Download - St Catherine's Hostel Wangaratta Inc...St Catherine's Hostel Wangaratta Inc RACS ID: 3063 Approved provider: St Catherine's Hostel Wangaratta Inc Home address: 59-69 Ryley Street WANGARATTA

StCatherine'sHostelWangarattaIncRACSID: 3063

Approvedprovider: StCatherine'sHostelWangarattaInc

Homeaddress: 59-69RyleyStreetWANGARATTAVIC3677

Followinganauditwedecidedthatthishomemet44ofthe44expectedoutcomesoftheAccreditationStandardsandwouldbeaccreditedforthreeyearsuntil22May2021.

Wemadeourdecisionon04April2018.

Theauditwasconductedon21February2018to22February2018.Theassessmentteam’sreportisattached.

Wewillcontinuetomonitortheperformanceofthehomeincludingthroughunannouncedvisits.

MostrecentdecisionconcerningperformanceagainsttheAccreditationStandards

Standard1:Managementsystems,staffingandorganisationaldevelopment

Principle:

Withinthephilosophyandlevelofcareofferedintheresidentialcareservice,managementsystemsareresponsivetotheneedsofcarerecipients,theirrepresentatives,staffandstakeholders,andthechangingenvironmentinwhichtheserviceoperates.

1.1 Continuousimprovement Met

1.2 Regulatorycompliance Met

1.3 Educationandstaffdevelopment Met

1.4 Commentsandcomplaints Met

1.5 Planningandleadership Met

1.6 Humanresourcemanagement Met

1.7 Inventoryandequipment Met

1.8 Informationsystems Met

1.9 Externalservices Met

Standard2:Healthandpersonalcare

Principle:

Carerecipients’physicalandmentalhealthwillbepromotedandachievedattheoptimumlevelinpartnershipbetweeneachcarerecipient(orhisorherrepresentative)andthehealthcareteam.




2.4 Clinicalcare Met

2.5 Specialisednursingcareneeds Met

2.6 Otherhealthandrelatedservices Met

2.7 Medicationmanagement Met

2.8 Painmanagement Met

2.9 PalliativecareMet

Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 2

2.10 Nutritionandhydration Met

2.11 Skincare Met

2.12 Continencemanagement Met

2.13 Behaviouralmanagement Met

2.14 Mobility,dexterityandrehabilitation Met

2.15 Oralanddentalcare Met

2.16 Sensoryloss Met

2.17 Sleep Met

Standard3:Carerecipientlifestyle

Principle:

Carerecipientsretaintheirpersonal,civic,legalandconsumerrights,andareassistedtoachieveactivecontroloftheirownliveswithintheresidentialcareservicesandinthecommunity.




3.4 EmotionalSupport Met

3.5 IndependenceMet

3.6 Privacyanddignity Met

3.7 Leisureinterestsandactivities Met

3.8 Culturalandspirituallife Met

3.9 Choiceanddecision-making Met

3.10 Carerecipientsecurityoftenureandresponsibilities Met

Standard4:Physicalenvironmentandsafesystems

Principle:

Carerecipientsliveinasafeandcomfortableenvironmentthatensuresthequalityoflifeandwelfareofcarerecipients,staffandvisitors




4.4 Livingenvironment MetHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 3

4.5 Occupationalhealthandsafety Met

4.6 Fire,securityandotheremergenciesMet

4.7 Infectioncontrol Met

4.8 Catering,cleaningandlaundryservices Met


AuditReportNameofhome:StCatherine'sHostelWangarattaInc

RACSID:3063

Approvedprovider:StCatherine'sHostelWangarattaInc

IntroductionThisisthereportofaRe-accreditationAuditfrom21February2018to22February2018submittedtotheQualityAgency.

AccreditedresidentialagedcarehomesreceiveAustralianGovernmentsubsidiestoprovidequalitycareandservicestocarerecipientsinaccordancewiththeAccreditationStandards.

Toremainaccreditedandcontinuetoreceivethesubsidy,eachhomemustdemonstratethatitmeetstheStandards.

TherearefourStandardscoveringmanagementsystems,healthandpersonalcare,carerecipientlifestyle,andthephysicalenvironmentandthereare44expectedoutcomessuchashumanresourcemanagement,clinicalcare,medicationmanagement,privacyanddignity,leisureinterests,culturalandspirituallife,choiceanddecision-makingandthelivingenvironment.

