decision to accredit southern cross apartments …...home name: southern cross apartments marsfield...

Decision to accredit

Southern Cross Apartments Marsfield

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Southern Cross Apartments Marsfield in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Southern Cross Apartments Marsfield is three years until 16 March 2014. The Agency has found the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. This is shown in the ‘Agency findings’ column appended to the following executive summary of the assessment team’s site audit report. The Agency is satisfied the home will undertake continuous improvement measured against the Accreditation Standards. The Agency will undertake support contacts to monitor progress with improvements and compliance with the Accreditation Standards. Information considered in making an accreditation decision

The Agency has taken into account the following:

•••• the desk audit report and site audit report received from the assessment team; and

•••• information (if any) received from the Secretary of the Department of Health and Ageing; and

•••• other information (if any) received from the approved provider including actions taken since the audit; and

•••• whether the decision-maker is satisfied that the residential care home will undertake continuous improvement measured against the Accreditation Standards, if it is accredited.

Home name: Southern Cross Apartments Marsfield Date/s of audit: 7 December 2010 to 8 December 2010 RACS ID: 0603 AS_RP_00851 v2.5

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Home and approved provider details

Details of the home

Home’s name: Southern Cross Apartments Marsfield

RACS ID: 0603

Number of beds: 40 Number of high care residents: 34

Special needs group catered for: • Dementia unit - 10 residents

Street/PO Box: 16 Vincentia Street

City: MARSFIELD State: NSW Postcode: 2122

Phone: 02 9805 0034 Facsimile: 02 9805 0279

Email address: Nil

Approved provider

Approved provider: Southern Cross Care (NSW & ACT)

Assessment team

Team leader: Colleen Fox

Team member/s: Allison Watson

Date/s of audit: 7 December 2010 to 8 December 2010


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Executive summary of assessment team’s report Accreditation

decision

Standard 1: Management systems, staffing and organisational development

Expected outcome Assessment team recommendations

Agency findings

1.1 Continuous improvement Does comply Does comply

1.2 Regulatory compliance Does comply Does comply

1.3 Education and staff development Does comply Does comply

1.4 Comments and complaints Does comply Does comply

1.5 Planning and leadership Does comply Does comply

1.6 Human resource management Does comply Does comply

1.7 Inventory and equipment Does comply Does comply

1.8 Information systems Does comply Does comply

1.9 External services Does comply Does comply

Standard 2: Health and personal care


Agency findings




2.4 Clinical care Does comply Does comply

2.5 Specialised nursing care needs Does comply Does comply

2.6 Other health and related services Does comply Does comply

2.7 Medication management Does comply Does comply

2.8 Pain management Does comply Does comply

2.9 Palliative care Does comply Does comply

2.10 Nutrition and hydration Does comply Does comply

2.11 Skin care Does comply Does comply

2.12 Continence management Does comply Does comply

2.13 Behavioural management Does comply Does comply

2.14 Mobility, dexterity and rehabilitation Does comply Does comply

2.15 Oral and dental care Does comply Does comply

2.16 Sensory loss Does comply Does comply

2.17 Sleep Does comply Does comply


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Executive summary of assessment team’s report Accreditation

decision

Standard 3: Resident lifestyle


Agency findings




3.4 Emotional support Does comply Does comply

3.5 Independence Does comply Does comply

3.6 Privacy and dignity Does comply Does comply

3.7 Leisure interests and activities Does comply Does comply

3.8 Cultural and spiritual life Does comply Does comply

3.9 Choice and decision-making Does comply Does comply

3.10 Resident security of tenure and responsibilities

Does comply Does comply

Standard 4: Physical environment and safe systems


Agency findings




4.4 Living environment Does comply Does comply

4.5 Occupational health and safety Does comply Does comply

4.6 Fire, security and other emergencies Does comply Does comply

4.7 Infection control Does comply Does comply

4.8 Catering, cleaning and laundry services

Does comply Does comply


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Assessment team’s reasons for recommendations to the Agency The assessment team’s recommendations about the home’s compliance with the Accreditation Standards are set out below. Please note the Agency may have findings different from these recommendations.

Name of home: Southern Cross Apartments Marsfield RACS ID 0603 AS_RP_00857 v1.5 Dates of site audit: 7 December 2010 to 8 December 2010

SITE AUDIT REPORT

Name of home Southern Cross Apartments Marsfield

RACS ID 0603

Executive summary This is the report of a site audit of Southern Cross Apartments Marsfield 0603 16 Vincentia Street MARSFIELD NSW from 7 December 2010 to 8 December 2010 submitted to the Aged Care Standards and Accreditation Agency Ltd.

Assessment team’s recommendation regarding compliance The assessment team considers the information obtained through audit of the home indicates that the home complies with:

•••• 44 expected outcomes

Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Southern Cross Apartments Marsfield. The assessment team recommends the period of accreditation be three years.

Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation.


Site audit report

Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 7 December 2010 to 8 December 2010 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997.

Assessment team

Team leader: Colleen Fox

Team member/s: Allison Watson

Approved provider details

Approved provider: Southern Cross Care (NSW & ACT)

Details of home

Name of home: Southern Cross Apartments Marsfield

RACS ID: 0603

Total number of allocated places:

40

Number of residents during site audit:

37

Number of high care residents during site audit:

34

Special needs catered for:

Dementia unit (10 residents)

Street/PO Box: 16 Vincentia Street State: NSW

City/Town: MARSFIELD Postcode: 2122

Phone number: 02 9805 0034 Facsimile: 02 9805 0279

E-mail address: Nil


Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Southern Cross Apartments Marsfield. The assessment team recommends the period of accreditation be three years.

Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation.

Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and the reasons for its recommendations are outlined below.

