buckland house nursing home - aged care quality...buckland house nursing home racs id 3478 loch...

Buckland House Nursing Home

RACS ID 3478 Loch Street

MANSFIELD VIC 3722

Approved provider: Mansfield District Hospital

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 22 May 2018.

We made our decision on 15 April 2015.

The audit was conducted on 03 March 2015 to 04 March 2015. The assessment team’s report is attached.

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

Home name: Buckland House Nursing Home RACS ID: 3478 2 Dates of audit: 03 March 2015 to 04 March 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

Buckland House Nursing Home 3478


Introduction

This is the report of a re-accreditation audit from 03 March 2015 to 04 March 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 03 March 2015 to 04 March 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: Tamela Dray

Team member: Marg Foulsum

Approved provider details


Details of home

Name of home: Buckland House Nursing Home

RACS ID: 3478

Total number of allocated places:

30

Number of care recipients during audit:

24

Number of care recipients receiving high care during audit:

Not applicable.

Special needs catered for: Nil.

Street: Loch Street

City: Mansfield

State: Victoria

Postcode: 3722

Phone number: 03 5775 8800

Facsimile: 03 5775 1352

E-mail address: [email protected]

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Management 2

Nursing staff 4

Clinical support nurse educator 1

Contracted pharmacist 1

Lifestyle staff and volunteers 3

Care recipients/representatives 5

Hospitality staff including management 9

Engineering services manager 1

Corporate finance and human resources staff 2

Sampled documents

Category Number

Care recipient files 5

Medication charts 5

Resident agreements 2

Other documents reviewed

The team also reviewed:

Audit schedule and reports

Cleaning schedules

Communication diaries

Complaints forms, register, trend analysis and reports

Continuous quality improvement plan

Education documentation

Emails

Ember attack plan

Evacuation list


External contractor service agreement

Fire and essential services maintenance, inspection and testing records

Food safety plan and external audits

Gastroenteritis outbreak handbook

Handbooks – staff and resident

Handover sheet

Incident and hazard reports and analysis

Infection control documentation

Internal disaster manuals, emergency procedures booklets and emergency management plan

Leisure and lifestyle documentation including benchmarking data

Letter of commendation from representative

Mandatory reporting registers

Material safety data sheets

Meal count sheets

Meeting minutes

Menu

Mission statement

Newsletters

Nursing registrations’ register

Pest control records

Police certificates’ register

Policies and procedures, review schedule and form

Preventative and reactive maintenance schedule, documents and electronic management system

Risk management plan, safety and quality reports and safety inspection reports

Roster

Schedule 8 drug monitoring books

Staff orientation documentation


Strategic plan

Surveys and results

Temperature check records

Work instruction manual.

Observations

The team observed the following:

Activities in progress

Archive storage shed

Brochures and feedback lodgement box

Charter of resident rights’ and responsibilities on display

Cleaners’ room, cleaning trolley and cleaning in progress

Confidential waste bins and waste storage area

Designated smoking area

Equipment and stock storage

Fire panel, fire detection and response equipment and evacuation maps

Internal and external living environment

Kitchen, food and catering equipment storage and meal preparation

Laundry trolley and collection area

Maintenance area

Medication administration and storage

Mobility, dexterity and sensory aids and equipment

Noticeboards and whiteboards

Nurses’ station and offices

Outbreak kit

Pan rooms and waste disposal area

Personal protective equipment

Pest baits

Resident evacuation name tags


Safety signage

Secure record storage

Security systems

Staff areas

Staff assisting and interacting with residents

Visitors and pet in the home.


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

The home actively pursues continuous improvement by implementing a quality system that identifies, actions, monitors and evaluates improvements across the four Standards. Local management is supported by a corporate quality assurance committee who monitor progress. Management identifies improvement opportunities through feedback forms, audits, meetings, surveys, root cause analysis, data analysis and other informal avenues.

