decision to accredit bass hill residential aged care facility · 2018-12-14 · decision to...

Decision to accredit

Bass Hill Residential Aged Care Facility

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Bass Hill Residential Aged Care Facility in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Bass Hill Residential Aged Care Facility is three years until 13 May 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: Bass Hill Residential Aged Care Facility Date/s of audit: 8 March 2011 to 9 March 2011 RACS ID: 2534 AS_RP_00851 v2.5

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Home and approved provider details

Details of the home Home’s name: Bass Hill Residential Aged Care Facility

RACS ID: 2534

Number of beds: 70 Number of high care residents: 65

Special needs group catered for: • Secure Dementia Unit

Street/PO Box: 119 Robertson Road

City: BASS HILL State: NSW Postcode: 2197

Phone: 02 9644 6122 Facsimile: 02 9644 2611

Email address: [email protected]

Approved provider Approved provider: Lend Lease Primelife Limited - Sydney

Assessment team Team leader: Wendy Ommensen

Team member/s: Helen Hill

Date/s of audit: 8 March 2011 to 9 March 2011


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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

2.1 Continuous improvement Does comply Does comply 2.2 Regulatory compliance Does comply Does comply 2.3 Education and staff development Does comply Does comply 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

3.1 Continuous improvement Does comply Does comply

3.2 Regulatory compliance Does comply Does comply

3.3 Education and staff development Does comply Does comply

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

4.1 Continuous improvement Does comply Does comply

4.2 Regulatory compliance Does comply Does comply

4.3 Education and staff development Does comply Does comply

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: Bass Hill Residential Aged Care Facility RACS ID 2534 AS_RP_00857 v1.5 Dates of site audit: 8 March 2011 to 9 March 2011

SITE AUDIT REPORT

Name of home Bass Hill Residential Aged Care Facility

RACS ID 2534 Executive summary This is the report of a site audit of Bass Hill Residential Aged Care Facility 2534 119 Robertson Road BASS HILL NSW from 8 March 2011 to 9 March 2011 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 Bass Hill Residential Aged Care Facility. The assessment team recommends the period of accreditation be 3 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 8 March 2011 to 9 March 2011 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: Wendy Ommensen

Team member/s: Helen Hill Approved provider details Approved provider: Lend Lease Primelife Limited - Sydney

Details of home Name of home: Bass Hill Residential Aged Care Facility

RACS ID: 2534

Total number of allocated places: 70

Number of residents during site audit: 65

Number of high care residents during site audit:

65

Special needs catered for: Secure dementia unit

Street/PO Box: 119 Robertson Road State: NSW

City/Town: BASS HILL Postcode: 2197

Phone number: 02 9644 6122 Facsimile: 02 9644 2611

E-mail address: [email protected]


Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Bass Hill Residential Aged Care Facility. The assessment team recommends the period of accreditation be 3 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

Operations manager 1 Residents/representatives 12

Hospitality services manager 1 Care staff 9

Facility manager 1 Dietician 1

Care manager 1 Chef 1

Quality coordinator 1 Catering staff 2

Administration staff 2 Laundry staff 2

Registered nurses 3 Contracted cleaning company management staff 2

Recreational activities officers 2 Cleaning staff 1 Sampled documents

Number Number

Residents’ files (including for example progress notes, medical officer notes, entry documentation, correspondence, results)

10 Medication charts 15

Computerised resident documentation (including for example assessments, care plans, progress notes, observation charts, wound assessments and documentation)

10 Personnel files 6

Other documents reviewed The team also reviewed: • Activities program


• Annual fire safety statement, fire safety system maintenance records, colour coded emergency procedure flip charts, emergency evacuation site plans

• Auditing schedules for internal and external audits, completed audits, results and actions • Catering services: NSW Food Authority licence, NSW Food Authority audit and action

plan, food safety program, food and equipment temperature records, labelling and dating of foodstuffs, rotation of food stock, dietician review of four week rotating menu, internal audits, residents’ dietary preference sheets, drinks list, special dietary needs, food allergies information, in-service training, kitchen cleaning schedules

• Cleaning audits, cleaning schedules, cleaning and laundry duties for staff, laundry cleaning schedules

• Clinical information and data - accident and incident reports, blood sugar level parameters, care plan summary reports, initial assessments, pad allowance and care plan folder, physical restraint authority, resident master register, resident of the day care chart

• Complaints register, compliments folder, complaints logs, improvement logs, family conference calendar and register

• Continuous improvement (CQI) documentation including plan for continuous improvement, quality activity/audit schedule, audit and survey results, indicator and audit analysis information, CQI improvement report forms

• Education records and planner, competency assessments, training attendance records, staff training records, orientation program and checklist, employee master register of training, course outlines and education resources

• Electronic communication systems including intranet, rostering program, e-mail and computer hardware

• Equipment and inventory processes, ordering processes, procurement procedures, preferred providers list, preventative maintenance program, maintenance request book, electrical tagging records

• External service contracts • Human resource forms, staff handbook, recruitment pack, personnel information,

reference checks, authority to practice records, criminal record checks, position descriptions, duties lists, leave application forms, probationary period performance report, performance appraisal forms, staffing rosters, card swipe rostering system, employee assistance program

• Infection control documentation and data collection – policies and practices manual including outbreak management guidelines, infection control training records, staff hand washing competencies, monthly summary of infections and trended data, immunisation records, water testing records, pest control records, outbreak management kit