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

Interviews

Number Number

Care team manager 1 Residents 5

Deputy care team manager 1 Representatives 5

Area manager 1 Pastoral care coordinator 1

Manager, Quality systems 1 Cook 1

Clinical consultant/registered nurse

1 Maintenance manager 1

Team leader 1 Physiotherapist 1

Care staff 8 Care staff/physiotherapy aide 1

Lifestyle coordinator 1

Sampled documents

Number Number

Residents’ files (electronic) and clinical files (hardcopy)

5 Service agreements/contracts 2

Medication charts 5 Personnel files 5

Medication incident with attached competency

3 Resident agreements 5

Medication charts 5

Other documents reviewed The team also reviewed:

•••• “Home Sweet Home” information

•••• Accident/incident summary reports

•••• Activity program/reviews/evaluations

•••• Activity records/needs assessments

•••• Annual fire safety statement

•••• Audit schedules, audit results

•••• Audit, meeting and planning calendar


•••• Blood glucose monitoring guide

•••• Cleaning schedules

•••• Clinical indicators

•••• Code of conduct – residents, staff

•••• Collective staff agreement 2009

•••• Communication diaries

•••• Competency assessments

•••• Compulsory reporting register

•••• Contractor registrations, certificates

•••• Dangerous drugs register

•••• Disaster plan

•••• Duty statements

•••• Environmental inspection reports

•••• Equipment register

•••• External contractor records

•••• Feedback forms, ‘Are you happy?’, ‘Happy with your meal today?’

•••• First aid certificates

•••• Food safety program

•••• Four weekly seasonal menu

•••• Handover sheets

•••• Hazard alert forms

•••• Hazardous substances register, risk assessments

•••• Job descriptions

•••• Kitchen cleaning and sanitation records

•••• Maintenance request register

•••• Maintenance schedules, internal and contractors

•••• Medication incident folder

•••• Meeting minutes – leadership, service review committee, medication management committee, families and friends, residents, staff

•••• Mentor checklist

•••• Newsletter

•••• NSW Food Authority licence

•••• Organisation chart

•••• Palliative care plan

•••• Pastoral care participants’ folder

•••• Pastoral care training manual

•••• Pest control records

•••• Police check register

•••• Policies and procedures

•••• Preferred suppliers list

•••• Privacy policy and consent forms

•••• Quality improvement action sheets

•••• Resident handbook

•••• Resident information pack

•••• Resident menu choices and dietary requirements

•••• Restraint authority

•••• Staff handbook

•••• Staff induction kit, checklist

•••• Staff information pack

•••• Staff memos

•••• Staff registration

•••• Staff rosters

•••• Staff training calendar


•••• Staff vaccination records

•••• Temperature records – food, kitchen appliances

•••• Thermometer calibration records

•••• Thermostatic mixing valve records

•••• ‘Tool box’ talk guidelines

•••• Training attendance and evaluation records

•••• Volunteers handbook

•••• Weekly schedule of activities

Observations The team observed the following:

•••• Activities board displaying activities of the day

•••• Activities in progress

•••• Audio visual training resources

•••• Brochures – external complaints services

•••• Charter of residents’ rights and responsibilities

•••• Chemical storage, material safety data sheets, spill kit

•••• Cleaning trolley

•••• Clinical waste disposal container

•••• Communication diary

•••• Council state emergency service information

•••• Daily menu display

•••• Emergency procedure flipcharts

•••• Equipment storage

•••• Equipment operation procedures

•••• Exercise classes in progress

•••• Feedback forms

•••• Fire safety - evacuation plans, equipment, procedures, inspection reports, evacuation chair

•••• First aid kits

•••• Food hazard analysis guidelines

•••• Gastro/influenza packs

•••• Hair salon

•••• Handover

•••• Incident/accident procedures on display

•••• Infection control resources – hand wash basins and sanitising gel, colour coded equipment, personal protective equipment, sharps containers

•••• Information posters regarding influenza outbreaks

•••• Interactions between staff/residents/representatives

•••• Living environment, internal and external

•••• Lunch time meal service

•••• Medication round

•••• Mission, philosophy, objectives

•••• New cordless phone

•••• Notice boards for staff and resident information

•••• Occupational health and safety (OH&S) pre-purchase assessment

•••• Public phones

•••• Resident dietary needs, dislikes (Kitchen and kitchenettes)

•••• Resident evacuation folder

•••• Resident fire emergency notice

•••• Resident welcome digital video disc (DVD)

•••• Residents in their rooms and in living areas

•••• Residents using mobility aids

•••• Residents’ art work displayed on walls


•••• Secure storage of medications including schedule eight

•••• Secure storage of residents’ information

•••• Staff orientation digital video disc (DVD)

•••• Staff practices (e.g. wearing protective equipment, using lifting equipment, responding to residents)

•••• Suggestion box and mail box

•••• Supply storage areas

•••• Visitor sign in/out book

•••• Watercoolers


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. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has an effective system for actively pursuing continuous improvement across all four Accreditation Standards. A review of relevant documentation and interviews with management and staff confirm that the continuous improvement program includes activities to monitor, assess, action, review and evaluate the home’s processes, practices, service delivery and management. Suggestions and ideas for improvement are initiated by staff and residents/representatives through meetings, feedback and incident forms, audit results, surveys and verbal discussion. Activities which support quality improvement include regular staff and committee meetings, an internal and benchmarking audit program and trend analyses of key performance indicators. Stakeholders are provided with feedback on improvement actions taken as appropriate. Examples of improvements in relation to Accreditation Standard One over the past year include:

•••• To improve consistency in the content of monthly ‘tool box’ sessions standardised resources are being provided by head office. Updates to policies and procedures are included in these sessions and this information is included in staff meetings throughout the month. This enhances staff learning opportunities and staff have given positive feedback on this regular education.

•••• Concerns were raised by staff regarding increased workloads because of the increasing needs of residents. Night duty staff have been increased to two, shifts have increased on weekends and an additional shift to assist with morning duties has been introduced. Staff are now able to complete duties and residents have provided good feedback.