Management prioritises activities and logs these to a register that identifies responsibilities and timeframes. Evaluation occurs through reauditing, data analysis, observations and feedback. Management informs stakeholders of improvements within the home through emails, intranet, newsletters, notices and meetings. Residents and representatives are satisfied with the home’s continuous improvement processes.

Improvements related to Standard 1 Management systems, staffing and organisational development include:

Management identified communication issues among nursing staff and implemented a three-monthly meeting. Registered nurses and unit managers attend and discuss relevant information and liaise with the organisation’s leadership group. This has improved staff awareness of roles and responsibilities and other relevant issues.

To improve staff knowledge of residents’ issues, management has added resident and representative feedback as a standing item to the staff meeting agenda. Informal feedback has been positive.


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 to identify, respond to and ensure the home meets relevant legislation, regulatory requirements, professional standards and guidelines across the four Accreditation Standards. Corporate management receive information through legal advisors, peak industry bodies and government departments. Corporate management are responsible for updating key policies and procedures in response to changes and for communicating relevant information to local management. Local management disseminate information to staff, residents and representatives through meetings, emails, intranet, letters and notices.

Regulatory compliance is discussed as an agenda item at relevant meetings. Staff confirmed they receive information about regulatory compliance matters relevant to their roles and demonstrated knowledge of regulatory requirements.

Evidence of regulatory compliance related to Standard 1 Management systems, staffing and organisational development includes:

An effective system to manage police certificates for all staff, volunteers and contractors

Statutory declarations in regard to citizenship or permanent residency of a country other than Australia since turning 16 years of age

Notification to stakeholders of the reaccreditation audit within regulated timeframes.


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


There is a system to ensure management and staff have the appropriate knowledge and skills to perform their roles. Recruitment processes and selection criteria consider experience, skills and qualifications required for each position. The home identifies education needs through needs analysis, audit results, resident needs, feedback and observations. The education program is delivered through on-line learning, on-site theory sessions, on the spot training and external education opportunities. Corporate management maintains attendance records and evaluates mandatory training and lengthy training sessions, however, not all staff have completed annual mandatory training as required. Staff are satisfied with the range of education and professional development opportunities available to them. Residents and representatives said staff have the skills and knowledge required to meet residents’ care needs and services.

Examples of education and training offered relative to Standard 1 Management systems, staffing and organisational development include:

Management and governance

Law and ethics.

1.4 Comments and complaints

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

Team’s findings


The home has a comments and complaints system accessible to all stakeholders. Management provide information about the system to residents and representatives through entry processes, handbooks, discussions and meetings and this is reinforced regularly.

Feedback forms and external complaints brochures, including advocacy information, are readily available. Complainants may choose to remain anonymous and complaints are treated confidentially. Staff assist residents to lodge complaints as required. Documentation confirmed management respond appropriately and complaints are analysed and inform the continuous improvement process. Residents and representatives said they know how to lodge complaints and feel confident to do so.


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


The home’s mission statement is documented and includes a commitment to provide consistent quality health services to the community that reflects best clinical practice, are cost effective and responsive to community needs. The values of sustainability, support, integrity and quality are promoted. These are on display in the home and included in all key documents.

1.6 Human resource management

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

Team’s findings


Management ensures the home has appropriately skilled and qualified staff to safeguard the delivery of care and services in line with the Accreditation Standards, care recipients’ needs and the home’s philosophy and objectives. Site level management are supported by a corporate human resource department who oversee the recruitment, retention and performance management of staff. A formal recruitment process is followed and management monitors qualifications and legislative requirements. New staff complete a formal orientation program that includes supported supernumerary shifts to assist them in adjusting to their new roles. All roles have position descriptions to guide staff and staff sign employment contracts. Rosters confirm that adequate staffing levels occur over all shifts.

Residents and representatives and staff are satisfied with current staffing levels at the home.

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


There is an effective system to ensure stocks of appropriate goods and equipment are available to staff and care recipients. Management ensure orders are placed according to a regular cycle and there are processes to access additional supplies in an emergency.