Eachhomeappliesforre-accreditationbeforeitsaccreditationperiodexpiresandanassessmentteamvisitsthehometoconductanaudit.TheteamassessesthequalityofcareandservicesatthehomeandreportsitsfindingsaboutwhetherthehomemeetsordoesnotmeettheStandards.TheQualityAgencythendecideswhetherthehomehasmettheStandardsandwhethertore-accreditornottore-accreditthehome.

Duringahome’speriodofaccreditationtheremaybeareviewauditwhereanassessmentteamvisitsthehometoreassessthequalityofcareandservicesandreportsitsfindingsaboutwhetherthehomemeetsordoesnotmeettheStandards.

Assessmentteam’sfindingsregardingperformanceagainsttheAccreditationStandardsTheinformationobtainedthroughtheauditofthehomeindicatesthehomemeets:44expectedoutcomes


ScopeofthisdocumentAnassessmentteamappointedbytheQualityAgencyconductedtheRe-accreditationAuditfrom21February2018to22February2018.

TheauditwasconductedinaccordancewiththeQualityAgencyPrinciples2013andtheAccountabilityPrinciples2014.Theassessmentteamconsistedoftworegisteredagedcarequalityassessors.

TheauditwasagainsttheAccreditationStandardsassetoutintheQualityofCarePrinciples2014.

DetailsofhomeTotalnumberofallocatedplaces:69

Numberofcarerecipientsduringaudit:69

Numberofcarerecipientsreceivinghighcareduringaudit:69

Specialneedscateredfor:Notapplicable


AudittrailTheassessmentteamspenttwodaysonsiteandgatheredinformationfromthefollowing:

Interviews

Positiontitle Number

Carerecipients 16

Representatives 5

Chiefexecutiveofficer 1

Caremanager 1

Financemanager 1

Administrativestaff 1

Registerednurse 3

Enrollednurse 3

Carestaff 6

Lifestylecoordinator 1

Hospitalityteamleader 1

Maintenance 1

Cateringmanager 1

Cateringstaff 2

Laundrystaff 1

OccupationalTherapist 1

Woundconsultant 1

Hairdresser 1

Sampleddocuments

Documenttype Number

Carerecipients’files 8

Medicationcharts 8


Stafffiles 8

Otherdocumentsreviewed

Theteamalsoreviewed:

Auditdocumentation

CateringanddietaryrecordsCleaningdocumentationClinicalobservationandmanagementdocumentsCommentsandcomplaintsdocumentationCompulsoryreportingdocumentationContinuousimprovementactionplanCorrectiveandpreventativemaintenancedocumentationDailycarefoldersEmergencymanagementprocedures

ExternalcontractsandassociateddocumentationFireandessentialservicesmaintenanceandtestingrecordsFoodsafetyprogram

Kitchencommunicationbookanddietarychanges

NewslettersNursingregistrationrecordsOrientationandinductioninformation

ResidentialagreementsRoomauditsSafetydatasheets

AdvancedcareplansandendoflifeformsAlliedhealthreferralfolders

Carerecipients’handbook

Equipmentandbedpoleassessmentsandreviews

Incidentreports,investigationsandevaluationsInfectioncontrolsurveillancerecordsInfectionoutbreakreport

LegislativeinformationLifestyledocumentationMaintenanceandhazardreportsMeetingscheduleandmeetingminutesMemoranda

PolicecertificatemonitoringrecordsPoliciesandprocedures


Satisfactionsurveys

StaffeducationrecordsStaffHandbookWorkhealthandsafetydocumentation

Observations

Theteamobservedthefollowing:ActivitiesinprogressArchivingsystemCleaners’roomsandchemicalstorageareasClinicalsuppliesEgressroutesExternalandinternalfeedbackmechanismsFireequipmentGeneratorHandhygienefacilities,personalprotectiveequipment,spillkitsandoutbreakkitsInteractionsbetweenstaffandcarerecipientsKitchen/cateringareasincludingfoodstorageLaundryandassociatedequipmentLivingenvironmentMealandrefreshmentservicewithmenudisplayMedicationadministration,storageanddisposalsystems.NoticeboardsandinformationdisplaysRe-accreditationnoticesdisplayedShortgroupobservationduringlifestyleactivity.

Self-assessmentSpecialistassessmentsandreviews

Woundandpressurecarerecords.


AssessmentinformationThissectioncoversinformationaboutthehome’sperformanceagainsteachoftheexpectedoutcomesoftheAccreditationStandards.