•••• Care staff identified that insufficient shower chairs were available for residents. Five new chairs have been purchased enabling safer and easier transfer of residents for those who require assistance. Positive feedback from staff has been received as these chairs assist in minimising manual handling injuries.

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 recommendation Does comply Interviews with management and staff, and a review of documentation, confirms that the home has systems in place to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. Corporate subscriptions to legal services and membership to peak bodies and associations assist in ensuring management staff receive updates of all legislation and regulations. Staff are informed of regulations, professional standards and guidelines in the staff handbook, at orientation and annual compulsory education sessions. Updated information is communicated at handover, staff memos and meetings and through updated policies and procedures. Staff confirm they are kept up to date with changes in regulations and legislation. Monitoring of compliance includes scheduled internal audits, staff competency assessments, appraisals and


observation of staff practices. Examples of compliance relating to Accreditation Standard One include:

•••• There is a system to ensure all staff, allied health personnel, volunteers, and contractors as required, have police checks. These are monitored for renewal.

•••• A system is in place to inform residents/representatives about accreditation audits.

•••• The team noted updated policies in response to legislative changes. 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 recommendation Does comply Documentation, observation and staff interviews confirm the home has systems in place to ensure management and staff have appropriate knowledge and skills to effectively perform their roles. Staff are encouraged and supported in attending education programs internally and externally which cover the four Accreditation Standards. Competency assessments are conducted at orientation and are ongoing to monitor staff practices. Organisational identified needs, compulsory training requirements and staff personal development needs guide the development of an annual education program. This is supplemented with other sessions based on clinical and personal care issues, legislative changes and trend analyses. Education sessions are offered in small groups and one-on-one and audio visual resources are available. Monthly ‘tool box’ sessions provide focused training for all staff on a topic which is then incorporated into handover and meetings to enhance learning. Staff members are offered opportunities to attend certificate programs. Training attendances and evaluation of programs are recorded. All residents/representatives interviewed state that staff provide appropriate care as needed. Education and training over the past year in relation to Accreditation Standard One includes effective communication, employee benefits, equal employment opportunity (EEO), aged care funding instrument (ACFI), mentor and ‘buddy’ roles, personal development plans, orientation, electronic care management system, Certificate III and IV in Aged Care, accreditation, frontline management, training and assessment. 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 recommendation Does comply The home has internal and external mechanisms for feedback and complaints which are accessible and available to all residents/representatives in the home. These are outlined in the resident agreement and handbook. On entry all new residents are made aware of feedback mechanisms and ‘Are you happy?’ forms are used for comments, complaints and suggestions. A separate form is in place for feedback about daily meal services. The manager has an ‘open door’ policy and the team observed residents/representatives communicating freely with management staff. Feedback forms and the suggestion box are centrally located. Posters and brochures for accessing external complaints services are displayed. All concerns are registered, collated monthly, analysed and transferred to the continuous improvement program if requiring further action. Resident meetings include updates on management actions taken in relation to resident initiated issues. Staff interviewed demonstrated awareness of complaints’ procedures. Interviews and documentation confirm complaints are acknowledged, followed up, and feedback is given to


complainants. All complaints are handled confidentially. Residents/representatives spoken with confirm that if they had any concerns they would be happy to raise them with staff and believe they would receive an appropriate response. 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 recommendation Does comply Management and staff practices and a review of documentation, such as policies and procedures, confirm a commitment to quality within the home. The mission, philosophy, and objectives statements are on display at various locations and are re-enforced to staff through the staff handbook and education sessions. These statements, as well as the Charter of Residents’ Rights and Responsibilities, are included in the resident handbook. A code of conduct is in place for residents and staff. The home is supported by organisational planning and leadership teams. The audit program, staff education and continuous improvement program ensure an ongoing commitment of quality to residents. 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 recommendation Does comply Interviews, documentation review and observation confirm the home has skilled and qualified staff sufficient to deliver appropriate levels of care to residents. Care staff are recruited in consideration of resident needs and the values of the home. Encouragement is given to new staff to complete certificate level III qualification if not held. An orientation program includes a ‘buddy’ system, and a mentoring process is in place. Job descriptions, duty statements, policies, and procedures inform staff of requirements for the delivery of quality care and services. Care service employees are trained to be multi-skilled, providing both care and hospitality duties. Expectations of staff performance are conveyed through the staff handbook and performance appraisals, and staff surveys provide feedback to management. Staff practices are monitored by observation, feedback and audit results, and staff development is encouraged. Competency assessments are conducted at orientation, annually, and as necessary for performance management. Staff registration renewals and police checks are monitored and recorded at the home. A registered nurse attends two days per week and is on call at other times. Staff rosters are adjusted according to workloads with casual staff covering leave occurrences. Interviews with care staff demonstrate they have sufficient time to complete their duties and enjoy the variety of their roles. They confirm attendance at compulsory education and appreciate ongoing development. All residents/representatives interviewed express satisfaction with the care they receive. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply Documentation and interviews with staff confirm the home has systems in place to order and have available, stocks of goods and equipment appropriate for quality service delivery. Stock