Management identifies equipment needs through assessments, reviews and consultations and there are processes for preventative and reactive equipment maintenance. New equipment is trialled and risk assessed prior to purchase whenever possible, and suppliers are responsible for training staff in correct use. Faulty equipment is labelled and removed from service.


Storage areas are well organised, clean and secure. Staff, residents and representatives are satisfied with the sufficiency and quality of supplies and equipment at the home.

1.8 Information systems

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

Team’s findings


There are effective information management systems in the home. Staff undertake orientation, there are ongoing education opportunities and they access information verbally and through the intranet, emails, meetings, communication diaries and notices. Residents receive an information pack, hand book and verbal information on entry and are further informed through notices, newsletters, meetings and discussions. Information is appropriately stored and there are processes for archiving and destruction of confidential documents. Electronic information is password protected with restricted levels of access and there are automatic back-up systems to an off-site server. Staff stated and documentation confirmed management provide information that supports delivery of care and services.

Residents said they are satisfied they receive sufficient and relevant information.

1.9 External services

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

Team’s findings


Management ensures externally sourced services are provided in a way that meets the home’s needs and quality goals. The organisation maintains service agreements with relevant external service providers. Contracts include responsibilities in relation to qualifications, certification, insurance, registrations and police certification. Local management monitors the quality of services through observation, resident and staff feedback and meetings. Residents, representatives and staff are satisfied with the services provided by external contractors.


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


The home’s continuous improvement program supports improvements related to care recipients’ health and personal care. Management and staff identify improvement opportunities through clinical incidents, feedback, clinical care audits, observation of practice, meetings and discussions. Refer to expected outcome 1.1 Continuous improvement.

Improvements related to Standard 2 Health and personal care include:

Medication chart audits identified signing omissions. Management engaged a clinical specialist nurse to conduct a new medication competency in addition to the standard annual competency assessment with relevant staff. Audit results indicate this has significantly improved compliance.

Auditing of wound records identified these had not been updated in response to care procedures. Management included wound care on the daily care schedule to alert staff and this has resulted in more consistency in care and documentation.


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 for identifying relevant legislation, regulations, professional standards and guidelines relating to care recipients’ health and personal care. Management inform clinical staff of clinical care updates through meetings, email and handover. Refer to expected outcome 1.2 Regulatory compliance.

Evidence of regulatory compliance related to Standard 2 Health and personal care includes:

Appropriately qualified staff to plan, supervise and undertake specialised nursing care

Monitoring of nursing registrations

Safe medication storage and management

Processes to manage and report the unexplained absence of a resident.




Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes.

Education offered relating to Standard 2 Health and personal care includes:

Stoma therapy

Tracheostomy care

Pain management.

2.4 Clinical care

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

Team’s findings


Management ensures care recipients receive appropriate clinical care. Staff use established clinical systems to assess residents’ needs upon entry and develop plans of care around these needs. Documentation tracks the monitoring of clinical care through charts, assessments, care plans and progress notes. Review of care needs occurs through the resident of the day process and as changes in residents’ health status require. A clinical manager oversees clinical care and is supported by registered and enrolled nurses. General practitioners and allied health professionals enhance the holistic approach to care. Formal and informal care consultations with residents and their representatives ensure satisfaction with the care provided and observation of any identified preferences and needs. Residents said they are satisfied with the clinical care provided.

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 registered and enrolled nurses and access to specialised community nurses through the co-located hospital to assess, plan, manage and deliver specialised nursing care needs to care recipients. Specific care plans are developed and individually tailored to guide staff. Staff reported changes in the care needs of residents are communicated effectively and staff are supported to ensure they have the appropriate skills and knowledge to meet a diverse range of specialised needs. Residents are satisfied their specialised care needs are identified and managed appropriately.


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


Management ensure care recipients have access to appropriate health specialists in accordance with their needs and preferences. The home has collaborative support from the wider health service including the co-located hospital. Medical practitioners visit the home at regular intervals with residents able to retain their own doctor if desired. There is a regular physiotherapy and podiatry service with a dietitian, occupational therapist and speech pathologist available as needed. Staff assist residents to attend other health professionals and specialists in the community as required. Residents are satisfied with the range of health specialists available.

