andrina aged care...andrina aged care racs id 4525 80 william road carrum downs vic 3201 approved...

Andrina Aged Care

RACS ID 4525 80 William Road

CARRUM DOWNS VIC 3201

Approved provider: Kwok Nominees Pty Ltd

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 01 September 2019.

We made our decision on 07 July 2016.

The audit was conducted on 07 June 2016 to 08 June 2016. The assessment team’s report is attached.

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

Home name: Andrina Aged Care RACS ID: 4525 2 Dates of audit: 07 June 2016 to 08 June 2016

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 care recipients, 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:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care 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 Care recipient security of tenure and responsibilities

Met

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.





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

Andrina Aged Care 4525


Introduction

This is the report of a re-accreditation audit from 07 June 2016 to 08 June 2016 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 07 June 2016 to 08 June 2016.

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: Gillian Walster

Team member/s: Rebecca Phillips

Approved provider details


Details of home

Name of home: Andrina Aged Care

RACS ID: 4525

Total number of allocated places:

50

Number of care recipients during audit:

44

Number of care recipients receiving high care during audit:

38

Special needs catered for: no

Street/PO Box: 80 William Road

City/Town: CARRUM DOWNS

State: VIC

Postcode: 3201

Phone number: 03 9784 2800

Facsimile: 03 9784 2899

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Director of Nursing 1

Clinical care coordinator 1

Clinical/care staff 7

Catering staff 2

Care recipients/representatives 7

Pharmacist 1

Lifestyle and leisure staff 2

Environmental staff 3

Sampled documents

Category Number

Care recipients’ clinical files and care plans 6

Care recipients’ leisure and lifestyle files and care plans 6

Care recipient agreements 4

Medication charts 10

Personnel files 6

Other documents reviewed

The team also reviewed:

Activities calendar and associated documentation

Allocation list

Catering documentation including temperature logs, cleaning schedules and menus

Clinical charts and forms

Continuous improvement register and associated documentation

Dietary records

Education training plan, summary sheet and feedback forms

Emergency response action instructions including evacuation lists


Emergency risk assessment and management form

External contractor documentation

Fire service records

Food safety plan

Infection register

Information for care recipients, their families and staff including handbooks

Maintenance schedules – preventative and reactive

Mandatory reporting register

Material safety data sheets

Meeting minutes

Newsletter

Occupational health and safety plan/register

Pest management records

Police certificates, statutory declarations, nursing registration information

Position descriptions, duty statements, schedules and duty lists

Process maps

Professional development record

Quality management schedule and audits

Recruitment policies and procedures

Risk register including safety/restraint data record and annual records

Roster

Self-assessment

Vision, mission and care and management philosophies.

Observations

The team observed the following:

Activities in progress

Advocacy information on display

Archive area


Cleaning in progress

Clear exits, illuminated signage and evacuation maps

Complaints mechanisms – internal and external

Equipment supply and chemical storage areas

Firefighting equipment, fire panel and evacuation kits

Interactions between staff, care recipients and representatives

Internal and external living environments

Meal and refreshment services in progress and assistance to care recipients

Medications storage and administration

Noticeboards and information displays

Notification of reaccreditation audit on display

Outbreak kit

Palliative care kit

Short group observation in dining room

Sign in/out registers

Suggestion box

The ‘Charter of care recipients’ rights and responsibilities – residential care’ on display

Waste and pest management systems.


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 has a system to actively pursue continuous improvement across the Accreditation Standards. The system encourages input from staff, care recipients and representatives and ideas for improvement are identified through ‘continuous improvement action plans’, audit and incident results and formal and informal feedback mechanisms. Continuous improvements are documented on a corresponding register which management then monitor and evaluate for effectiveness. Relevant stakeholders are kept informed of improvements via electronic messaging systems, meetings and minutes, memoranda, display and formal and informal communication means. Care recipients, representatives and staff are satisfied that continuous improvement occurs at the home.

Examples of recent improvements relating to Standard 1 Management systems, staffing and organisational development include:

Review of the current storage system indicated that supplies and equipment were not always stored in an orderly fashion. This made it difficult for staff to locate particular items when needed. Management purchased additional shelving which then provided additional room for bulkier items to be stored on the ground which were then easier to access. Management and staff advise the increased room in the storage areas makes it easier to identify what supplies and equipment are available and helps with inventory processes.