levels are managed, maintained and ordered by staff in the home. Organisational and local suppliers are used and services are regularly monitored and evaluated. An external supplier provides chemical stocks and provides education in their use. External maintenance contracts and internal maintenance programs ensure equipment is monitored and replacement needs are identified. Purchases are decided through consultation with staff and management. All storage areas viewed confirm there are adequate supplies and there is a stock rotation policy. The team observed items stored appropriately in locked storage areas. Staff and residents/representatives interviewed said adequate supplies of goods and equipment are available. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply Interviews, documentation review and observation confirm the home has effective information systems in place to provide access to current information to all stakeholders. Audit and survey results and feedback mechanisms provide information to management and staff about the home’s performance. Staff members are informed on all aspects of care and service delivery by a staff handbook, position descriptions, policies, procedures, and duty statements. On commencement of employment staff sign a confidentiality statement. Key staff have password protected access to the network system, and all staff and allied health personnel have access to the care management system. Care staff report updated information is available through handover, progress notes, care plans, memos, communication diary, and staff meetings. A resident agreement and handbook inform residents/representatives and updated information is provided through resident meetings, newsletter, noticeboards and verbal communication. Residents/representatives report they are kept informed. Practices are in place for confidential storage, electronic back up, archiving and destruction of documentation at the home. 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 recommendation Does comply The home has systems and processes to ensure external services are provided to meet the care service needs of residents. Documentation review and staff interviews confirm that external providers used are managed by head office and at the home. Service agreements which include insurance and registration details are in place for regular suppliers. These ensure agreed standards for delivery and specifications of service. All work performed is monitored for quality and staff provide feedback to management regarding the effectiveness of services. Changes are made when services received do not meet expected requirements for the needs of residents or the home. Prior to the renewal of agreements consideration is given to services provided and a tender process is used. Staff state they are satisfied with the quality of services provided by external suppliers in meeting residents’ needs.


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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system which exists in the home. Examples of improvements over the past year in relation to Accreditation Standard Two include:

•••• The resident exercise program has been reviewed by the physiotherapist due to the increase in residents presenting with poor mobility, stiffness and falls. A regular exercise class has commenced using a variety of exercises, with improved resident strength and mobility noted.

•••• To assist residents at risk of skin tears and increased falls protective measures such as tubular bandaging and hip protectors have been introduced. Staff monitor residents to ensure their safety and minimise injury and discuss those at risk daily at handover. Other measures to maintain skin integrity include: to provide quality of care and comfort for residents at risk of developing pressure areas, a hospital bed and air mattress have been purchased; education has been given to improve documentation and charting of wound status, and care required on discharge from hospital. This ensures wound management practices are appropriate.

•••• A change has been made with the pharmacist providing pharmacy reviews because of service delays. The pharmacist now use email reviews directly to medical officers, and this has resulted in improved responses from them. Other measures introduced to assist in minimising medication errors include: medication pack check competency assessments have been completed; packaged medications are checked weekly on arrival; resident identification photographs on packaging have been improved by the supplying pharmacist.

•••• The organisation recognised the critical importance of securing resident continuity of care immediately following hospital discharge. A memorandum of understanding for reference regarding residents’ discharge has been developed and distributed to the local hospital. Staff obligations regarding communication with the care consultant on residents’ discharge have been emphasised and discussed at staff meetings. Information has been placed at each nurses’ station and has been positively received. These processes will ensure residents receive necessary care after discharge from hospital.

2.2 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 about health and personal care”. Team’s recommendation Does comply The home has systems in place 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:


•••• The home has a system to monitor and record professional and allied health staff authorities to practice.

•••• Medication management practices are monitored and reviewed for compliance.

•••• A system is in place to manage unexplained absences of residents in accordance with regulatory requirements.

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply Refer to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. The team verified that over the last year a range of education and training sessions have been attended in relation to health and personal care and some of these include diabetes, oral health, medication protocols and management, schedule eight (S8) medication, care planning for behaviours of concern, Parkinson’s disease, dementia, continence management, wound care, palliative care, catheter care, oxygen therapy, and medication competency assessments. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply

The home has systems, processes, policies and procedures to ensure that residents receive appropriate clinical care. The home conducts pre entry interviews to determine resident needs and to identify appropriate equipment, environment and technical interventions. All residents are assessed for their care needs and care plans developed are based on these assessments. Interventions are evaluated on a regular three monthly basis by the registered nurse and the deputy care team manager. Review of resident records demonstrates residents are regularly seen by their treating medical practitioner. Care staff are multi-skilled and have completed competencies such as, oxygen therapy, basic wound dressing and monitoring blood sugar levels and giving insulin via insulin pens. The provision of care is monitored via audits, surveys, collection of key performance indicators and the comments and complaints mechanisms. Residents/representatives interviewed said they are involved in care planning and residents’ individual needs and preferences are considered at all times. Residents also confirm that they receive appropriate care and are satisfied with the care provided.

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

Team’s recommendation Does comply

The home has an effective system to identify residents requiring specialised nursing care and ensure appropriately qualified nursing staff meet these needs. The clinical consultant is involved in pre-entry interviews to determine resident needs. Assessment procedures include initial and ongoing assessments. Appropriate care delivery is regularly reviewed and evaluated in consultation with residents/representatives including input from other health professionals as required. The clinical care consultant is on duty two days per week for the


provision of specialised nursing care. The home has access to consultants for advice regarding residents' specialised care needs. Staff training is provided to address specific care needs. Current specialised care needs include the management of diabetic care and catheter management. Residents interviewed by the team confirm their specialised nursing care needs are being met.

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


Southern Cross Apartments Marsfield has systems to ensure referral to appropriate health specialists occurs in accordance with residents' needs and preferences. Referrals occur as the need requires, with transport provided by resident representatives, or other appropriate transport arranged by the home. The home also organises health and related service referrals including, but not limited to, optometry, podiatry, speech pathology, physiotherapy, dietician, psychogeriatrician, dental, pathology, radiography, palliative care services, hairdressing, and audiometry. Staff liaise with the area health service to access health specialists as required, and the team sighted documented examples of resident referral to appropriate health specialists. The team reviewed clinical files where reports of these visits are filed and entries of these visits are also reported in progress notes. Resident/ representative interviews and review of documentation confirm that residents’ specialised nursing care needs are being met.