2.7 Medication management

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

Team’s findings


The home has systems to support safe and correct medication management. Competency tested nurses administer medications, and education and incident management processes ensure this is completed safely and correctly. The home has a process for assessing and monitoring those residents who wish to self-manage and self-administer medications.

Processes exist for the ordering, delivery and disposal of medications with access to urgent medications through a local pharmacy service and the local hospital. Medications are stored safely and securely and in accordance with regulatory guidelines. A multi-disciplinary advisory committee meets regularly to discuss the medication needs at the home and instigate any improvements. Policies and procedures and current medication resources are readily accessible and guide staff practice. Residents are satisfied with how staff manage their medication needs.

2.8 Pain management

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

Team’s findings


The home ensures all care recipients are as free as possible from pain. Residents are assessed for previous and current pain on entry and changes in pain status prompt staff to reassess and make referrals to appropriate health professionals. A variety of methods are utilised to help manage residents’ pain and these include the use of ‘as needed’ medication where appropriate. A physiotherapist, in conjunction with the registered nurses, oversees a pain management program for residents assessed with chronic pain. Staff are aware of verbal and non-verbal pain cues in residents and use these to guide pain prevention and


management on an individual level. Residents are satisfied with the pain management strategies provided by the home.

2.9 Palliative care

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

Team’s findings


Staff and management ensure the comfort and dignity of care recipients in their final phase of life. Consultation occurs between staff and residents or their representatives about the residents’ advanced care wishes and this forms the basis for care provided in the terminal stage. If required, staff access palliative care assistance through the local hospital and health service. Spiritual and emotional support is available for the resident and their family if desired and representatives are supported to stay by their loved ones’ side overnight if they wish.

Representatives expressed satisfaction with how staff respect and support individual beliefs and comfort levels during the palliative care process.

2.10 Nutrition and hydration

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

Team’s findings


Management and staff ensure care recipients receive adequate nourishment and hydration. Clinical systems prompt staff to identify and assess care recipients’ nutritional needs, preferences and the level of staff assistance required. Staff monitor residents’ weight and guidelines prompt staff on how to manage any losses or gains with the assistance of the dietitian when required. Assistive devices are available to help residents maintain their independence with eating and drinking. Residents are satisfied with the quality of food and beverages provided at the home.

2.11 Skin care

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

Team’s findings


Staff assess and care for care recipients in a way that promotes optimal skin integrity. Staff assess residents’ skin integrity on entry, when care plans are reviewed and as health needs change. Barrier cream is applied and pressure area care strategies utilised to promote skin integrity. Staff assist residents to maintain their skin in a healthy state and a visiting podiatrist and hairdresser help them maintain their nails and hair. Monitoring of skin tears and wounds occurs and care is reflected on appropriate charts. Policies and procedures are available to guide staff in wound assessment and management, and specialist care by a wound care


consultant is available if staff need further advice. Residents are satisfied with the home’s approach to maintaining their skin integrity.

2.12 Continence management

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

Team’s findings


Management and staff ensure care recipients’ continence needs are managed effectively and with dignity. Staff assess the residents’ continence needs on entry and as their needs change. Assessments take into consideration the staff assistance levels required and any continence aids needed. The home’s approach to continence management encourages promotion of independence and dignity and education is provided on continence management. Residents stated their continence needs are met.

2.13 Behavioural management

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

Team’s findings


Management and staff ensure the needs of care recipients with challenging behaviours are managed effectively. Staff conduct behavioural assessments and use the information gathered to formulate care plans that outline any identified triggers and management strategies. Staff receive education to help manage behavioural challenges especially those related to dementia. Local health services and specialist groups are utilised as a supportive resource for staff and to help implement strategies for residents with challenging behaviours. Residents said they are satisfied with the management of any behavioural issues that occur within the home and the behaviour of other residents does not impact on their own wellbeing

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


Staff and management ensure care is provided in a way that guarantees optimum levels of mobility and dexterity are achieved for care recipients. Each residents’ mobility and dexterity needs are assessed on entry and mobility aids provided if required. Physiotherapy services are provided regularly at the home, with all residents assessed and reviewed as required.

