendations made evident in the residents’ care plans and progress notes. Residents and their representatives interviewed confirm they are satisfied with the home’s management of behaviour.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


The home ensures optimum levels of mobility and dexterity are achieved for all residents through assessment and care planning processes. The home’s physiotherapist visits two days a week and is responsible for the completion of physiotherapy assessments, care planning and ongoing reviews for all residents. A gentle exercise class is conducted Monday to Friday and physiotherapy aides assist with implementation of the residents’ physiotherapy care plans. The home has a range of equipment including pedal exercisers, pulley systems, and foot massagers available for residents’ supervised use. Manual handling requirements for all residents is also assessed and documented to assist staff in understanding individual requirements. Staff receive training in the correct use of the range of manual handling equipment available in the home and all staff undergo manual handling competencies.

Interviews with residents and their representatives confirm they are satisfied with the ways they are assisted to maintain their mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


The home has a system to ensure residents’ oral and dental hygiene is maintained. A review of documentation shows oral health is assessed when a resident enters the home and their individual needs are documented on care plans that are reviewed and updated regularly. The home assists families in arranging appointments and transport for residents to external dentists of their choice and a visiting dental health service can be arranged as required. Staff interviews demonstrate knowledge in how they assist residents with oral and dental care.

Staff confirm they have adequate supplies available to them. Interviews with residents and their representatives confirm staff assist them with their oral and dental care.


2.16 Sensory loss

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

Team’s findings


The home has processes to identify and effectively manage residents’ sensory losses. Assessments of sensory losses are completed on entry to the home and when there has been a change in condition with strategies and interventions documented on care plans. Interviews with and observations of staff demonstrate assistance is provided to residents in relation to their sensory losses. The home has good lighting and corridors were observed to be free of clutter. The home’s recreational activity staff include activities and equipment specifically targeting sensory losses. There is a sensory room in the adjacent day care centre that can be accessed by staff and residents if required. Residents are able to access specialist health professionals of their choice or appointments are made to the services that regularly visit the home. Interviews with residents and their representatives confirm they are satisfied with the home’s management of sensory losses.

2.17 Sleep

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

Team’s findings


The home ensures residents are able to achieve natural sleep patterns through the initial assessment and care planning process. A sleep assessment is undertaken when required with strategies documented on care plans. Discussions with staff confirm they are aware of ways to assist residents achieve natural sleep patterns such as offering snacks, a warm drink, toileting and repositioning. Residents are able to choose their own sleeping and waking times and these are respected and accommodated by the staff. Residents interviewed confirm the home is generally quiet at night and they are able to sleep.


Standard 3 – Care recipient lifestyle

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



Team’s findings



Examples of recent improvements implemented in relation to Accreditation Standard Three include:

Following a suggestion by recreational activities officers, an underutilised space has been equipped as a ‘spa corner’. This provides a space for one to one pampering time for residents. Resources have been purchased such as hand towels and aromatherapy oils. This relaxation and pain management therapy is proving to be a popular activity.

Students from the local public school provided a program at Easter which residents attended. This is to be on ongoing event and residents will attend the school regularly for this and other programs. Residents interviewed stated they enjoy the interaction with the local school.

An iPad has been purchased which has enabled residents to interact with families and friends on Skype. Residents interviewed stated they also enjoy playing games on the iPad and learning new technology.



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

Team’s findings



Examples of regulatory compliance with Accreditation Standard Three include:

A resident and accommodation agreement is offered to residents/representatives to meet legislative requirements. Information provided by the home has been updated to include changes to legislation on 1 July 2014 in relation to rates and accommodation bonds.

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



Team’s findings


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

Examples of recent education and development attended by staff in relation to Accreditation Standard Three include:

Care recipients’ rights and responsibilities; privacy and dignity; independence; emotional care and facilitating choice; cultural and spiritual life; 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".

Team’s findings


The home has a system to ensure each resident receives support in adjusting to life in the new environment and on an ongoing basis. Newly arrived residents and their representatives are supported as the resident adjusts to their new environment. Friends and family are


encouraged to visit the home and observations of staff practices and interactions with residents during the visit showed respect, understanding and warmth. The recreational activity staff visit to encourage and assist the resident to participate in the home’s activity program. Care conferences with families are usually in the months following the initial assessment period to ensure care needs are being met and to discuss any issues. Residents and their representatives interviewed expressed satisfaction with the initial and ongoing support residents receive from the staff in the home.