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


The home demonstrated that staff have the necessary knowledge and skills required to safely and correctly administer the medications prescribed by their medical practitioners. This includes secure and correct medication storage, incident reporting, and auditing of systems in place. The home’s medication management policy has recently been updated. Care staff administer medications to the residents from a multi dose packaging system. Education on medication management is conducted annually and as required for staff who administer medication. An accredited clinical pharmacist attends the home and undertakes medication reviews for all residents on an annual basis. The use of psychotropic medication is monitored and reviewed, and recommendations made and discussed with staff. Medication reports from these reviews are provided to the home and emailed to treating medical practitioners. A review of medication charts confirms that they are appropriately documented and contained relevant information. A random check of medications shows that all medications in use were within the expiry date. Schedule eight registers are reviewed on a weekly basis by two staff members. Residents interviewed by the team advised that they are satisfied with the care provided, including the management of medication.

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


The home’s approach to pain management includes the ongoing identification of individual resident’s pain management requirements ensuring all residents are as free from pain as possible. This includes initial and ongoing pain assessments using observation, discussion,


and pain assessment forms. Referrals to health professionals are organised as required. Documentation in resident records confirms that pain management intervention outcomes are identified. Residents are monitored for pain and appropriate action is taken. Effectiveness of strategies and medication administration is recorded in progress notes and pain charts. Complimentary strategies such as massage, heat/cold gel packs and exercise are used in conjunction with medication. Care staff are able to describe their role in pain management, including the identification and reporting of pain. Residents interviewed by the team confirm that pain management including complimentary therapies appropriately meets their needs.

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


The comfort, dignity and wishes of terminally ill residents are maintained and respected. During entry to the home, if appropriate, residents and relatives are given the opportunity to indicate any specific instructions in relation to palliative and terminal wishes. Terminally ill resident’s wishes are respected and acted upon. If required resources such as Greenwich hospital community palliative care service is used. The home has policies and procedures to assist the staff in the care of terminally ill residents and those requiring a palliative approach. Residents’ medical practitioners review residents in relation to pain management. Care staff manage residents’ pain, hydration, nutrition, physical and emotional needs. In addition staff are aware of the social implications for residents receiving palliative care. The home’s pastoral care team members are available for support of residents and relatives when required. Family and friends are also encouraged to be involved in palliative care matters. Resident/representative interviews confirm that they are comfortable with the knowledge that their wishes would be considered and respected. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”.


The home can demonstrate residents’ nutrition and hydration needs are assessed and strategies are implemented to promote the residents’ well being. Nutritional and dietary assessments are completed on entry and as required to identify food preferences and nutritional risk. This information is documented in the residents’ electronic care plans that can be accessed by appropriate staff. Residents have an opportunity to provide feedback on their satisfaction with meals through forms, regular resident meetings and resident surveys. The residents are offered a varied, healthy and well balanced diet that is developed to also meet the likes and dislikes of the residents. Residents are weighed on admission and regularly thereafter. Medical practitioners are contacted to review residents identified with problematic weight loss/gain and appropriate action implemented. Residents with a poor appetite are supplied with dietary supplements and high protein drinks. Care staff have received education on nutrition and hydration and appropriate feeding of residents with swallowing difficulties. Care staff demonstrated an understanding of the residents’ dietary needs, residents’ swallowing pattern and/or food refusal. Staff report any changes in these areas. Residents are very happy with the food choices provided to them by the home.


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


The home can demonstrate residents are provided with care and services, which promote general health and well being, ensuring skin integrity is maintained. The home also monitors accidents/incidents including wound infections and skin tears and acts appropriately on trends identified. Staff undertake a holistic approach to skin integrity, ensuring individual resident’s nutrition, hydration, continence, mobility and activity is reviewed to assist in the maintenance of their skin integrity. Residents’ skin integrity is assessed and care plans developed that identify issues relating to personal care, continence, manual handling, hair and nail care. The home provides appropriate devices to manage residents’ skin integrity, for example, moisturising creams and pressure relieving mattresses. A podiatrist visits the home regularly. The team reviewed residents’ wound charts that include a photo of the wound, size and state of wound, type of treatment and report on the state of healing. Wound infection and pressure injury statistics are collected monthly and are reported as key quality indicators. Residents/representatives comment that residents’ skin integrity issues are appropriately treated and that there are referrals to appropriate specialists and allied health professionals.

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


The home can demonstrate residents’ continence needs are assessed, monitored and evaluated to ensure that residents’ continence is managed effectively to promote residents well being and dignity. The system includes individual continence assessments, and the development of individualised care plans. These include the type of continence aids and bedding required, dietary and fluid intake, toilet times and aperients required. Residents’ choice and maintenance of dignity is considered when determining the types of aids for residents. Staff report individual continence programs are documented and they are aware of individual resident’s identified needs. Education is provided three monthly to staff to ensure correct management of continence aids. Care staff monitor bowel management via daily recording and reporting. High fibre foods, fruit and juices are included in residents’ diets. Infection data, including urinary tract infections, is regularly collected, collated and analysed. Resident interviews demonstrate they are satisfied with the home’s approach to continence management.

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


The home ensures that the needs of the residents with challenging behaviours are monitored and managed effectively. All residents are assessed to determine if any challenging behaviours are exhibited. Following assessment, an individualised care plan is developed that includes strategies to address residents’ specific needs. Episodes of challenging behaviour are recorded, monitored closely and evaluated regularly to determine the effectiveness of interventions. Care conferences are conducted as required to discuss behavioural issues. Care treatments and routines are flexible to minimise verbal and physical aggression. Episodes of challenging behaviour are documented on accident/incident forms,


and risk management strategies are implemented in response to the behaviour. The home has access to specialist consultants including the geriatric mental health team and a psychogeriatrician. The team reviewed referrals and a report from the mental health team with links to the resident’s progress notes and behaviour care plans. Staff confirm there is ongoing education in managing challenging behaviours and could demonstrate how to identify and manage residents’ behaviour. Residents/representatives interviewed comment that they are satisfied that behaviours of concern are addressed appropriately and that resident distress is minimised by the approach adopted by the home.