• Information posted on noticeboard in staff room, handover sheets, meeting schedule, meeting minutes, communication diaries, doctors’ contact list, general diary

• Medication care plans, medication fridge temperature control log, medication incident reports, nurse initiated medications, schedule eight register, schedule for registered nurses

• Nutrition assessment program • Occupational health and safety – residents’ falls risk assessments, global minimum

requirements for safety, hazard register, hazard reports, environmental audits, workplace inspection checklists, Back Attack – Injury Prevention Proposals 2008

• Regulatory compliance - compulsory reporting register, staff and contractor criminal record checks, professional registration logs, legislative update service, registry of signatures

• Planning documentation - mission, vision, values, goals and commitment to quality on display and recorded in the various handbooks

• Policy and procedural manuals paper based and electronic copies on computerised management system

• Residential handbook, residents’ information package, residents’ survey, residential agreement, newsletter, meeting minutes


Observations The team observed the following: • Activities in progress • Charter of Residents’ Rights and Responsibilities, organisational vision, mission and

philosophy on display • Chemical storage • Complaints information, forms and brochures on display, suggestion boxes for

confidential feedback to management • Dining rooms during meals, including resident seating, staff serving/supervising/assisting

residents with meals • Emergency procedures guide on display • Equipment and supply storage areas including medical stores, wound dressing trolley • Evacuation egresses unobstructed, evacuation maps suitably located and oriented,

evacuation kit • Fire fighting equipment checked and tagged • Four weekly menu, daily display • Infection control equipment, hand washing bays throughout the building, hand washing

sanitisers, colour coded equipment, personal protective equipment, spill kits, sharps containers

• Information for staff and residents displayed on noticeboards throughout the home • Kitchen, preparation and clean up sections, dry stores, refrigerator and freezer • Laundry • Living environment (internal and external, including residents’ rooms, bathrooms and

toilets, outdoor communal living areas, dining and lounge areas, landscaped gardens) • Manual handling equipment and instructions for use; mobility equipment including

mechanical lifters, pelican belts, slide sheets • Material safety data sheets • Medications - storage, refrigerators, trolleys, S8 drug cupboard, medication round • Memoranda, sign in/sign out records for residents, visitors and contractors • Notices of impending Accreditation Site Audit posted throughout the home • Personal protective equipment in use in all areas • Safe storage of medications • Secured key pad access and egress to the building, surveillance camera observance of

external environment and entry/exit egresses • Staff practices and courteous interactions with residents, visitors and other allied health

professionals • Waste management system - general, contaminated and recycled waste


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 Bass Hill Residential Aged Care Facility operates within an organisational quality framework which includes systems and processes that proactively identify areas for improvement across all aspects of care and service delivery to residents at the home. The continuous improvement framework consists of performance measures, a meeting structure which includes staff and resident representation and reporting processes. Information is collected through internal and external auditing processes, clinical indicator data collection and analysis, comments, complaints and feedback mechanisms, resident and staff meetings, resident and staff surveys and legislative changes. Resident, resident representatives and staff interviewed confirmed that they are able to make suggestions and have input into the continuous improvement mechanisms through a variety of processes, both verbal and written. Examples of continuous improvement activities relevant to Accreditation Standard One include: • Following on from meetings with nursing staff and the operations manager, it was

decided that nursing hours should be increased to provide an improved quality of care for residents. An extra six hour shift for assistants in nursing was added to the morning roster and an extra 5 hours was added to the afternoon roster. It is planned to increase the night shift by an extra six hours as soon as funds become available. This will allow staff to work in pairs across all shifts and reduce any occupational health and safety issues that may arise.

• The phone system in the nursing stations and reception area was barred from making

STD and mobile calls. This has been lifted to enable broader communication across the network, registered nurses can now contact families with relative ease and staff replacement issues are no longer compromised.

• To broaden both the skills and qualifications of the management team at the home a

quality manager, who is also a registered nurse, has been recruited to coordinate quality initiatives and the education needs of the workplace.

• The home had been engaging a large number of staff from a contracted staffing agency

and it was felt that this was costly and was compromising the consistency of care to residents. A recruitment drive resulted in the employment of ten casual staff, four registered nurses, three assistants in nursing, and two general service officers. As permanent part time positions become available casual staff will be offered permanent hours. This has reduced the use of Agency staff at the home by 70% and it is considered that the benefits will be ongoing.


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 Organisational systems ensure the identification and implementation of changes in legislation, regulatory requirements, professional standards and guidelines. Information is sourced through, subscriptions to a legislative update service, through industry related newsletters, from peak bodies, from State and Commonwealth government departments, from statutory authorities and the internet. Changes to legislation are disseminated to the home’s staff via the intranet, through memos, meetings and education sessions. Policies and practice procedures are reviewed and updated in line with new legislation. Internal and external audits, surveys, quality improvement activities, staff supervision and support processes ensure that work practices are consistent and compliant with legislative requirements. The following examples illustrate regulatory compliance pertaining to Accreditation Standard One: • Prospective employees’ criminal records are checked prior to engagement and there is a

process in place to review the currency of this status every three years. Any volunteers assisting at the home and contracted service personnel are also required to complete criminal record checks.

• Mandatory reporting guidelines regarding elder abuse have been implemented at the home. A critical incident reporting system is in place and consolidated records are maintained to support notification, investigation and actions taken for alleged or proven elder abuse.