To support the implementation of new software, management purchased new computer systems including laptops and tablets. The additional computers have increased accessibility for staff to the electronic network which includes the new electronic documentation system. Due to the portability of the tablets, staff can access care recipients’ information at the point of care and input data immediately, streamlining documentation processes.


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


Management has a system for identifying and maintaining compliance with relevant legislation, regulations, guidelines and standards. Management subscribes to various legislative services and are members of industry bodies to ensure they receive notification of changes in legislation. Reports of any changes undergo review and management then develops or modifies processes and corresponding procedures to meet the updated legislative requirements. Staff receive information of any regulatory changes through electronic messaging, handover and meetings. Management also determines if education and training is required to ensure staff compliance with the newly introduced or revised legislation, on an ongoing basis. Management then monitors staff practice to ensure alignment with current legislation through observation of practice, review of audits and incident data. Staff stated they receive information regarding regulatory compliance relevant to their roles and demonstrate knowledge of regulatory requirements.

Examples of recent improvements relating to Standard 1 Management systems, staffing and organisational development include:

There is a system to ensure all staff, volunteers and relevant contractors have current police certificates and statutory declarations as applicable.

There is a system to monitor the currency of professional registrations.

There was notification to stakeholders of the re-accreditation audit.


1.3 Education and staff development

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

Team’s findings


The education program ensures management and staff have appropriate knowledge and skills to perform their roles. The education calendar includes mandatory training sessions and topics in response to changes to regulatory compliance, staff feedback during performance appraisals, changes to processes and work practices and care recipients’ care requirements. Management offers a range of education topics delivered through in-house practical sessions, one to one training, video training packages, external facilitators and staff are encouraged and facilitated to upgrade qualifications. Management records and monitors staff education attendance and staff complete feedback forms for each session. Staff are satisfied with the education and development opportunities offered.

Education relating to Standard 1 Management systems, staffing and organisational development includes:

continuous improvement

electronic documentation package training

incident management and compliance with documentation requirements

understanding accreditation.

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


There are formal and informal comments and complaints processes that are accessible to care recipients, representatives, staff and visitors. Information regarding internal and external complaints mechanisms and advocacy services is made available to care recipients and representatives. A variety of communication strategies is utilised to encourage stakeholders to raise their feedback in person or document it using specific forms which are on display in the home. Staff are available to address any concerns care recipients or representatives have and escalate concerns to management if necessary. Management and staff practice ensures confidentiality of information and the availability of a suggestion box preserves anonymity if preferred. Care recipients and representatives are aware of the comments and complaints processes available to them and feel confident in using them if required.


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 organisation prominently displays its vision, mission and care and management philosophies at the home. This information is also available in a variety of publications the home distributes to care recipients, representatives and staff.

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


There are appropriately skilled and qualified staff to meet care recipients’ needs and lifestyle preferences. Management follows recruitment, selection and orientation procedures including qualification, police certificate and reference checking. Management monitors the roster to ensure the appropriate level and skill mix of staff reflects care recipients’ clinical and leisure needs. Staff are aware of the requirements of their roles through position descriptions, process maps and duty lists. Management monitors and maintain the skill level of staff through the education program and the staff performance appraisal system. Staff said the level and skill mix of staff is appropriate for care recipients’ needs. Care recipients and representatives are satisfied with the responsiveness of staff and quality of care provided.

1.7 Inventory and equipment

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

Team’s findings


The home has adequate stocks of goods and equipment to support quality of care and service delivery. Ordering of clinical and non-clinical supplies occurs through preferred suppliers and stock monitoring and re-stocking systems are in place. Goods are stored in secure areas and processes to monitor and maintain equipment include the availability of asset registers and a preventative and reactive maintenance program. Staff, care recipients and representatives are satisfied with the quantity and quality of supplies and equipment available.


1.8 Information systems

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

Team’s findings


Management ensures effective information management systems are in place. The quality management system which includes policies, procedures and process maps guide staff practice. Clinical and lifestyle documentation generally describes care recipients’ needs.

Management collects, collates and analyses key information to identify potential risks and improvement opportunities. Confidential information is stored securely, computer systems are password protected and management has a system for archiving and destroying documentation. Staff report they have access to information to help them perform their roles. Management communicates with care recipients and representatives through discussions, consultations, meetings, newsletters and noticeboards. Staff, care recipients and representatives are satisfied with the information provided by staff and management.