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


Residents’ mobility, dexterity and rehabilitation needs are assessed on entry to the home to ensure optimum levels of mobility and dexterity are achieved for all residents. Physiotherapy assistants assist the physiotherapist with residents’ mobility and provide support for the exercise programs. Residents’ responses to mobility and physiotherapy care plans are monitored and evaluated. Gentle exercise or chair aerobics groups are held daily to promote range of movement, dexterity, continence, circulation, breathing and balance. Residents attending chair aerobics commented they look forward to the sessions with a resident commenting they had increased range of movement. Walking groups are also offered to encourage exercise and time spent outdoors. The home utilises the services of the recreational activity team to also implement mobility and exercise programs. A falls prevention program is provided for residents identified as having a high risk of falls. Additionally these residents are encouraged to use hip protectors, assessed as to correct footwear, and medication reviews are undertaken. The team observed residents using mobility aids and handrails suitably placed throughout the home. Falls/slips and fractures are monitored and recorded monthly as a key quality indicator. Staff are also provided with safe manual handling training. The team observed residents who were enjoying chair aerobics as part of the home’s exercise program.

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


The home has systems to ensure residents’ oral and dental health is maintained. Review of residents’ clinical and care information and interviews with staff and residents confirms that each resident’s needs are assessed on entry to the home and on an ongoing basis. Dental and oral assessments indentify deficits in taste, smell, swallowing, posture, and show the need for aids and prosthesis. Special diets such as blended, soft food or thickened fluids are arranged as required, and recorded on residents’ care plans. Care staff assist or prompt residents with tooth and denture cleaning and report any changes in oral health. Access to external dentists and dental technician services are available by appointment. Staff interviewed demonstrated knowledge of oral care and residents that require assistance with their dentures. Residents/representatives report that residents are assisted with their oral care when required.


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


The home has a system to identify and effectively manage residents’ sensory losses. The system includes initial and ongoing assessment of residents’ sensory needs and the development of a plan of care that incorporates these needs. Activity programs address the need of residents with sensory loss. The local library visits weekly with a large assortment of literature and residents have access to large print books, and "talking books" and audio tapes are accessed if required. Appropriate referrals are made to external agencies to provide goods and service to vision and hearing impaired residents Care staff are able to describe their roles in maintaining sensory aids such as spectacles and hearing aids. Residents interviewed by the team express satisfaction with the care provided, including the management of sensory loss. The activity program incorporates sensory stimulation, such as hand massage, music, garden walks and cooking. Special cutlery and crockery are available for residents with impaired dexterity. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”.

Team’s recommendation Does comply The home ensures residents are able to achieve natural sleep patterns through initial and ongoing identification of night care requirements and sleep assessment. Residents are encouraged to maintain their natural bed times, for example residents may choose to read or watch television before retiring. Residents are assessed for their sleep patterns and night staff develop care plans to specifically address individual resident’s sleep needs. Single rooms allow for music and low light environments. Residents are also encouraged to remain active during the day. Staff report they have attended education on non-pharmacological alternatives that may be used to enhance residents’ sleep. Strategies include food or a warm drink or snacks, relaxing music, appropriate continence management, one-to-one time, interventions and night sedation if ordered by a doctor. Residents interviewed report that the home’s environment is quiet at night and they are assisted to achieve natural sleep patterns.


Standard 3 – Resident lifestyle Principle: Residents 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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system which exists in the home. Examples of improvements over the past year in relation to Accreditation Standard Three include:

•••• Management identified a lack of familiarity with the details of residents’ social profile information and documentation and have introduced processes to improve this. A training package has been developed and during orientation new staff are partnered with the leisure and lifestyle co-ordinator. Staff have received education on the value of the social profile in facilitating residents’ self expression and policy for completion. Staff are increasingly recognising and respecting residents’ individuality and getting to know them better.

•••• The activity program has been reviewed and to increase activities for residents with dementia an outdoor gardening program developed. Raised garden beds have been installed and residents enjoy this activity. It was also identified that there was an increased need for one-on-one support for residents with wandering tendencies. Pastoral care workers have been trained and additional assistance is now being given which enhances residents’ lifestyle.

•••• To provide varied activities for residents from different cultural backgrounds one-on-one support is given. Staff have gained knowledge of various cultures and beliefs and weekly religious readings have been introduced. This has been very effective with positive feedback received from both residents and their families.

•••• A monthly coffee shop ‘Chat café’ is held on a Saturday afternoon to provide a social gathering for residents. This is open to family and friends with cakes and drinks available for purchase for a nominal fee in a café environment. All funds raised are used for additional resources for resident activities.

3.2 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, about resident lifestyle”. Team’s recommendation Does comply The home has systems in place 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 Three include:

•••• New residents receive a resident agreement which includes information provided in accordance with regulatory compliance such as security of tenure and residency rights and responsibilities.

•••• All staff sign a confidentiality statement in relation to resident information.

•••• A system is in place for compulsory reporting in accordance with regulatory requirements.


3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply Refer to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. The team verified that over the last year education and training sessions have been attended in relation to resident lifestyle and some of these include privacy, confidentiality, compulsory reporting, social profile documentation, and Certificate IV in Leisure and Lifestyle. 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s recommendation Does comply The home has a system to ensure residents receive support in adjusting to life in the home and on an ongoing basis. All residents receive a welcome card and flowers on day of arrival. Care staff undertake the initial entry process, while the lifestyle coordinator is involved in the social history, lifestyle and cultural assessment of the residents. Residents’ emotional needs are assessed on an individual basis with consideration for their background, family dynamics and physical health. The care staff informed the team of ways in which they provide residents with emotional support. These include encouraging residents/ representatives to bring the resident’s own special belongings to decorate their new room, creating a homelike feel. Staff introduce the new resident to other residents and staff members. The team observed staff interactions with residents that showed warmth, respect, empathy and understanding. Residents are extremely satisfied with the way that staff support them and make them feel welcome to the home. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s recommendation Does comply The home has a system to ensure that residents are assisted to achieve and maintain maximum independence and friendships and to participate in community life within and outside the home. Individual care plans and the recreational program support the resident’s social independence. Strategies are also developed to maximise community involvement. Residents are able to make choices for themselves in the attendance of social and spiritual events. The activities program is designed to facilitate independence and community participation within the community such as bus trips. The team observed residents with family members returning from an external community event. The effectiveness of the assistance provided to residents in relation to their independence is monitored through regular review of care plans and resident satisfaction surveys, comments and complaints and resident/representative meetings. Documents reviewed confirm residents’ individual care needs are identified, assessed and strategies are implemented to maintain maximum independence. Residents interviewed state they are encouraged to maintain their independence and participate in community life. Residents’ ability to make choices is