Standard1–Managementsystems,staffingandorganisationaldevelopment

Principle:

Withinthephilosophyandlevelofcareofferedintheresidentialcareservices,managementsystemsareresponsivetotheneedsofcarerecipients,theirrepresentatives,staffandstakeholders,andthechangingenvironmentinwhichtheserviceoperates.

1.1 Continuousimprovement

Thisexpectedoutcomerequiresthat“theorganisationactivelypursuescontinuousimprovement”.

Team'sfindings

Thehomemeetsthisexpectedoutcome

Thecontinuousimprovementprogramincludesprocessesforidentifyingareasforimprovement,implementingchange,monitoringandevaluatingtheeffectivenessofimprovements.Feedbackissoughtfromcarerecipients,representatives,staffandotherstakeholderstodirectimprovementactivities.Improvementactivitiesaredocumentedontheplanforcontinuousimprovement.Managementusesarangeofmonitoringprocessessuchasauditsandqualityindicatorstomonitortheperformanceofthehome'squalitymanagementsystems.Outcomesareevaluatedforeffectivenessandongoingmonitoringofnewprocessesoccurs.Carerecipients,representatives,staffandotherpersonnelareprovidedwithfeedbackaboutimprovements.Duringthisaccreditationperiodtheorganisationhasimplementedinitiativestoimprovethequalityofcareandservicesitprovides.RecentexamplesofimprovementsinStandard1Managementsystems,staffingandorganisationaldevelopmentare:

1.2 Regulatorycompliance

Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines”.

Team'sfindings

Managementimplementedelectronicrosteringtoreplacetheexistingpaper-basedsystem.Managementandstaffspokepositivelyaboutthechangewhichenablestheestablishmentofamonthlyrosterandashortmessagealertsystemforunplannedleave.Managementsaidthesystemensurestherosteringprocessmorestreamlinedandefficientandhascreatedgreatertransparencyandequityinshiftallocation.Inresponsetoongoingchallengespromotingstaffattendanceattrainingsessions,managementexploredoptionstoimplementanonlinelearningframework.ThisleadtotheimplementationoftheVictorianRegionalHealthServiceseLearningNetworkatthehome.Staffthroughtheirindividualloginshaveaccesstoalargerangeofmandatoryandothereducationtopics.Managementsaidstaffenjoytheflexibilitythatonlinelearningprovides.



Thehomehasagenerallyeffectivesystemtoidentifyrelevantlegislation,regulatoryrequirementsandguidelines,andformonitoringtheseinrelationtotheAccreditationStandards.Managementhasestablishedlinkswithexternalorganisationstoensuretheyareinformedaboutchangestoregulatoryrequirements.Wherechangesoccur,managementtakesactiontoupdatepoliciesandproceduresandcommunicatethechangestocarerecipients,theirrepresentativesandstaffasappropriate.Arangeofsystemsandprocesseshavebeenestablishedbymanagementtoensurecompliancewithregulatoryrequirements.Staffhaveanawarenessoflegislation,regulatoryrequirements,professionalstandardsandguidelinesrelevanttotheirroles.ExamplesofregulatorycompliancerelatingtoStandard1Managementsystems,staffingandorganisationaldevelopmentinclude:

1.3 Educationandstaffdevelopment

Thisexpectedoutcomerequiresthat“managementandstaffhaveappropriateknowledgeandskillstoperformtheirroleseffectively”.

Team'sfindings


Thehome'sprocessessupporttherecruitmentofstaffwiththerequiredknowledgeandskillstoperformtheirroles.Newstaffparticipateinanorientationprogramthatprovidesthemwithinformationabouttheorganisation,theirposition,keypoliciesandproceduresandequipsthemwithmandatoryskillsfortheirrole.Staffarescheduledtoattendregularmandatorytraining;attendanceismonitoredandaprocessavailabletoaddressnon-attendance.Theeffectivenessoftheeducationprogramismonitoredthroughattendancerecords,evaluationrecordsandobservationofstaffpractice.Carerecipientsandrepresentativesinterviewedaresatisfiedstaffhavetheknowledgeandskillstoperformtheirrolesandstaffaresatisfiedwiththeeducationandtrainingprovided.ExamplesofeducationandtrainingprovidedinrelationtoStandard1Managementsystems,staffingandorganisationaldevelopmentincludeattendingthe:

1.4 Commentsandcomplaints

Thisexpectedoutcomerequiresthat"eachcarerecipient(orhisorherrepresentative)andotherinterestedpartieshaveaccesstointernalandexternalcomplaintsmechanisms".