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 has a system that ensures externally sourced services are provided in a way that meets the home’s needs and quality goals. Management engages the services of external providers in response to specified care and service needs. There are specific agreements with external contractors that set out criteria and regulatory requirements.

Monitoring of external services occurs to ensure satisfaction of completed works via observations, inspections and feedback from stakeholders. To further monitor attendance of external services, contractors are required to sign in and out each time they visit. Care recipients, representatives and staff are satisfied with the environment which external contractors enhance with the provision of their services.


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 pursues continuous improvement related to health and personal care systems. Refer to expected outcome 1.1 Continuous improvement for detailed information regarding the home’s continuous improvement system and process.

Examples of recent improvements relating to Standard 2 Health and personal care include:

As part of a management initiative, an electronic documentation system was introduced to replace the existing paper based system. Management said the newly introduced system facilitates a streamlined approach to documentation management and assists in clinical monitoring.

To assist staff in taking care recipients’ temperature, management purchased an infrared thermometer. Management said the new device is less invasive than the previous thermometer, is easy to use and assists in the prevention of the spread of infections.

To provide more timely catheterisation, if required, of male care recipients, training was provided to registered nurses to become skilled in this task. Consequently there are now appropriately qualified staff on site to change catheters promptly as necessary, reducing the need to rely on external services.



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


Management and staff demonstrate there are systems and processes to identify and ensure compliance with relevant legislation, regulations, professional standards and guidelines related to care recipients’ health and personal care. Refer to expected outcome 1.2 Regulatory compliance for detailed information regarding the home’s regulatory compliance system and process.

Examples of responsiveness to regulatory compliance relating to Standard 2 Health and personal care include:

Management has processes to ensure medications are appropriately and securely stored.

Registered nurses supervise the provision of clinical care according to relevant legislation and care recipient needs.

Management has systems and processes to ensure compliance with legislation in the event of a care recipient’s unexplained absence.



Team’s findings


Management and staff have appropriate knowledge and skills to perform their roles in relation to health and personal care. Staff are required to complete a range of clinical education sessions and management encourages and supports further education. Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education system and processes.

Education relating to Standard 2 Health and personal care includes:

incontinence – back to basics

managing challenging behaviours

nutrition and hydration

Parkinson’s disease

sleep and sensory loss.


2.4 Clinical care

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

Team’s findings


There are processes to ensure care recipients receive clinical care appropriate to their needs and preferences. Assessments, care plans, progress note entries and charting of clinical observations inform management and staff of individual needs and requirements. There is a regular review process to assess care recipients and monitor the effectiveness of care provided. Appropriately qualified and experienced staff provide care, document clinical incidents and increased monitoring occurs when needed. Medical and allied health personnel review care recipients as required and there is ongoing consultation with care recipients and representatives regarding care recipients’ care. Care recipients are satisfied with care provided and said any episodes of ill-health or incident are responded to quickly and properly and representatives are informed as required.

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


There are processes to ensure the appropriate identification and management of care recipients’ specialised nursing care needs. Registered nurses oversee the complex care needs of care recipients. Care plans reflect the assessment and consultation process and include instructions, parameters and equipment required. There is adequate equipment and supplies to meet the specialised needs of care recipients and there is access to specialists and external health care services if required. Management provides policies, procedures, process maps and education to support staff in meeting care recipients’ complex care needs. Care recipients and representatives are satisfied with the specialised care provided.

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


Staff refer care recipients to appropriate health care specialists for review, advice and management in accordance with their health care needs and preferences. Care recipients have access to health professionals who visit the home regularly as well as when requested by staff to manage individual care recipient needs. Staff assist care recipients to access outside providers when necessary and inform representatives of the referral process and any arrangements needing their input. Staff maintain records of specialist reviews and carry out care according to instructions. Care recipients are satisfied referrals to health and related services occur in line with their needs and wishes.


2.7 Medication management

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

Team’s findings


There is a system to safely and effectively manage care recipients’ medication. Policies, procedures, medication charts and care plans guide staff in the administration of each care recipient’s medications. Medications are stored according to regulatory and manufacturers’ requirements, checking mechanisms are in place and processes ensure consistent supply and disposal of medication. There are audits to monitor the system, an external pharmacist reviews care recipients’ medications and the medication advisory committee meets regularly to discuss issues, policies and improvements. Policies and procedures guide staff in the administration of medication. Care recipients are satisfied with medication management.