3.5 Independence

This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".

Team’s findings


The home has a system to assist residents achieve and maintain maximum independence and participate in the life of the community. Individual needs are assessed on entry to the home and strategies put in place through consultation with the resident and their representatives. Residents are encouraged to be as independent as possible with their activities of daily living and are regularly reviewed by the physiotherapist. Gentle exercise classes are held Monday to Friday and the physiotherapy aides can provide individual assistance to help maintain mobility. Observations confirm residents use a variety of mobility aids and their rooms have personal items displayed. All residents are of Chinese origin and the information/signage throughout the home is written in Chinese and English. A regular newsletter provides residents and their families with information of upcoming events and what’s happening in the home. Interviews with residents and their representatives confirm satisfaction with the assistance provided by staff to maintain their independence.

3.6 Privacy and dignity

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

Team’s findings


Residents’ right to privacy, dignity and confidentiality is recognised and respected by the staff at the home. Policies and procedures are in place and staff receive training in relation to privacy and dignity, as well as signing confidentiality agreements on commencement of employment. The majority of residents reside in single and double rooms and we observed staff practices to maintain privacy and dignity including knocking on doors and using privacy curtains. We also observed documentation relating to residents is securely stored in the nursing work areas. Interviews with residents and their representatives confirm staff address residents by their preferred name and are kind and respectful of residents’ privacy, confidentiality and dignity.


3.7 Leisure interests and activities

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

Team’s findings


The home encourages and supports residents to participate in a wide range of interests and activities that are of interest to them. On entry to the home residents’ interests and activity preferences are identified through the completion of range of lifestyle and social assessments. Individual care plans are developed and there is a regular review process in place to ensure interventions are relevant. Activities are provided in the large dining/ lounge area and there is a small area where residents can sit to play Mah-jong. Recreational activity staff are available seven days a week. A calendar of events is on display showing the range of activities offered including twice a month bus trips, external entertainers, crafts, and music therapy. Residents/representatives informed us they are satisfied with the activities available to them.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


The home has a system to ensure residents’ individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. On entry to the home residents’ individual customs and beliefs are documented with relevant information transferred to care plans. The significant days/festivals of China and Australia are celebrated throughout the year including Chinese New Year, Dragon boat festival, Easter and Christmas.

Representatives of various religious denominations can visit the home and provide spiritual support to residents. Residents’ birthdays are acknowledged on the day and celebrated monthly. Staff are aware of the residents’ beliefs and cultural backgrounds and interviews with residents and their representatives indicate they are satisfied residents’ needs are being met.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".

Team’s findings


The home has systems whereby each resident and/or their representative is enabled to participate in decisions about the services they receive and exercise choice and control over their lifestyle. Preferences for showering and bed times, participation in activities, choice of personal items in their rooms and freedom to move around the home are all examples of residents exercising control and choice. Residents’ representatives interviewed confirm they are kept informed of changes to residents’ health. Review of documentation demonstrate that


monthly resident and relative meetings and the comments and complaints mechanism provide residents and their representatives avenues to provide feedback and to participate in decision making relating to the services they receive.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Bernard Chan Nursing Home has processes to ensure residents have secure tenure and are assisted to understand their rights and responsibilities. Management provides a range of information to residents and their representatives on admission to the home and meets with representatives before the end of the first month. Documentation provided to all new residents and/or their representatives includes the resident agreement and handbooks that explain the services provided by the home. They also contain information relating to security of tenure and identify the circumstances and restrictions for moving the resident from their room. The charter of residents’ rights and responsibilities is displayed in the home. Residents and representatives reported a general awareness of resident rights and responsibilities and felt secure about resident tenure.


Standard 4 – Physical environment and safe systems

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



Team’s findings



Examples of recent improvements implemented in relation to Accreditation Standard Four include:

Following comments from residents/representatives about cramped space in the activity/dining room, this area has been redesigned and changes made to the space. A wall was removed, a kitchenette installed and a resident room moved. This has created a more spacious area for lounge/dining/activity room. Residents/representatives commented the space is more open and easier to access.

A resident/relative survey identified the need to increase the amount of usable outdoor space. An electronic shade cloth system, which is waterproof, has been installed to provide shade and shelter from sun and rain when required. Since the opening on 28 February when a celebration high tea was held, the area has been well utilised by residents/representatives.