Team'sfindings


Thereareprocessestoensurecarerecipients,theirrepresentativesandothersareprovidedwithinformationabouthowtoaccesscomplaintmechanisms.Carerecipientsandothersaresupportedtoaccessthesemechanisms.Facilitiesareavailabletoenablethesubmissionof

Processesensureallrelevantindividualsincludingvolunteershaveacurrentpolicecertificatecheck.Informationregardingexternalcomplaintmechanismsiscommunicatedtocarerecipientsandrepresentatives.Managementhasasystemtoundertakeself-assessment.Confidentialdocumentationisstoredsecurely.

BetterPracticeconferenceregionalforumofindustrypeakbody.


confidentialcomplaintsandensureprivacyofthoseusingcomplaintsmechanisms.Complaintsprocesseslinkwiththehome'scontinuousimprovementsystemandwhereappropriate,complaintstriggerreviewsofandchangestothehome'sproceduresandpractices.Theeffectivenessofthecommentsandcomplaintssystemismonitoredandevaluated.Managementandstaffhaveanunderstandingofthecomplaintsprocessandhowtheycanassistcarerecipientsandrepresentativeswithaccess.Carerecipientsandtheirrepresentativesinterviewedhaveanawarenessofthecomplaintsmechanismsavailabletothemandareeithermostlyoralwayssatisfiedthatstafffollowupwhentheyraisethingswiththem.

1.5 PlanningandLeadership

Thisexpectedoutcomerequiresthat"theorganisationhasdocumentedtheresidentialcareservice’svision,values,philosophy,objectivesandcommitmenttoqualitythroughouttheservice".

Team'sfindings


Theorganisationhasdocumentedthehome'svision,philosophy,objectivesandcommitmenttoquality.Thisinformationiscommunicatedtocarerecipients,representatives,staffandothersthrougharangeofdocumentsandisdisplayedinthehome.Ninetythreepercentofcarerecipientsinterviewedfortheconsumerexperiencereportsaidtheystronglyagreethehomeiswellrunwhiletheothersevenpercentagreedthehomeiswellrun.

1.6 Humanresourcemanagement

Thisexpectedoutcomerequiresthat"thereareappropriatelyskilledandqualifiedstaffsufficienttoensurethatservicesaredeliveredinaccordancewiththesestandardsandtheresidentialcareservice’sphilosophyandobjectives".

Team'sfindings


TherearesystemsandprocessestoensuretherearesufficientskilledandqualifiedstafftodeliverservicesthatmeettheAccreditationStandardsandthehome'sphilosophyandobjectives.Recruitment,selectionandinductionprocessesensurestaffhavetherequiredknowledgeandskillstodeliverservices.Staffinglevelsandskillmixarereviewedinresponsetochangesincarerecipients'needsandthereareprocessestoaddressplannedandunplannedleave.Thehome'smonitoring,humanresourceandfeedbackprocessesidentifyopportunitiesforimprovementinrelationtohumanresourcemanagement.Staffaresatisfiedtheyhavesufficienttimetocompletetheirworkandmeetcarerecipients'needs.Carerecipientsandrepresentativesinterviewedarehighlysatisfiedwiththeavailabilityofskilledandqualifiedstaffandthequalityofcareandservicesprovided.

1.7 Inventoryandequipment

Thisexpectedoutcomerequiresthat"stocksofappropriategoodsandequipmentforqualityservicedeliveryareavailable".

Team'sfindings


Thehomehasprocessestomonitorstocklevels,ordergoodsandmaintainequipmenttoHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 12

ensuredeliveryofqualityservices.Goodsandequipmentaresecurelystoredand,whereappropriate,stockrotationoccurs.Preventativemaintenanceandcleaningschedulesensureequipmentismonitoredforoperationandsafety.Thehomepurchasesequipmenttomeetcarerecipients'needsandmaintainsappropriatestocksofrequiredsupplies.Staffreceivetraininginthesafeuseandstorageofgoodsandequipment.Staff,carerecipientsandrepresentativesinterviewedstatedtheyaresatisfiedwiththesupplyandqualityofgoodsandequipmentavailableatthehome.

1.8 Informationsystems

Thisexpectedoutcomerequiresthat"effectiveinformationmanagementsystemsareinplace".