2.8 Pain management

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

Team’s findings


There are processes to ensure care recipients are as free as possible from pain. Staff conduct pain assessments using verbal, non-verbal and behavioural indications of pain. The physiotherapist contributes to pain management and interventions provided by staff and the physiotherapist include medication, medical and medication review, massage, heat packs, repositioning and exercise programs. Staff monitor care recipients’ pain, record the use and effects of interventions and strategies used to relieve pain and refer to care recipients’ medical officers as required. Management provides education to staff regarding pain management. Care recipients and representatives are satisfied with staff assistance to manage care recipients’ pain.

2.9 Palliative care

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

Team’s findings


Staff provide care recipients with end of life care that ensures their comfort and respects their dignity. Care recipients and representatives have the opportunity to discuss their advanced care requests and complete documentation which details preferences during the palliative stage. Staff access medical care for care recipients as necessary and make referrals to external services if required to provide additional support. Care includes nursing and complementary care and care plans include management of symptoms, pain management, pastoral and spiritual care, cultural considerations and social emotional support. Staff maintain the comfort and dignity of care recipients, consult with representatives regarding the care environment and their role during palliative care and offer support to families at this time.


2.10 Nutrition and hydration

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

Team’s findings


There are processes to ensure care recipients receive adequate nourishment and hydration. Staff consult with care recipients and representatives to identify and assess each care recipient’s nutritional needs and preferences and to establish the level and type of assistance required. Staff monitor care recipients’ weights and follow policies, procedures and process maps to manage any weight loss or gain. Nutritional supplements and individualised strategies such as provision of finger food and sequencing of meals are provided as required. Catering staff provide meal choices and maintain current documentation of preferences, allergies, specialised diets, texture modified diets and fluid needs. Aids assist care recipients’ independence and where needed, staff provide assistance during meals.

Care recipients are satisfied with the quality and variety of food and beverages provided.

2.11 Skin care

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

Team’s findings


There are processes to promote care recipients’ skin integrity consistent with their overall health. Staff assess care recipients’ skin integrity to identify risks which may impair their skin integrity. Care plans outline strategies to prevent skin breakdown including the application of moisturisers and the use of protective devices and pressure relieving equipment. Staff assist care recipients with ambulation, position changes when needed and manage skin tears and wounds. Staff are provided with education and resources to effectively manage wounds.

Management monitors and evaluates the effectiveness of skin care and injury prevention and monitors skin integrity and pressure injury incidents. Care recipients 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


There are processes to ensure care recipients’ continence needs are managed effectively. Staff assess each care recipient’s continence needs and document the level of assistance necessary and continence aids if required. Staff review and update care plans regularly and as care recipients’ needs change. Continence aids are stored discreetly and staff said sufficient supplies are maintained and they attend education in relation to continence management. While assisting care recipients with continence management staff support them to maintain


their dignity and independence. Care recipients are satisfied their continence needs are met and aids are provided as necessary.

2.13 Behavioural management

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

Team’s findings


There are processes to ensure the needs of care recipients with challenging behaviours are managed effectively. Staff assess care recipients and identify medical, emotional and cognitive reasons for challenging behaviour. Policies, procedures, process maps and resources are in place to manage challenging behaviours. Staff are encouraged to complete education in caring for care recipients living with dementia. Staff access specialist practitioners and advisory services for care recipients who require additional review for the management of challenging behaviours. Care recipients are satisfied with the way in which staff manage care recipients’ challenging behaviours.

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 promote and optimise care recipients’ mobility and dexterity. Care plans include details of assistance required, aids used and falls prevention strategies to enhance care recipients’ independence. Staff consult with specialists and allied health professionals and use mobility and transfer aids, sensor mats, hip protectors and dexterity aids such as adaptive cutlery and crockery to maximise care recipients’ mobility and dexterity. Staff follow policies, procedures and process maps when incidents occur where care recipients have fallen. Appropriate transfer equipment is available and staff undertake manual handling training. Care recipients are satisfied with staff assistance to achieve optimal mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


There are processes to maintain care recipients’ optimal oral and dental health. Staff assess care recipients’ oral and dental needs and preferences. Staff assist care recipients with brushing teeth, denture and oral care as needed and issues identified are reported to the care recipient’s medical practitioner. Dental and speech pathology appointments are arranged and facilitated as required. Specific strategies which include texture modified diets, aids and assistance with meals are formulated for care recipients with swallowing difficulties. Care recipients are satisfied with the home’s approach to managing their oral and dental care.