facilitated and respected including their right to participate or not in the activities and community life offered at the home. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s recommendation Does comply Resident/representative interviews confirm that residents’ privacy and dignity is respected at all times. Residents’ personal preferences and needs for privacy are documented on care plans. The team’s observation of staff and resident interaction show that staff respect the privacy and dignity of residents. Observations include staff knocking and waiting for permission before entering residents’ rooms, and referring to residents by their preferred name. Staff sign privacy and confidentiality statements. The team observed personal information stored securely. Residents’ clinical records are stored in cupboards that are locked and electronic care information is protected by password access by authorised staff only. The team was advised the shredding of documentation via an external provider promotes containment of private information. Written consent is obtained from residents to place photographs on display and publish their names in newsletters. Staff are educated on elder abuse and neglect during orientation, annually, and as required. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s recommendation Does comply The home encourages and supports residents to participate in a wide range of interests and activities that are of interest to them. Initial assessment of residents includes understanding each resident’s leisure interests and social life. Each resident is visited by the lifestyle coordinator who discusses recreational assessment and lifestyle choices including socialisation. Residents’ leisure interests are identified and this information is used in resident care planning. Residents are encouraged to provide feedback regarding programs either face to face or via resident meetings. The activities program is announced daily to all residents and displayed on the activity notice board for easy access. Residents with vision impairments are given a large version of the same program. A special program for the dementia specific area has been developed by the lifestyle coordinator for care staff in this area to implement. Group and one to one activities are conducted including hand and foot massages, cooking, reminiscence sessions and concerts. Documentation review and interviews with residents confirmed linkage between residents’ individual interests and the activity programs offered by the home. Residents report that they are satisfied with the range of activities on offer, are asked for their ideas and can choose whether or not to participate. 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 recommendation Does comply The home can demonstrate that residents’ individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. The resident handbook and monthly newsletters refers to activities and chaplaincy services. A spiritual assessment and cultural history is completed with the resident’s preferred practices identified and respected.


Residents are actively encouraged to maintain cultural and spiritual links in the community. Church services held weekly include Presbyterian, Salvation Army, Uniting Church and Baptist. Catholic communion is provided in resident’s rooms. Pastoral carers assist residents with cultural, spiritual care and emotional support. Provision is also made for the celebration of special days such as Australia day, ANZAC day, Christmas day and Easter. Care staff come from a variety of cultural backgrounds and attend education on all aspects of spiritual and cultural diversity. Residents interviewed expressed a high level of satisfaction with the pastoral care services and report their cultural and spiritual needs are being met. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s recommendation Does comply The home ensures residents/representatives participate in decisions about the services the resident receives, ensuring residents exercise choice and control over their lifestyle. The resident charter of rights and responsibilities and comments and complaints mechanisms are discussed pre entry and are also documented in the residents’ handbook. Choice and decision making is discussed at care conferences. Each resident’s right to refuse treatment is recognised and documented in their clinical record. A review of documentation including care plans and minutes of residents’ meetings show residents and their representative exercise choice and control over their care and lifestyle without impinging on the rights of others. During the initial assessment process residents/representatives are involved in making decisions about services offered by the home. Services include personal care, choice of doctor, meal choice, and the level of involvement in activities. As relevant, new residents are given “Let me decide” (advanced care directive booklet). Residents who wish to are assisted to maintain their community requirements through voting. The team observed staff consulting with residents about their day-to-day wishes and preferences. Residents report that they are provided with sufficient up to date information to assist with their choices and decisions regarding their care and lifestyle at the home. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s recommendation Does comply The home is able to demonstrate that residents have secure tenure within the home and their rights and responsibilities are understood. Prior to entering the home relevant information about security of tenure, residents’ rights and responsibilities, feedback mechanisms and financial requirements is provided and discussed with residents and their representatives. This information plus specified care and services are included in the resident handbook and agreement offered to residents. The home enables ‘ageing in place’ however if it becomes necessary for any changes in room or location this is done in consultation with residents and/or their representatives. Ongoing communication with residents and/or representatives is through meetings and notices on display and those spoken with state they are kept informed. The Charter of Residents’ Rights and Responsibilities is displayed in the home. Residents/representatives interviewed feel secure with residency in the home and confirm awareness of residents’ rights and responsibilities.


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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system which exists in the home. Examples of improvements over the past year in relation to Accreditation Standard Four include:

•••• Concerns were raised about the cleanliness of carpets on each floor. A contractor has been organised to clean carpets on a regular basis in main areas and corridors. New linoleum floor covering has replaced torn and soiled carpet in some areas including the special unit and some resident rooms, and this is ongoing. This covering is much easier to keep clean and eliminates odours.

•••• Access and exits to the building were reviewed to ensure systems were in place for the provision of a safe and secure living environment for residents. Following an investigation of options a door alarm system has been implemented. Processes have been introduced for deliveries by contractors. All doors have keypad security and additional sensor alarm systems have been installed.

•••• Management identified an apparent unreliability in staff incident reporting. A ‘tool box’ session on incident reporting was implemented and was included in staff meetings over a month. Staff said this was very educational and was effective in alerting them to reporting requirements.