• Changes under the Aged Care Act 1997 effective from 1 January 2009 have been implemented in regard to notification of missing residents to the Police Department and Department of Health and Ageing.

• Accreditation site audits are discussed at residents’ meetings, residents’ families are advised by letter and notices of impending audits are displayed prominently throughout the home.

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 To ensure that management and staff have appropriate knowledge and skills to perform their roles effectively there is a system in place for the induction of new staff and to address the ongoing education needs of all staff. Training needs are identified through: legislative change, review of industry issues, performance appraisals, surveys, observation of work practices, results of audits, monitoring of incidents and issues raised at meetings. From these sources, annual centralised and home specific schedules are developed. The home subscribes to an electronic training program which covers all aspects of the Accreditation Standards. Education sessions are coordinated and conducted by the educator, who attends on two days of the week. Responsive in-service education is also conducted by the facilities manager, care manager, product suppliers and other externally sourced professionals. The orientation program for new staff is currently being reviewed. Competency assessments are conducted to ensure relevant staff skills are maintained. Compulsory training is provided in


fire safety and evacuation, manual handling, infection control and mandatory reporting in relation to elder abuse an. Records of attendance are maintained and there is a system to monitor attendance at compulsory training.

Interviews with staff and review of the staff attendance records highlighted the following examples of training provided in relation to Accreditation Standard One: • Bullying and harassment in the workplace, elder abuse and mandatory reporting

responsibilities • Care planning and documentation using the new computerised program • Leadership training for registered nurses • Teamwork – managing conflict • TARS - The Advocacy Rights Service – residents rights and responsibilities explained 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 Brochures and information explaining the internal and external complaints’ mechanisms are on display in the foyer. The processes for feedback are discussed with residents and their representatives as part of the entry process, and information is available regarding aged care advocacy services. Incident registers and management reports are in place to track and trend comments and complaints and a review of these demonstrates that issues are investigated, analysed and responded to in a timely manner. There is a system for making confidential complaints. Annual general surveys of service satisfaction are conducted and the results used as a basis for quality improvements. Residents and their representatives confirm an awareness of the mechanisms by which they may make complaints or compliment staff for good service. Those who have raised an issue have found management and staff responsive to their concerns and report that matters have been addressed promptly. Staff are able to outline the processes for management of complaints from residents and their representatives and the ways in which they can personally raise issues of concern. 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 The organisational vision, mission, values, objectives and philosophy of care are documented and on display at the home. These are discussed with staff at orientation, displayed at the home and documented in the various handbooks, newsletters and corporate publications.


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 There are systems and processes in place to ensure that the home has sufficient appropriately skilled and qualified staff to provide services in accordance with the Accreditation Standards and the home’s philosophy and objectives. Policies, procedures and forms that guide the human resources practices are accessible to all staff on the intranet and in hard copy. Staff recruitment includes criminal record and reference checks, orientation and “buddying” processes to assist familiarisation with the working roles. Annual performance reviews through an appraisal and competency assessment program are in place. Grievance processes are documented. Job descriptions for all positions are in place and are currently being reviewed. An electronic rostering system assists staff management. Relief arrangements include permanent part time staff, who are available to work extra shifts and a casual pool of staff, which has recently been increased following a recruitment drive. Agency staff may be used from time to time to ensure that shifts are adequately staffed. Rosters are developed fortnightly in advance and a review of rosters confirmed that staff, who are unable to work, are replaced. Staffing levels are flexible and are monitored in line with residents’ specific care needs and related dependencies. Skills mix review data, observation of work practices; auditing and clinical indicators and stakeholder feedback inform this process. An employee assistance program is in place for the support of staff. 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 Residents, representatives and staff confirm that there are adequate supplies of goods and equipment for the delivery of quality services. Cleaning products, linen, food supplies, continence aids, wound products and medical stores were observed to be well stocked. A budget is in place for the purchase of entertainment programs and recreational materials to enhance resident lifestyle. There are computerised ordering processes and stock rotation systems for perishable items. Management staff members have been allocated responsibility for monitoring stocks and ordering necessary supplies. Purchasing of equipment and assets management is in place at the organisational level. Safe risk assessment processes and trials of products and equipment are conducted by an occupational health and safety consultant. New equipment is purchased through preferred suppliers who meet organisational requirements. Preventative and reactive maintenance programs ensure service delivery supports a safe living and working environment. The incidence of repairs and recommendations regarding replacement of equipment is monitored by a program which links to the corporate maintenance division. Interviews with staff and residents indicate that all maintenance is prioritised and responded to in a timely manner.


1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply There are effective information management systems in place. Confidential files such as staff and resident files are stored securely. Review of residents’ files and care planning documentation indicates that clinical care plans are reviewed regularly and there is a system for consultation with residents, their relatives or representatives. The home has a number of trained committee representatives and a schedule of meetings to ensure relevant information is available in a timely manner to all stakeholders. Information is disseminated through a secured password protected email and electronic management system, the intranet, notice boards, newsletters, memoranda, staff handovers, formalised feedback mechanisms and informal lines of communication. Policies are procedures are available in hard copy as well as electronically. The home conducts surveys, audits and peer reviews and collects data to provide information regarding the quality of care and services provided. Archiving processes which adhere to legislative guidelines are in place. 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 Externally sourced services are provided to a standard that meets the home’s requirements for quality service goals. The organisation has a list of preferred service providers and suppliers and contracts are negotiated and managed through the organisational procurement division of the company. Service providers must produce evidence of licensing, safe work method statements, public liability and professional indemnity insurance, and are required to have completed criminal checks and adhere to appropriate behaviour if interacting with residents. Service agreements and contracts with external providers are monitored in a variety of ways which include audits and inspections, feedback from residents and staff. Supervision of the contracted clinical services by the care manager and observation of the work practices of contractors by the facilities manager are important in ensuring contractual arrangements are being met. Poor performance may lead to cancellation of the contract. External contracts include (but are not limited to): pharmacy services, podiatry, physiotherapy, hairdressing, waste management, grease trap cleaning and pest control.