2.16 Sensory loss

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

Team’s findings


There are processes to identify and manage the impact of care recipients’ sensory losses. Staff assess care recipients’ sensory needs to identify a decline or loss and determine any required interventions. Staff consult with specialist service providers about the effective management of sensory losses and needs. Management conducts audits and inspections to ensure the home is safe and uncluttered and provides safe accessibility for care recipients with sensory difficulties. Staff assist care recipients who require help with the care, maintenance, fitting and cleaning of aids and devices. Care recipients are satisfied with staff assistance with their sensory needs.

2.17 Sleep

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

Team’s findings


Care recipients are supported to achieve natural sleep patterns. Staff complete sleep assessments to determine care recipients’ natural sleeping patterns, settling and rest requirements. Care plans detail individual preferences and needs including preferred settling times, routines, bedding and environmental preferences for sleep. Both medication and non- medication interventions are used to promote sleep when needed. To help care recipients sleep staff ensure they are comfortable, free from pain where possible, that noise and light are at a minimum and supper and warm drinks are provided. Care recipients said the home is quiet at night and that they sleep well.


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 pursues continuous improvement related to care recipient lifestyle systems. Refer to expected outcome 1.1 Continuous improvement for detailed information regarding the home’s continuous improvement system and process.

Examples of recent improvements relating to Standard 3 Care recipient lifestyle, include:

To enhance the independence of a care recipient who required continuous oxygen therapy, management arranged for the purchase of an oxygen concentrator. Management and staff advise the concentrator is easier to manoeuvre than the oxygen cylinder and provides the care recipient with opportunities to be more mobile. As a consequence the care recipient is engaging in a larger range of activities which enhances socialisation and provides more opportunities for choice and decision making.

In response to care recipient feedback, staff facilitated the creation of individual gardens. Allocating gardens to specific areas outside the rooms of those who wish to participate, care recipients tend garden beds and pot plants, decorating these areas how they wish. The newly introduced activity enhances socialisation, increases independence and provides opportunities for care recipients to reminisce about their own gardens. Management state care recipients gain a high level of pleasure and pride in creating something themselves, for all to enjoy.

Following review of literature regarding enhancing the quality of life of care recipients living with dementia, management made available reminiscence boxes. These boxes include a range of different materials that prompt care recipients to engage in tasks they are familiar with. Such resources include socks, clothes pegs and cleaning utensils. Management and staff advised the availability of these boxes which provide self-directed activities contribute to a more relaxed environment and reduction of episodes of behaviour.



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


Management and staff demonstrate there are systems and processes to identify and ensure compliance with relevant legislation, regulations, professional standards and guidelines related to care recipients’ lifestyle. Refer to expected outcome 1.2 Regulatory compliance for detailed information regarding the home’s regulatory compliance system and process.

Examples of responsiveness to regulatory compliance relating to Standard 3 Care recipient lifestyle include:

Management has processes to manage mandatory reporting requirements.

Care recipients receive information on their rights and responsibilities, security of tenure, care and services provided by the home and complaints mechanisms in their information booklet and residential agreement.

‘Charter of care recipients’ rights and responsibilities – residential care’ is prominently on display.



Team’s findings


Staff have the appropriate knowledge and skills to perform their roles in relation to care recipients’ lifestyle. Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education system and processes.

Education undertaken relating to Standard 3 Care recipient lifestyle includes:

grief and loss

mandatory reporting, elder abuse

optimising independence, mobility and dexterity

three staff currently undertaking a certificate four in leisure and health.


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 demonstrate each care recipient receives emotional support adjusting to life in the new environment and on an ongoing basis. On entry to the home, all care recipients receive an information booklet which includes details of the care and services provided. Additional support is provided during this time to assist care recipients to settle into the home. Lifestyle staff establish individual social and emotional preferences and develop strategies to support these. Socialisation through activities which include both group and individual sessions enhances emotional support. Staff described emotional support strategies they provide to both care recipients and representatives especially during the provision of palliative care. Care recipients and representatives spoke positively about staff skills and attitude stating care recipients receive appropriate emotional support.