Management decided to take advantage of a government initiative for the installation of solar power. This was completed in February 2015 and management anticipate a reduction in the cost of electricity. The positive impact on the environment was also a consideration in the installation of the solar power.

A discussion at a meeting led to a change in the type of needles used in the administration of insulin. These needles are now retractable. This means the possibility of needlestick injury is eliminated. Staff report the needles are easier to remove once they have administered the insulin. They also note that the total elimination of needlestick injuries following administration is an improvement in work health and safety.



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

Team’s findings



Examples of regulatory compliance with Accreditation Standard Four include:

A current fire safety statement meets regulatory requirements.

The home has a food safety program audited by the NSW Food Authority and a current NSW Food Authority licence for vulnerable persons on display.



Team’s findings


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

Examples of recent education attended by staff in relation to Accreditation Standard Four include:

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

4.4 Living environment

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

Team’s findings


Bernard Chan Nursing Home is a 45 bed home with accommodation provided in three, two and single bedded rooms with shared bathrooms. Rooms are personalised with items from residents’ homes. There are communal and private areas and gardens for resident and visitor use. Maintenance programs and a regular cleaning schedule ensure that the home’s environment is well maintained. The safety and comfort of the living environment is monitored


through feedback from meetings, audits, environmental inspections, incident and hazard reporting and observations by staff. Residents and their representatives said the living environment is comfortable and meets their needs.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


The home provides a safe working environment consistent with workplace, health and safety (WHS) policy and regulatory requirements. There is a system to record, analyse and review staff incidents and identified hazards. The home has two trained health and safety coordinators who attend quarterly organisational forums. WH&S is a standing agenda item at the home’s meetings. Staff receive WHS education on orientation and on an ongoing basis.

Management monitors the WHS system through regular inspections, incident and hazard reporting, audits and feedback. New equipment is risk assessed for safety considerations and staff training is provided as needed. The home has a return to work program if required following any staff injuries. Safe work practices were observed on site and staff stated they receive relevant education.

4.6 Fire, security and other emergencies

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

Team’s findings


The home has systems to minimise fire, security and emergency risks. These include regular checks of equipment by staff and contractors and emergency and fire evacuation procedures. An external provider monitors all fire and safety processes. The home is equipped with fire warning and firefighting equipment, extinguishers and fire blankets, all of which are regularly checked and maintained. Evacuation diagrams are displayed in public areas throughout the home. Staff confirmed they attend compulsory education for fire training and management monitor their attendance. Emergency exits are clearly marked and pathways to exits were observed to be free of obstructions with exit doors operating as designed. Staff stated they have received training and know how to respond in the event of the fire alarm sounding. Residents are generally aware to await staff instructions and stated they feel safe at the home.

4.7 Infection control

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

Team’s findings


The home has an effective infection control program to identify, contain or prevent potential and actual sources of infection including a plan in the event of an outbreak. Education is provided for staff in infection prevention and staff demonstrated an understanding of infection


control practices relating to their area of work. Processes are established for the identification of resident infections and staff are kept informed of infection incidence through the communication book, handovers and at meetings. Staff monitor temperatures of fridges and freezers, use and understand colour coded equipment and wear protective clothing when required. Hand washing facilities and personal protective equipment are available for use by staff. Staff demonstrated an understanding of, and commitment to, infection control principles and guidelines. Systems for waste management, spills, sharps disposal and effective pest control are in place. Temperatures of equipment for cold food storage and medication refrigerators are monitored to minimise the risk of contamination.

4.8 Catering, cleaning and laundry services

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

Team’s findings


There are systems for all aspects of hospitality services to be conducted in accordance with infection control and WHS guidelines. Culturally appropriate fresh cooked meals are prepared in the on-site kitchen by the cook. The menu has been assessed by a dietician and caters for special diets and for the individual needs and preferences of residents. The home is cleaned regularly according to a schedule and includes periodic high cleaning and detail cleaning. There is an on-site laundry for laundering of personal clothing and flat linen six days a week. Residents’ personal items are labelled to assist with prompt return. Hospitality services are monitored through feedback, audits, surveys and meetings. Residents are satisfied with the catering, cleaning and laundry services provided by the home.

bernard chan nursing home - aged care quality · 2018-12-14 · bernard chan nursing home racs id...

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