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 The results of the team’s observations, interviews and review of documentation revealed that the home is pursuing continuous improvement in relation to health and personal care of residents. For information regarding the continuous improvement system see expected outcome 1.1 Continuous improvement. The following are examples of some of the improvements undertaken in relation to health and personal care of residents: • A continence consultant conducted an audit of the continence management system and

the application of appropriate aids in November 2010 and this returned an unsatisfactory score of 48%. A continence link nurse was appointed to coordinate the continence processes at the home and a re-audit in February 2011 returned compliance of 100%.

• Internal audits identified that during the transition from the paper based to the electronic

documentation system the data captured in some care plans did not accurately reflect the care delivery when needs changed. To overcome an inconsistency in dietary information all diet preference sheets have been reviewed, cross referenced and updated to ensure specialised nursing care needs are identified as necessary. Residents requiring diabetic, texture modified meals, a high energy diet or are dysphagic now have this information clearly documented.

• An audit demonstrated some inconsistencies with care plans not reflecting the actual

needs of residents, particularly those with specialised care needs requiring complex nursing interventions. A review of all care plans was completed to ensure documentation of individualised resident’s needs. Information sheets outlining care needs are now located in residents’ wardrobes to provided clearer directions for care staff.

• To improve the quality of care it was found necessary to identify key clinical indicators

such as blood glucose levels, observations and weight variances in order to implement appropriate actions and interventions. The facility manager received education on the use of the clinical dashboard, an organisational initiative found on the intranet which captures information on key clinical indicators. For example, weight parameters for residents are now set by the medical officers and registered nurses document monthly (or as indicated) weights of residents. Variances are highlighted as “alerts” on the system and referrals are made by the medical officers to specialists. Care plans in relation to nutrition and hydration are updated when the residents’ needs change.


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 accreditation team’s observations, interviews and review of documentation demonstrate that an effective system is in place to manage regulatory compliance in relation to health and personal care. For comments regarding the system see expected outcome 1.2 Regulatory compliance. Evidence that there are systems in place to identify and ensure regulatory compliance relating to health and personal care includes: • Authority to practice registrations for registered nurses and the attending medical officers

are sighted and records maintained by the home. Contracted professionals providing services to the home include, but are not limited to, the accredited pharmacist, the podiatrist, the dietician and the physiotherapist.

• There are registered nurses on all shifts and they are responsible for the care planning and assessment processes and specialised nursing services implemented for all residents.

• The home ensures residents are provided with services, supplies and equipment as required under the Quality of Care Principles (1997).

• The home’s storage of medication is in accordance with the relevant legislation including The Poisons and Therapeutic Drugs Act and Regulations.

• Changes of regulators on medical oxygen cylinders to enhance the safety of end users by eliminating the risk of connecting incorrect gas cylinders for medical oxygen applications has been completed in line with the recently reviewed Australian Standards for Medical Oxygen Cylinders.

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 sources of evidence and a description of the organisational system. Examples of training and education provided in relation to health and personal care include • Clinical skills assessments – Head to toe • Continence management • Dementia care • Managing challenging behaviours • Medication management • Oral and dental care • Oral medication administration competencies for registered nurses • Person centred care


2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply The home has systems in place to ensure that residents receive appropriate clinical care. Residents and their representatives advise that they are able to nominate a doctor of choice. There are arrangements to ensure residents have access to medical treatment after hours and the ability to transfer residents to hospital at any time. Resident files and computerised documentation systems confirmed care needs are assessed and evaluated and resident preferences identified. Progress notes and medical officer notes confirm regular consultation with medical officers. Staff are able to confirm knowledge of procedures that they are required to undertake for residents relating to clinical care and ways that individualised care is provided to the residents. A ‘resident of the day’ program ensures a formal review of care on a regular basis and contact with the family on this day to keep them informed regarding care and lifestyle needs. Residents and representatives confirm they are satisfied with the care provided, that the staff are very caring and they have confidence in the staff caring for their needs. 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 systems in place to ensure that residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. Registered nurses provide twenty four hour coverage at the home. Care staff interviewed say that they are provided with education regarding any specialised care need that may be required at the home. Further, they not expected to care for any specialised care need unless they are provided with the knowledge and experience to do so. The registered nurses oversee the specialised care needs being provided. Residents and representatives interviewed confirmed that the residents who had a specialised care need were appropriately cared for by the staff. The home cares for residents with specialised nursing procedures such as blood glucose monitoring, urinary catheters, colostomies and oxygen therapy. Residents’ files confirm consultation with appropriate specialists to assist in the management of specialised care needs. Care plans describe care required for individual residents. 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”. Team’s recommendation Does comply The home has an effective system to ensure there are referrals of residents to appropriate health specialists. The team’s review of documentation confirmed that residents are referred to other health and related services as their clinical condition requires. This was confirmed by interviews conducted with care staff, residents and their representatives. Staff informed the team that there is a wide range of other health and related services available, such as podiatry, speech pathology, optometry, pathology, wound management and pain/palliative care team, some of which will visit the home. Staff advise and residents and their representatives confirm that staff at the home arrange referrals and assist to arrange transportation as required.