Assistive devices, such as those for eating, are available and their use promoted. There are adequate mobility and dexterity aids to cater for residents’ needs. Residents report their mobility and dexterity is supported by staff when needed and encouragement is given to maintain their independence with the assistance of aids if required.


2.15 Oral and dental care

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

Team’s findings


Staff ensure assistance is given to care recipients to maintain optimal oral and dental health. Staff conduct assessments of residents’ oral and dental needs and preferences on entry and include details in care plans about assistance levels required and daily care of teeth, mouth and dentures as appropriate. Residents are assisted to access dentists and dental technicians, which may be of their own choice if desired. Staff assist and prompt residents with daily dental hygiene and observe and document any relevant dental issues. There is a process for the provision of additional oral and dental care during the palliative phase. Staff formulate specific strategies for residents with swallowing difficulties which include texture modified diets and staff assistance with meals. Residents stated staff provide assistance with their oral and dental hygiene.

2.16 Sensory loss

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

Team’s findings


Staff and management ensure care recipients’ sensory losses are identified and managed effectively. Staff assess residents’ sensory deficits upon entry and as changes in care needs require. Staff organise assistance for residents to attend appointments with their own preferred provider or specialist providers when required for hearing and vision assessments. The home is well lit, has adequate handrails and visible signage. Staff are aware of individual needs and assist residents who require help with care, maintenance, fitting and cleaning of aids and devices. Residents stated staff assist with their sensory loss needs.

2.17 Sleep

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

Team’s findings


Staff and management ensure care recipients are assisted to sleep in a natural and non- invasive way. Normal sleep and wake patterns are assessed on entry and, if possible, pre entry patterns are supported by staff through the care planning and actioning process. A variety of methods is used to promote sleep including settling routines, evening drinks and snacks and medication as prescribed. Records show staff respect residents’ wishes regarding sleep. Residents said the home is quiet at night, their preferred wake and sleep times are respected and they sleep as soundly as possible.


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


The home’s continuous improvement program includes processes to identify and implement improvements related to care recipient lifestyle. Residents and representatives make suggestions through feedback forms, focus groups, surveys, meetings and informal discussions. Refer to expected outcome 1.1 continuous improvement.

Improvements related to Standard 3 Care recipient lifestyle include:

To formalise consultation with residents and their families about all aspects of the resident’s life at the home, management has updated the resident review form to include this requirement. Relevant staff now formally contact and document consultation. Resident and family feedback has been very positive and they feel more informed and involved in decision making.

To support a resident whose spouse was receiving palliative care at the resident’s family home, staff arranged to transport and accompany the resident on regular visits to enable the couple to spend time together. The family was very appreciative.

With donations received, management purchased a recliner chair for use by family members who wish to spend the night with their loved ones during palliative care. Families have utilised this opportunity and are thankful to have this option available.



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

Team’s findings


The home has systems for identifying relevant legislation, regulations and guidelines relating to care recipient lifestyle. Residents and representatives receive information on entry and this is reinforced during meetings and displayed in the home. Refer to Expected outcome 1.2 Regulatory compliance.

Evidence of regulatory compliance related to Standard 3 Care recipient lifestyle includes:

Procedures and documentation for recording and reporting alleged or suspected resident assault

Resident agreements that outline care and services and security of tenure.



Team’s findings



Education offered relating to Standard 3 Care recipient lifestyle includes:

Privacy and dignity dynamics toolkit

Depression.