Team'sfindings

ThehomemeetsthisexpectedoutcomeManagementandstaffhaveaccesstoinformationappropriatetotheirrole.Policies,procedures,positiondescriptions,plannededucation,meetings,handoverandelectronicmemorandainformstaff.Newsletters,notices,meetings,publicannouncementsandinformaldiscussionsprovideongoinginformationforcarerecipientsandrepresentatives.Staffreviewclinicalinformationregularlyanddemonstrateeffectivesystemsforcommunicatingchangesincarerecipients’treatmentandneeds.Confidentialinformationisstoredandarchivedinlinewithlegislatedrequirements.Electronicsystemsarepasswordprotectedwithinformationrestrictedtoappropriatestaff.Managementcollect,collateandanalysekeyinformationtoidentifypotentialrisksandimprovementopportunities.Staffsaidtheyhaveadequateaccesstoinformationtohelpthemperformtheirroles.Carerecipientsandrepresentativessaidtheyreceiveinformationregardingcarerecipients’careandinformationaboutactivitiesandeventsinthehome.Carerecipientsaresatisfiedstafftakethetimetoexplainthingstothem.

1.9 Externalservices

Thisexpectedoutcomerequiresthat"allexternallysourcedservicesareprovidedinawaythatmeetstheresidentialcareservice’sneedsandservicequalitygoals".

Team'sfindings


Thehomehasmechanismstoidentifyexternalserviceneedsandqualitygoals.Thehome'sexpectationsinrelationtoserviceandqualityisspecifiedandcommunicatedtotheexternalproviders.Thehomehasagreementswithexternalserviceproviderswhichoutlineminimumperformance,staffingandregulatoryrequirements.Thereareprocessestoreviewthequalityofexternalservicesprovidedand,whereappropriate,actionistakentoensuretheneedsofcarerecipientsandthehomearemet.Staffareabletoprovidefeedbackonexternalserviceproviders.Carerecipients,representativesandstaffinterviewedstatedtheyaresatisfiedwiththequalityofexternallysourcedservices.


Standard2-Healthandpersonalcare

Principle:

Carerecipients’physicalandmentalhealthwillbepromotedandachievedattheoptimumlevel,inpartnershipbetweeneachcarerecipient(orhisorherrepresentative)andthehealthcareteam.



Team'sfindings


RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard2Healthandpersonalcareare:


Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelinesabouthealthandpersonalcare”.

Team'sfindings


RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.

ExamplesofregulatorycompliancerelatingtoStandard2Healthandpersonalcareinclude:

Theobservedbenefitsofthevisitingnursepractitionerprogramledtoadecisionbymanagementtoincreaseintheprogramfromonedayaweektofourhoursforthreedaysaweekandanoncallservice.Managementspokepositivelyaboutthebenefitsoftheprogramwhichincludeimprovedclinicalassessmentsandstaffeducation.Carerecipientsandrepresentativesspokehighlyaboutthequalityoftheservice.Onerepresentativesaidhavingthenursepractitioneronsitehasenabledtheirfather,whoisanxiousaboutleavingthehome,toreceiveallhiscareatthehome.Inresponsetothefindingsofacoronialinquestintobluerecliningcomfortchairs,managementtookadecisiontophaseoutthisequipmentfromuseatthehome.Thewoundcarespecialistandoccupationaltherapistreviewedtheseatingrequirementsforallcarerecipientsandmaderecommendationsofspecificpressurerelievingseatingforeachcarerecipient.Managementpurchasedalternatecomfortchairsandpressurerelievingcushionsinaccordancewiththeensuingreport.Theoccupationaltherapistwillcontinuetoreassesscarerecipients’pressurecareneedsastheirconditionchangesensuringoptimumpressurecare.

Managementmonitorandensurethecurrencyofallnursingregistrationsismaintained.Registerednursesundertakeandoverseecareplanningandspecialisednursingcare.Medicationmanagement,administrationandstorageoccursinaccordancewithlegislativerequirements.




Team'sfindings


Thehomehasasystemtomonitorandensurestaffhavetheknowledgeandskillstoenablethemtoeffectivelyperformtheirrolesinrelationtohealthandpersonalcare.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard2Healthandpersonalcareinclude:

2.4 Clinicalcare

Thisexpectedoutcomerequiresthat“carerecipientsreceiveappropriateclinicalcare”.