•••• A preferred supplier has been appointed by the organisation to provide dry, chilled and frozen foods. This will improve processes for the delivery of goods and provide cost benefits to the organisation. The cook has commenced ordering all frozen goods from the supplier without any problems.

4.2 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, about physical environment and safe systems”. Team’s recommendation Does comply The home has systems in place 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 Four include:

•••• Staff have attended compulsory training on fire safety and manual handling and these are conducted annually.

•••• A fire safety statement meets regulatory requirements.

•••• A food safety program is in place and a NSW Food Authority licence is held to comply with legislation for vulnerable persons.


4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply Refer to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. The team verified that a range of education and training sessions have been attended over the last year in relation to the physical environment and safe systems and some of these include fire safety, manual handling, infection control, food safety handling and nutrition, chemical safety, OH&S, gastroenteritis outbreak management, personal protective equipment, hazard analysis critical control point (HACCP) food safety, and appliance temperature recording. 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 recommendation Does comply A review of documentation and interviews with staff confirm the home has systems in place to provide a safe and comfortable environment consistent with residents’ care needs. Environmental inspection reports, risk assessments, and maintenance records demonstrates hazards are identified and managed. Internal and contractor preventative maintenance schedules are in place and maintenance staff attend repair requests as required. Regular audits ensure that residents’ rooms, communal and outside areas are safe and well maintained. Residents are accommodated in single rooms with ensuites on three floors and residents are encouraged to personalise their rooms. Rooms are fitted with ceiling fans and wall heaters, and communal areas are air conditioned. All resident rooms and bathrooms are fitted with nurse call alarms which are checked monthly. Pleasant dining rooms and sitting areas on each floor provide a homelike atmosphere. The team observed well lit corridors with handrails and clear signage. Residents have access to outside balconies and paved garden areas. A secure garden area is provided for those residents inclined to wander. Risk assessments and preventative processes such as equipment checks and electrical appliance inspections are conducted to ensure safety. A keypad secure environment is provided. Informal and formal staff inspections ensure the living environment is well maintained and resident/representative interviews confirmed this. 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 recommendation Does comply The home has a system in place to ensure that management and staff are actively working together to provide a safe working environment that meets regulatory requirements. A review of documentation confirms the system involves risk assessment, audits, inspections, hazard and accident reporting systems, and training in safe work practices and procedures. Occupational health and safety (OH&S) matters are addressed at staff meetings with transferral to the continuous improvement program as appropriate. A staff member is a trained OH&S representative and a return to work co-ordinator is accessible at head office. Policies, procedures and notices inform staff and OH&S training is given to all staff during


orientation and annually. All staff are required to have completed first aid training. An external supplier provides education in safe chemical handling. The team observed safe work practices, personal protective equipment and clothing, and first aid kits readily available. Interviews confirm staff awareness of OH&S practices and attendance at compulsory 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 recommendation Does comply The home has systems in place to minimise fire, security and emergency risks which include regular maintenance checks of fire fighting equipment, alarms and systems by an external company. Fire and emergency policies, procedures and notices inform staff and ready reference emergency procedure flipcharts are displayed at various locations. Staff interviews demonstrate awareness of procedures and confirm compulsory fire training is attended. Fire procedures for residents are displayed behind residents’ doors. Checks by the team confirm a resident evacuation folder which includes mobility status is available, evacuation plans and signage are in place, and emergency exits are free from obstruction. Fire fighting equipment inspection and testing is current, and an annual fire statement is on display. Preventative processes include environmental audits, appropriate electrical appliance inspections and a designated smoking area. Security measures for the home include keypad, sensor alarm and lighting systems, video surveillance and night lock up procedures. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply Documentation, staff interviews and observation of staff practices demonstrates the home has an effective infection control program. Use of personal protective equipment/clothing and colour coded equipment is observed in all areas. Staff interviewed demonstrate awareness of infection control. The home accesses infection outbreak information from head office and government departments. Guidelines, procedures and outbreak packs are available. Staff practices are monitored and infection statistics are recorded, analysed and reviewed monthly. Infection control training is given at orientation and annual attendance is compulsory. Hand washing competency assessments are conducted annually. A food safety program, cleaning schedules, and laundry practices are observed to follow infection control guidelines. External providers are used for contaminated waste collection and pest control services. Hand wash basins, sanitising agents and emergency supplies are readily available. Sharps’ containers and spill kits are accessible. A vaccination program is available for staff and medical officers provide vaccinations to residents. 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 recommendation Does comply Documentation, staff interviews and observation confirm that processes, policies, and duty statements are in place for all aspects of hospitality services. Care service employees attend cleaning, laundry, and catering duties, and schedules and operational procedures are in place. Observation and interviews confirm they are conducted in accordance with infection


control and OH&S guidelines. Interviews with residents/representatives confirm satisfaction with hospitality services. Catering A seasonal menu of meals is cooked onsite by a cook. Meals are collected and taken to satellite kitchens on each level for serving. A food safety program is in place and food preferences, allergies, and special dietary needs are identified and communicated to the cook and to care staff. Interviews with staff confirm awareness of safe food handling. Residents have access to meal feedback forms and discuss menus at meetings. Cleaning Cleaning services are provided by care staff and are conducted according to set schedules, and as required. Extra cleaning duties are scheduled on weekends. Residents’ rooms and all common areas were observed to be clean. Staff interviews demonstrated a working knowledge of safe chemical use and an awareness of infection control procedures. The team observed colour-coded cleaning equipment in use. Laundry Care staff launder residents’ personal items seven days a week and linen is laundered by an external contractor. Observation and staff interviews demonstrates laundry operations are in accordance with infection control guidelines. Residents have access to their own laundry if they prefer. Procedures are in place for delivering residents’ personal clothing and linen and the team observed linen storage and available supplies.