2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply Results of the team’s observations, interviews and document review indicate that the home has a system in place to ensure that residents’ medication is managed safely and correctly. Residents and their representatives interviewed report that they are happy with the care given and with their medication requirements. Medications are administered to the residents by care staff from a multi-dose blister packaging system and by registered nurses. An external pharmacist undertakes regular medication reviews to identify potential risks to residents related to poly-pharmacy. A review of medication charts by the team confirmed they are reviewed by medical officers regularly. A medication incident reporting system is in place. Staff confirm that management requires them to demonstrate competency with medication management annually. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply The home has a system in place to ensure that all residents are as free as possible from pain. Residents are initially assessed on entry to the home to identify residents whose condition may cause them to experience pain. Ongoing pain management assessments are conducted for these residents to enable pain levels to be continuously monitored. Alternative pain relief measures are also available such as heat rubs, massage and pressure relieving mattresses. Staff interviewed are able to demonstrate an understanding of the need to identify pain and ways in which the staff can assist in identifying those residents who may be experiencing pain. Residents and their representatives confirm that they are maintained as free from pain as possible and that staff ask about their pain needs regularly. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply The home has a system to ensure that terminally ill residents have their comfort and dignity maintained. During entry to the home residents are given the opportunity to indicate any specific instructions in relation to palliative and terminal wishes. A palliative care/pain management team is available to assist the home with the care for residents. Care staff say that they are provided with education to enable them to provide comfort and dignity to terminally ill residents. Residents and their representatives interviewed confirm that they are comfortable that their wishes are considered and respected. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply Staff and residents/representatives interviewed and review of documentation confirmed that residents receive adequate nourishment and hydration. Residents’ nutrition and hydration


needs are assessed initially on entry then recorded on the care plan. The residents are offered a menu that is developed to also meet the likes and dislikes of the residents. Staff monitor all resident’s weights monthly and dietary supplements are introduced where there is a noted decline in appetite or weight loss. A dietician oversees the weight recorded for each resident on a monthly basis and consults residents who have fluctuations in weight which may impact on their health status. A speech therapist also monitors residents with swallowing difficulties and provides recommendations for residents regarding the texture of foods and thickness of fluids. All residents and their representatives interviewed are satisfied with the quantity and quality of food offered. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply The home has a system to ensure that residents’ skin integrity is consistent with their general health. Residents’ files confirm that an assessment of their skin integrity is completed on entry to the home and a care plan is developed. Care plans include individual assistance provided in maintaining/improving the residents’ skin integrity. Management strategies included on the care plans include specialised mattress products, application of skin emollients and the use of sheepskin products. A hairdresser and podiatrist are also available to assist in the promotion and maintenance of residents’ hair and toenails. Staff say that residents’ skin integrity is monitored daily and that they report any abrasions, rashes or abnormality to the registered nurse. Residents and their representatives confirm they are happy with the care provided. All residents who have wounds have a wound assessment and ongoing wound management is recorded. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Results of the team’s observations, interviews and document review indicate that the home has a system in place to ensure that residents’ continence is managed effectively. Residents’ files show that this system includes an assessment of the residents’ needs on entry to the home, and as required thereafter. Care plans which include individual toileting programs are developed and reviewed to evaluate the care strategies. A disposable continence aid system is used for residents who are assessed as requiring it and a staff member is allocated responsibility for monitoring residents’ needs and reporting changes to the registered nurses. Staff interviewed confirm there are adequate supplies of disposable continence aids of varying sizes available for residents. Residents and their representatives confirm they are happy with the care provided. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply The home has effective systems in place to manage residents’ behaviours. Residents and their representatives confirm they are very happy with the care and the staff management and interaction with residents requiring care. Behaviour assessments are completed as required and care plans and progress notes indicate development of strategies for each


resident. This includes the ongoing evaluation of the effectiveness of the strategies for each resident. There is a dementia specific area where a specialised program, which assists in minimising behaviours, is run for residents. Staff interviewed were able to confirm various strategies they use to assist in modifying residents’ behaviours and also say they are given education to improve their behavioural management skills. Staff were observed during the visit to interact with residents in a caring and calming manner. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply The home has an effective system in place to ensure that optimum levels of mobility and dexterity are achieved for all residents. A physiotherapist assesses all residents at entry to the home and then as required should the resident’s condition or needs change. An individualised program is then developed for residents that may include a range of movement exercises, walking programs, specific exercises and breathing exercises. All staff are actively encouraged to take part in maintaining and promoting residents’ mobility and dexterity. Residents and their representatives state they are happy with the mobility program provided and confirmed that some residents are able to carry out the exercise program with assistance from staff and also gave examples of improvements achieved. Staff were able to advise the team of how they assist with maintaining mobility for residents. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply The home is continuing to develop strategies to ensure the residents’ oral and dental health is maintained. Residents and their representatives said that they are happy with all care provided. Residents’ oral and dental needs are assessed during the entry process and then transferred to the care plan. The team was informed by the care staff that if residents needed to attend their dentist staff would assist in arranging appointments and transport. Dental services are available to visit the home and provide assessment of needs and basic care. Any more complex care needs can be arranged either in the dental surgery or hospital. Staff interviewed demonstrated sound knowledge of oral care and care of residents’ dentures. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply The home has a system in place to identify and effectively manage residents’ sensory losses. Assessments of residents’ sensory needs are undertaken during entry to the home and when there is a change in the resident’s condition. Interviews with staff and review of clinical documentation confirm that all residents are assessed for the identification of their sensory loss and needs. Residents, who are identified as having sensory deficits, for example, require glasses or hearing devices, have management strategies documented in their care plans. Residents and their representatives interviewed report that staff assist them with the care and maintenance of their glasses and hearing devices. Staff who provide activities for the residents were able to identify sensory activities offered such as smelling, touching and tasting, as well as outdoor garden walks and hand massage.