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 encourage care recipients to achieve maximum independence and maintain community ties and friendships. The home’s assessment process identifies each care recipient’s needs and preferences for maintaining independence. Lifestyle staff develop activities based on these preferences and include bus outings, exercise programs, and links with community groups. Friends and family are welcome to visit the home throughout the day and evening and there is a range of internal and external areas throughout the home that can host social gatherings with friends and family. Staff encourage care recipient independence through the use of equipment such as mobility aids and specialised crockery and cutlery.

Care recipients and representatives are satisfied staff assist care recipients to be as independent as possible.

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 demonstrate there are processes to recognise and respect each care recipient’s privacy, dignity and confidentiality. Care recipients’ information is stored electronically which is accessible by user initiated password only. Each care recipient has a single room with a private ensuite and there are facilities available for care recipients to store their valuables securely. Staff have access to care recipient information that includes their


preferred name and specific wishes during the terminal phase of their life, to maintain dignity at all times. Staff assist care recipients in a respectful manner, knock on doors before entering care recipients’ rooms and provide care and services according to care recipients’ wishes as outlined in the care plan. Availability of sitting areas provides additional space for care recipients and their visitors to use privately. Care recipients and representatives are satisfied staff treat care recipients with both dignity and respect.

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


Management and staff demonstrate there are processes to encourage and support care recipients to participate in a wide range of interests and activities they enjoy. On entry to the home, lifestyle staff establish care recipients’ interests, cultural and spiritual preferences and likes and dislikes. Based on this information, staff invite care recipients to attend activities including both group and individual sessions. Care recipients are notified of the activity schedule via the monthly newsletter and through noticeboard displays. The activity program has a range of leisure options to cater for all levels of ability and includes interaction with community organisations, bus outings, quizzes, music art and craft. Care recipients and representatives said care recipients are encouraged to attend the lifestyle program and are satisfied with the activities available.

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


Management and staff demonstrate there are processes to ensure care recipients’ individual customs, beliefs and cultural backgrounds are fostered and valued. On entry to the home, staff establish care recipients’ cultural and spiritual preferences. Activities are incorporated into the monthly schedule to align with care recipients’ specific cultural and spiritual backgrounds. Based on personal preferences, care recipients can attend celebrations of specific cultural and religious days. Kitchen staff enhance such celebrations through the provision of food specific to the theme of the day. There are regular church services at the home and access to other religious personnel ensures religious needs of all care recipients are met as required. Care recipients and representatives are satisfied with the cultural and spiritual support provided for care recipients.


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 demonstrate there are processes for care recipients to exercise choice and decision-making while not infringing on the rights of others. Care recipients have input into the services they receive such as preferred rising and settling times, food and dining preferences and preferred title and name. Care recipients and representatives are encouraged to provide feedback about the care provided via formal mechanisms such as meetings, improvement forms and satisfaction surveys. There is a wide range of activities on offer and care recipients can choose their participation levels. Care recipients and representatives are satisfied staff acknowledge and respect care recipients’ preferences and choices. Care recipients said other care recipients in the home do not infringe on their rights.

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


Management and staff demonstrate there are processes to ensure care recipients have secure tenure within the service and understand their rights and responsibilities. On entry to the home, all care recipients receive an information booklet and residential agreement which includes a copy of the ‘Charter of care recipients’ rights and responsibilities – residential care’. This information also includes details on security of tenure and specified care and services. Consultation occurs with care recipients and representatives if there is any alteration to specified care and services and preceding any change to accommodation arrangements. Care recipients and representatives are satisfied with the security of tenure provided by the home.


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


The home pursues continuous improvement related to the physical environment and safe systems. Refer to expected outcome 1.1 Continuous improvement for detailed information regarding the home’s continuous improvement system and process.

Examples of recent improvements relating to Standard 4 Physical environment and safe systems, include:

To encourage care recipients to utilise the existing garden space, management purchased new furniture. This included new benches which are heavier, more stable and ergonomically designed. Management advised since the purchase of the new furniture an increase number of care recipients utilise this area, under the gazebo. We observed care recipients and representatives using the new furniture during the reaccreditation audit.

As an extension of the gardening program introduced by the lifestyle and leisure staff, care recipients became involved in the cultivation of raised vegetable gardens. In addition to enhancing the external environment, the vegetable gardens yield produce for use by the kitchen. Care recipients enjoy being involved in the planting and harvesting of vegetables and get great satisfaction of seeing the food they have grown included in the menu.