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


Management and staff support care recipients in adjusting to life in the home and on an ongoing basis. Assessment of residents’ emotional support needs and preferences occur upon entry and care plans are developed to meet their needs. Review of residents’ emotional support needs occurs on a regular basis by nursing and lifestyle staff and care plans are updated as required. Residents and representatives are provided with a resident information handbook to assist their orientation to the home. The local community visitors’ scheme assist residents who wish to have a friendly face outside of staff to assist with their emotional needs.


Residents confirmed their satisfaction with the initial and ongoing emotional support they receive at the home.

3.5 Independence

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

Team’s findings


Management and staff ensure care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Initial and ongoing assessment and care planning processes identify, assess and plan for residents’ optimal independence. Staff utilise multiple strategies to promote independence including one to one activities. Community groups and schools visit regularly to help bring the community into the home. Residents confirmed they are satisfied their independence is supported by the home.

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


Management and staff ensure each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. The shared residents’ rooms have privacy curtains and the home welcomes visitors whom residents can receive in their rooms or in private communal areas. We observed staff engaging in practices to protect residents’ privacy and dignity including knocking on doors, not discussing private information in public areas and calling residents by their preferred name. Residents and representatives confirmed staff respect their privacy 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


Staff and management ensure care recipients are encouraged and supported to participate in a wide range of interests and activities. A lifestyle portfolio and assessment guide staff in developing a care plan and occurs in consultation with the resident and their representatives if appropriate. The resident of the day program prompts staff to review these needs on a regular basis. The lifestyle program includes a wide range of activities which are advertised through a weekly lifestyle newsletter, displayed on noticeboards and distributed to residents. An event planner includes celebration of days of significance as well as residents’ birthdays if they wish. The program caters for multiple one to one activities to support the frailty and high care needs of the resident population. Weekend activities are managed by nursing staff or volunteers with


instructions on how to run activities available to assist. Management obtains feedback on the program via meetings, direct feedback, observations and through lifestyle participation records. Residents confirmed they are satisfied with the lifestyle program and are supported to participate in a range of activities at the home.

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


Staff and management ensure care recipients’ individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. Staff identify residents’ cultural and spiritual beliefs and needs through the assessment process. There is provision for various church services at the home including a weekly ecumenical service. There are special days held throughout the year and staff have access to culturally specific services to assist in meeting individual cultural needs if required. Residents and representatives confirmed they are satisfied with the home’s response to residents’ cultural and spiritual needs.

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


Management and staff ensure each care recipient, or their representative, has input into the services the care recipient receives and is enabled to exercise control and choice over their lifestyle without infringing on the rights of others. The assessment and care planning process includes input from the resident and their representative, and care consultations ensure ongoing satisfaction with the choices and decisions made. There are regular resident meetings and other formal processes for residents and representatives to provide feedback about their care and services. Management have an open door policy to ensure they are easily accessible if needed. Staff support residents to manage their own financial affairs if required and residents have access to a guardianship service to handle resident funds.

There is a wide range of activities on offer and residents can choose their participation levels. Residents confirmed their individual choices and decisions are encouraged, respected and supported by management and staff.


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


Care recipients have secure tenure within the home and there are processes to ensure they understand their rights and responsibilities. Management communicates information regarding rights and responsibilities, tenure, complaints mechanisms and specified care and services to residents and representatives on entry and these are included in the residential agreement and handbook. The Charter of residents’ rights and responsibilities is on display. Consultation precedes any change of resident room. Residents and representatives are satisfied with the security of 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


Improvements related to the physical environment and safe systems are evident in the continuous improvement program. Management identify these through environmental audits, incident and hazard reports, maintenance requests and stakeholder feedback. Refer to expected outcome 1.1 Continuous improvement.

Improvements related to Standard 4 Physical environment and safe systems include:

To improve the living environment, management purchased new dining tables and soft furnishings. Residents were consulted and selected materials. Feedback has been positive with new blinds offering better sun protection and privacy.

Staff observed dining chairs to be too low for resident comfort. Management purchased chair cushions that were covered in matching fabric. Feedback through the representatives meeting was excellent.