2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply The home has implemented strategies to assist residents to achieve natural sleep patterns. A sleep assessment is conducted in the initial assessment period after entry to the home and then documented on the care plan which is regularly evaluated. Residents and their representatives advise that the environment is conducive for them to achieve uninterrupted sleep. Staff confirmed various ways in which they can assist in supporting an adequate sleep pattern for residents.


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 The home is pursuing continuous improvement in relation to resident lifestyle and this was confirmed by the team’s observations, interviews and review of documentation. For comments regarding the continuous improvement system see expected outcome 1.1 Continuous improvement. Some examples of the improvements made to resident lifestyle are outlined: • There were no structured activities being offered on weekends and feedback from the

residents and their representatives when surveyed in August 2010 indicated that this extension would enhance the quality of life for residents. The position was advertised and a recreational activities officer with a Certificate IV in Leisure and Lifestyle as well as experience in aged care has been engaged. Activities have been reviewed and input from residents and families has been incorporated into the program which now runs over seven days of the week. Ongoing evaluation is planned.

• It has been recognised that the leisure and lifestyle team needs assistance and guidance

with their work and bi-monthly meeting have been scheduled to assist this process. Consultation by the team with the organisational recreational coordinator in Melbourne will be ongoing.

• A project encompassing refurbishment of the home for the comfort of residents has

begun. Residents have been engaged throughout the process in selection of colour schemes and fabric choices. Repainting is underway and all furniture is to be replaced. The project will be spread across 2011 to ensure minimal disruption to life at the home.

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 results of the team’s observations, interviews and review of documentation revealed that an effective system is in place to manage regulatory compliance in relation to resident lifestyle. For comments regarding the system see expected outcome 1.2 Regulatory compliance: Evidence that there are systems in place to identify and ensure regulatory compliance related to resident lifestyle includes: • The Charter of Residents’ Rights and Responsibilities is clearly displayed at the home

and is documented in the resident agreement and in the residents’ handbook.


• Resident information and files are kept in a manner that meets legislated privacy requirements. Staff are advised of their role in relation to the Privacy and Personal Information Protection Act (1998) at orientation and are provided with Employee Behaviour Standards which outline their responsibility in relation to confidentiality. Staff are able to outline their roles regarding residents’ privacy and dignity

• All residents are issued with a residential agreement which incorporates clauses required by law such as a 14 day cooling off period, reference to the User Rights Principles (1997) and the provision of specified care and services.

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 sources of evidence and a description of the organisational system for monitoring education and staff development.

Examples of training and education provided in relation to resident lifestyle include: • Dementia care • Grief awareness • Cultural and spiritual life

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 systems in place to ensure each resident receives emotional support in adjusting to life in the new environment through the pre-entry process, during the entry process and the orientation process, including assessments of emotional, leisure, physical, cultural, social and family care needs. The results of the team’s observations, interviews and document review revealed that residents and their representatives receive emotional support from management, care staff, and the recreational staff. The team observed that residents have personalised their rooms with family photos and other items. The staff identify ways in which they provide residents with emotional support, particularly during the early days after arrival, such as introducing them to other residents and checking on a daily basis to ensure they are aware of and invited to attend activities on the day. Residents/representatives provide positive comments regarding the way the staff make them feel welcome. 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 Residents and their representatives interviewed stated that residents are encouraged to maintain their independence and participate in community life, and that their ability to make choices is facilitated and respected including participation in activities and community life. The Charter of Residents’ Rights and Responsibilities is on display within the home and


documented in the residents’ handbook and agreement. Residents who wish to participate in activities and community outings are encouraged to do so. Community groups and entertainers are encouraged to visit the home, and residents are supported in maintaining their contacts with family and the community. The activities program ensures that residents, who are able, have access to the community via bus trips and visits to local organisations. 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 The home has systems in place to ensure each resident’s right to privacy, dignity and confidentiality is recognised and respected. Residents and their representatives interviewed confirmed to the team that residents’ privacy and dignity is respected at all times and that staff are particularly considerate when attending to personal care. The team observed the nurses’ offices which are designed to enable residents’ personal information to be maintained in a confidential manner. During the site audit the team observed staff to be diligent about maintaining residents’ privacy, using privacy screens, closing doors to residents’ rooms and knocking before entering a resident’s room. 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 leisure interests and activities by providing a varied group and individual recreational activity program. The team observed the monthly activity programs which are displayed throughout the home. The programs indicate the activities to be varied and interesting. There are separate programs for mainstream care and the dementia specific area. Some of the activities are able to be attended and the activity participated in by all of the residents in a combined group. During the entry process an assessment of social needs and interests of residents is completed. This information obtained assists in development of the monthly activity program. The activities officers informed the team that other information used to assist in the development of the program includes attendance at activity sessions and feedback via the resident meetings. Individual room visits are provided for those who choose not to participate in group activities. Residents and their representatives interviewed confirm they are supported and encouraged to participate in activities and speak particularly of their enjoyment of bus trips. 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 has systems in place to ensure that individual interests, beliefs and cultural and ethnic backgrounds are valued and fostered. Residents and their representatives say that the home values and fosters residents’ individual interests, customs, beliefs and cultural backgrounds. The staff advised the team that they arrange days to maximise residents’ enjoyment in cultural experiences. Culturally specific days are celebrated for example, St. Patrick’s Day, Melbourne Cup, Christmas, Anzac Day and Easter. Religious services are made available to residents at the home on a regular basis for residents wishing to