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


Management and staff demonstrate there are systems and processes to identify and ensure compliance with relevant legislation, regulations, professional standards and guidelines related to physical environment and safe systems. Refer to expected outcome 1.2 Regulatory compliance for detailed information regarding the home’s regulatory compliance system and process.

Examples of responsiveness to regulatory compliance relating to Standard 4 Physical environment and safe systems include:

Chemicals are stored safely in secure areas and material safety data sheets are available.

The home has a food safety program.

Regular monitoring and maintenance of fire and safety systems occurs.



Team’s findings


Management and staff have the appropriate knowledge and skills to provide a safe and comfortable environment for care recipients. Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education system and processes.

Education undertaken in relation to Standard 4 Physical environment and safe systems includes:

fire safety and emergencies

food handling refresher course

infection control – outbreak management

manual handling

occupational health and safety.


4.4 Living environment

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

Team’s findings


Management and staff work actively to provide a safe and comfortable environment consistent with care recipients’ care needs. Each care recipient has a single room with a private ensuite, with some double rooms available for couples. There is safe access to clean, comfortable and well-maintained communal, private, dining and outdoor areas with sufficient and appropriate furniture. Management and relevant staff monitor the safety of the home via stakeholder feedback, audits, preventative maintenance processes, incident and hazard reporting mechanisms. Cleaning regimes and reactive maintenance processes ensure a comfortable and functional environment for care recipients and staff. Provision of equipment such as mobility aids and call bells enhances care recipients’ safety. Care recipients and representatives spoke positively of the well maintained living environment and stated care recipients feel safe and secure in the home.

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


Management is actively working to provide a safe working environment that meets regulatory requirements. The occupational health and safety committee meets regularly to discuss any issues and record, investigate, analyse and action incidents, near misses and hazards.

Management ensure the completion of regular audits and risk analyses and safe work processes have been recorded for work tasks thought to pose a risk. Relevant staff ensure equipment receives preventative and corrective maintenance as needed. There are areas to provide secure storage for all chemicals and dangerous goods. The occupational health and safety representative receives external training and staff are provided education and training in occupational health and safety relevant to their roles. Staff said they are aware of how to report hazards and are satisfied management provide a safe environment.


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


Management and staff work actively to provide an environment and safe systems of work that minimise fire, security and emergency risks. There are procedures to respond to a range of internal and external emergencies. Qualified external contractors maintain fire safety equipment and there are processes to ensure essential services equipment is maintained.

Management displays emergency evacuation plans and ensures emergency exits and egress routes are free from obstruction. There are processes to maintain current emergency evacuation lists and response packs. All staff are required to complete annual mandatory fire and emergency training and management provide a secure environment with surveillance cameras, sign in processes and key padded entry and exit points. Care recipients and representatives are satisfied the home is safe and secure.

4.7 Infection control

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

Team’s findings


There is an effective infection control program with preventative and responsive processes documented for all work areas along with contingency plans for various outbreaks. Infection control measures include the availability of personal protective equipment, hand hygiene facilities, policies and procedures, audits, orientation and education. Staff collect care recipient infection data which management uses to identify any trends and implement strategies which are discussed at relevant meetings. The kitchen has a current food safety plan and there are infection control processes related to laundry, cleaning systems and pest control. Management ensures appropriate waste disposal including contaminated waste and processes and equipment related to outbreak management. Staff have completed hand hygiene competencies and education in relation to infection control practices and demonstrate knowledge of appropriate infection control practices relevant to their duties.

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


Management and staff demonstrate there are processes to ensure hospitality services enhance the life of care recipients. Catering staff provide meals and snacks according to care recipients’ specific nutrition and hydration preferences and requirements. A food safety plan, policies and procedures and duty lists guide staff in undertaking their roles. Cleaning staff carry out their roles according to schedules and have access to adequate supplies and equipment. Relevant staff complete all laundry on site and there are established processes to


reduce the incidence of lost property. Management monitors the effectiveness of hospitality services through internal and external audits, surveys, meetings and formal and informal feedback. All hospitality services staff undertake training relevant to their role on commencement of employment and regularly thereafter. Care recipients and representatives are satisfied with the hospitality services provided at the home.

andrina aged care...andrina aged care racs id 4525 80 william road carrum downs vic 3201 approved...

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