To ensure the safety of residents who wish to independently access the local community, management is liaising with local council to improve roadside curbing. Regular meetings are underway.



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

Team’s findings


The home has systems for identifying relevant legislation, regulations and guidelines relating to the physical environment and safe systems. This was confirmed through observation of the living environment and support service areas, staff practice and document review. Refer to expected outcome 1.2 Regulatory compliance.

Evidence of regulatory compliance related to Standard 4 Physical environment and safe systems includes:

Procedures for recording, managing and reporting infectious diseases and outbreaks

A food safety program and external audits

Fire and essential services inspection and testing systems.



Team’s findings



Education offered relating to Standard 4 Physical environment and safe systems includes:

Snake bite management

Antimicrobial awareness.

4.4 Living environment

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

Team’s findings


Management is actively working to provide care recipients with a safe and comfortable environment consistent with their care and lifestyle needs. Residents are encouraged to personalise their rooms. Rooms and communal areas are well lit, appropriately furnished, well maintained, uncluttered and kept at a comfortable temperature. Residents have access to


comfortable outdoor areas. Management ensures the buildings, grounds and equipment are maintained through preventative and reactive maintenance programs and monitored through observations and audits. Residents and representatives are satisfied the home provides a comfortable, safe and secure environment.

4.5 Occupational health and safety

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

Team’s findings


The home has systems and processes to provide a safe working environment that is aligned with regulatory requirements. There are policies, procedures and guidelines in relation to safe work practice. Staff are informed of their responsibilities through orientation, education, handbooks, intranet, meetings and displayed information. The home’s education program includes training in manual handling, infection control, fire and emergency response and chemical safety. The occupational health and safety committee meets regularly and oversees workplace health and safety. Staff and management identify and report hazards and these are responded to appropriately. Staff confirmed they are kept informed and able to approach management with occupational health and safety issues.

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 processes to minimise fire, security and other emergencies. Specialist external contractors maintain fire and essential services equipment. There are processes to ensure regular testing of electrical equipment. Management displays emergency evacuation plans and ensures emergency exits and egress routes are free from obstruction. There are effective processes to ensure the resident evacuation list remains current at all times. Staff are expected to complete fire and emergency training annually as part of the organisational mandatory training day. A secure environment is maintained through keypad security systems, signing in books and lock up procedures. Residents and representatives are satisfied the home provides a safe and secure environment.

4.7 Infection control

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

Team’s findings


Management demonstrates they have an effective infection control program. The program detects, manages and monitors infections within the home. Management, with assistance from the corporate infection control practitioner and committee, collate infection data and report any trends at meetings. Staff practice is guided by comprehensive policies and procedures and government resources, which are noted to cover the management and containment of


infectious outbreaks. Infection control kits, which include signage and personal protective equipment, are available to staff and hand hygiene facilities are prevalent. There is a food safety program and cleaning schedules are followed throughout the home. Infectious waste, sharps disposal and pest control within the home is managed by external contractors. Resident and staff vaccinations are encouraged and monitored with high levels of uptake. Residents said staff identify infections and manage them appropriately.

4.8 Catering, cleaning and laundry services

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

Team’s findings


The home ensures hospitality services meet the needs of care recipients, visitors and staff. Catering, cleaning and laundry services are delivered by the organisation’s staff. Catering staff prepare food in the main kitchen and deliver this to the kitchenette in the home for serving. Food services are managed in line with an externally audited food safety program and there is a four-week rotational menu that has been reviewed by a dietitian. Residents are offered a choice of menu items and special requirements are catered for. Staff provide cleaning and laundry services over seven days. Cleaning staff perform their duties according to established schedules and the home was observed to be clean with no unpleasant odour. Personal clothing, linen and towels are laundered in the organisation’s main laundry located in a separate building a short distance away. Double sided industrial washing machines ensure minimal risk of cross contamination. There is a labelling service available and minimal lost laundry. Residents and representatives said they are very satisfied with catering, cleaning and laundry services.

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