participate. Some residents are taken to services in the community by their families. Residents confirm their satisfaction with the services available to them. 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 has effective mechanisms to assist residents/representatives to participate in decisions about care and services residents receive. Residents and their representatives interviewed by the team were able to confirm a number of choices and decisions that they are encouraged to make. These include for example choice of meals, choice of medical officer and choice of participation in activities. They stated they have been made aware of their rights and responsibilities and were complimentary of the service’s encouragement and response regarding individual choices and decisions. Minutes of the meetings available to the team confirmed that there are discussions on topics such as meals, outings and recreational programs. 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 understand their rights and responsibilities. Relevant information about security of tenure and residents’ rights and responsibilities is provided and discussed with prospective residents and their representatives prior to and on entering the home. The resident agreement accompanied by the resident handbook outlines care and services, residents’ rights and feedback mechanisms. Any changes in rooms and/or location within the home are done in consultation with residents and/or their representatives. Ongoing communication with residents/representatives is through meetings, notices on display and verbally through one to one communication. Residents and representatives interviewed by the team feel secure in their residency at the home and confirm awareness of their 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 sources of evidence and additional information including a description of the overall system of continuous improvement. The home has made planned improvements relating to the physical environment and safe systems including: • To ensure identification and implementation of opportunities for best practice in infection

control practices and outbreak management, independent infection control consultants have been engaged by the organisation. A risk assessment conducted by the consultants at the home in November 2010 scored under 90% and an action plan for improvement was implemented. A re-audit will be conducted to ensure a higher rating which must exceed 90% and follow up audits will be conducted second yearly.

• Some of the residential rooms became very hot during the summer and cooling was not

adequate to offset these temperatures. In November 2010 the installation of a reverse cycle air conditioning system throughout the building was approved and has since been installed. Some single rooms are still to have individual units replaced. Ceiling fans in residents’ rooms remain to allow alternate methods of cooling for the comfort of residents who may choose this option.

• A contracted service has been engaged and a co-mingled recycling system has been

implemented to manage the tins, bottles, paper and cardboard waste generated by the home.

• Most of the home’s outdoor furniture has been earmarked for replacement through a

staged process which will be finalised by August 2011. This will ensure a safer and more comfortable living and working environment for residents and staff.

• The organisation is implementing an injury prevention strategy, Back Attack, across all

sites with the aim of reducing the possibilities of sprain and strain injuries caused by manual handling. This comprehensive program involves the training of mentors who in turn will be responsible for training and supporting the staff team at the home to understand the dynamics of back injury and to adopt best practice in regard to manual handling, to principles of hazard identification and prevention, risk identification and assessment criteria. Evaluation of this program includes post implementation audits, trend analysis on incident and claims reports and competency review of all trainers.


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 results of the team’s observations, interviews and review of documentation revealed that an effective system is in place to manage regulatory compliance in relation to the physical environment and the implementation of safe systems. For comments regarding the system see expected outcome 1.2 Regulatory compliance.

Documents are on display to inform staff of relevant legislation and regulatory requirements. Compliance with legislation is ensured through monitoring of staff work practices, education, risk identification, hazard reporting, incident and accident reporting, environmental audits, routine and preventative maintenance systems, and occupational health and safety processes. Evidence that there are systems in place to identify and ensure regulatory compliance related to the physical environment and safe systems include: • The Annual Fire Safety Statement certifying that fire equipment is appropriate and

suitably serviced is current and on display. • The NSW Food Authority licence, under the legislation governing food services to

vulnerable persons has been received. During early 2011 an ‘A’ rating was achieved by the home as the result of an audit by the NSW Food Authority. The chef has implemented food safety guidelines in the kitchen.

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 sources of evidence and a description of the organisational system for monitoring education and staff development.

Education sessions and activities that relate to this standard include: • Safe handling of chemicals • Fire safety training (theory and practical) • Infection control (including outbreak management) • Food hygiene and food safety • Injury prevention strategies for manual handling – introduction to “Back Attack” • Occupational health and safety consultation training


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 Residents’ needs are identified on entry and residents and their representatives are advised of care and services available at the home. Mechanisms, such as residents’ surveys, residents’ newsletters, quality improvement forms and residents’ meetings, allow residents and their representatives to contribute ideas about their living environment. Accommodation consists of single and multi-bed rooms with shared bathrooms and toilets. There are a two lounge dining areas, which are also used for activities and a quiet room where residents may meet privately with visitors. The residential rooms, offices and communal areas are brightly painted and lighting is appropriate. A covered courtyard in the centre of the building and a large garden courtyard at the back provide pleasant areas for residents and visitors to sit outside during the day. Residents are invited to bring small items of a personal nature to decorate their rooms. Hand rails in the hallways, grab rails in the bathrooms and toilets, mobility aids, lifting equipment and access to a nurse call system contribute to safety in the living environment. Internal temperatures are comfortably maintained by the reverse cycle air conditioning system and overhead fans in residential rooms provide alternate cooling. To ensure safety and security for all residents and staff egress through all external doors is key padded. Residents and their representatives expressed satisfaction with the cleanliness of the living environment and the sense of security provided at 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 recommendation Does comply The home has an occupational health and safety system including comprehensive polices and procedures. Trained occupational health and safety (OH&S) staff members assume responsibility for monitoring the living and working environment and reporting risks and hazards. Accident and incident data is presented, analysed and trended at meetings. The home monitors work practices which support a ‘no lift policy’, mechanical lifters are available, and staff complete manual handling training during orientation and annually. Personal protective clothing and equipment is available to all staff and was observed being used appropriately. Chemicals are securely stored and material safety data sheets are readily accessible. Safe work practices which reflect regulatory compliance are documented and monitored. All staff are encouraged to report unsafe work practices. Identified risks are recorded in the maintenance request book, prioritised for repair and actioned in a timely manner by the maintenance staff or contracted services. The facility manager has completed training and is the return to work coordinator for injured staff at the home. 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

Systems are in place to ensure the safety and security of residents and staff. Regular checks of equipment by external contractors, audits, key padded external doors and fire and emergency evacuation procedures are in place. Staff wear identification badges and there is


a sign in and sign out register for residents, representatives, contractors and visitors. Fire evacuation maps are correctly orientated and emergency procedure folders are located at strategic points throughout the building. The home is fitted with fire warning and fire fighting equipment, smoke detectors, emergency lighting, extinguishers and fire blankets, all of which are checked and maintained according to the home’s policy. Electrical tagging is completed according to specific scheduling. Chemical storage is secured and in line with hazardous substances guidelines – material safety data sheets are located in the chemical storage area and throughout the home. A chemical spills kit is also available. A designated smoking area has been nominated. Staff confirmed their attendance at compulsory fire safety training and demonstrated an understanding of evacuation procedures and use of fire fighting equipment. An emergency evacuation kit is in place and contains an occupancy list with current residents’ names, tags and relevant information. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply Policies and procedures for infection control including outbreak management guidelines are available to all staff. The home’s infection control program consists of an infection control surveillance and reporting system, education for all staff, hand washing competencies and resident immunisations. Cleaning and maintenance schedules, adherence to food safety guidelines, dirty to clean flow in the laundry, temperature monitoring, use of spills kits and safe disposal of general and infectious waste further enhance the program. Personal protective clothing and equipment, hand washing facilities and hand sanitiser are readily available across the home. Sanitisation processes are in place in the laundry. The home’s infection control program is monitored by a number of key staff including the care manager who acts as the infection control co-ordinator. The organisation subscribes to an external infection control consultancy service which provides regular newsletters, conducts audits, provides advice regarding outbreak management and supports best practice guidelines. Audits and monitoring data indicate that the program is constantly reviewed and improvements implemented. Resident infections are identified; medical officer reviews initiated and pathology services organised to enable effective treatment. The team observed good infection control practices being undertaken by all staff in their day to day interactions with 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 Catering The home has a system where food is fresh cooked on site following a 28-day rotating menu which is regularly reviewed by the dietician for nutritional content. Catering staff have implemented food safety guidelines in the kitchen and processes ensure that residents’ food and drink preferences are identified. Communication between care and catering staff support any changes to clinical nutritional requirements. Texture modified food and nutritional supplements are provided as required. Trays are taken to residents who are unable to attend the dining rooms throughout the home. The chef attends residents’ meetings to discuss feedback regarding the menu and recommendations are implemented. Cleaning The living environment was observed to be clean and cleaning programs were documented and noted to be in place. The cleaning staff, who are contracted from an external service,


demonstrated a working knowledge of the home’s cleaning schedules, infection control practices and safe chemical use. Chemicals used in the service were observed to be safely stored and material safety data sheets were available and accessible. The cleaning roster ensures all rooms, communal areas, hallways and offices are cleaned according to a set schedule. The kitchen areas are cleaned by catering staff and the maintenance officer, and trolleys and equipment are regularly cleaned by designated staff according to set schedules. The team observed colour-coded cleaning mops and buckets, personal protective clothing in use in all areas. The cleaners’ storage area is locked and the cleaning trolleys are not left unattended. Residents and their representatives interviewed by the team are very satisfied with the level of cleanliness of their rooms and of the home. Regular audits of the building and the cleaning service are undertaken and actions implemented to address any shortfalls. Laundry All flat linen and residents’ personal clothing is laundered in the home’s laundry which operates seven days per week. Residents’ clothes are ironed when necessary. The laundry staff explained the labelling system and processes in place for the management and return of laundry to reduce loss of personal items. A dirty to clean flow of laundry is maintained. Chemicals are automatically dosed into all of the washing machines which operate on specifically programmed wash cycles. Mop heads are washed on the last cycle of the day. Material safety data sheets are in place in the laundry and chemicals are replenished by the maintenance officer. The team observed the laundry operating in accordance with the home’s infection control guidelines. Residents and representatives interviewed expressed satisfaction with the laundry services and said that staff respond promptly to comments and suggestions.