Team'sfindings


Carerecipientsreceiveclinicalcareappropriatetomeettheirneedsandpreferences.Transferdataandentryassessmentsformthebasisforaninterimcareplan,whichprovidescareguidelinesuntilstaffcompleteallassessmentsandcareplanning.Careplansincludeinputfromotherhealthprofessionalsandreflectcarerecipients’preferencesandtheassessmentdata.Nursingstaffreviewcareplanstwomonthlyorwhentriggeredbymedicalreviewsorchangesinthecarerecipients’condition.Anursepractitionerisavailablethreedayseachweekprovidingsupportforstaffandisparticipatingintheprovisionofcarerecipients’clinicalcare.Staffhaveaccesstopoliciesandproceduresandeducationtoguidetheirpractice.Audits,carereviews,stakeholderfeedbackandclinicalindicatorssuchasskintears,falls,behaviouralandmedicationsincidentscontributetothemonitoringofcareoutcomes.Carerecipientsandrepresentativesaresatisfiedwiththeclinicalcareprovidedforcarerecipients.

2.5 Specialisednursingcareneeds

Thisexpectedoutcomerequiresthat“carerecipients’specialisednursingcareneedsareidentifiedandmetbyappropriatelyqualifiednursingstaff”.

Team'sfindings


Carerecipients’specialisednursingcareneedsareidentifiedandmetbyappropriatelyqualifiednursingstaff.Registerednursesmanagecarerecipients’specialisednursingcarecompletingassessments,developingcareplansandevaluatingspecialisedcareregularly.Staffconsultthemedicalpractitionerandthegerontologynursepractitionerforanysignificantchangeincarerecipients’healthstatus.Otherhealthspecialistsprovidecareplaninputand

Managementhaveapolicyandprocedureforunexplainedabsencesofacarerecipientincludingtherequirementtonotifyallrelevantauthorities.

advancedcareplanningdementiaessentialspainmanagementwoundcare.


expertiseasrequired.Careplanscontainreferraloutcomesanddetailsofprescribedtreatments.Specialistequipmentisavailableandtheeducationprogramprovidesstaffwiththeopportunitytodevelopspecialisedskillsandknowledge.Carerecipientsandrepresentativesaresatisfiedappropriatelyskilledandqualifiedstaffattendtocarerecipients’specialisedcareneeds.

2.6 Otherhealthandrelatedservices

Thisexpectedoutcomerequiresthat“carerecipientsarereferredtoappropriatehealthspecialistsinaccordancewiththecarerecipient’sneedsandpreferences”.

Team'sfindings


Carerecipientscanaccessawiderangeofhealthspecialistsaccordingtotheirneedsandpreferences.Medicalpractitionersvisitthehomeregularlyandcarerecipientscanretaintheirownmedicalpractitionerofchoice.Managementandthemedicalpractitionerprovidecarerecipientsandrepresentativeswithinformationabouthealthspecialistsassistingthemtomakeinformedchoices.Arangeofhealthspecialistsvisitthehomeandstaffassistcarerecipientstoattendexternalappointmentsorfacilitatetele-conferencingappointmentswithagedcarespecialists.Clinicaldocumentationincludesoutcomesofhealthspecialists’referralsandsubsequentupdatestocareplanning.Carerecipientsandrepresentativesaresatisfiedcarerecipientsreceiveadequateassistancetoaccesstheirpreferredhealthspecialists.

2.7 Medicationmanagement

Thisexpectedoutcomerequiresthat“carerecipients’medicationismanagedsafelyandcorrectly”.

Team'sfindings


Carerecipients’medicationismanagedsafelyandcorrectly.Registerednurses,medicationendorsedenrollednursesandmedicationcompetentcarersadministermedicationsfrommultidoseadministrationaidsandoriginalpackaging.Initialandongoingassessmentsidentifycarerecipients’medicationrequirementsandpreferences,allergiesanddegreeofassistanceneeded.Medicationchartsareuptodateandincludeclearmedicationorders,identificationinformationanddetailresidents’preferencesfortakingmedication.Registerednursesmaintainresponsibilityforrestrictedmedicationsandmedicationrequiringregulardoseadjustmentaccordingtotheprescriber’sinstructions.Processesincludecheckingofmedicationsnotincludedindoseadministrationaidsandfortheadministrationof‘asrequired’medications.Medicationsarestoredsecurelyandthereareprocedurestomaintainsupplyandtodisposeofunnecessarymedication.Managementmonitorsthemedicationsystemthroughincidentanalysis,pharmacyreviews,auditsandmedicationadvisorymeetings.Carerecipientsandrepresentativesaresatisfiedmedicationismanagedsafelyandcorrectly.

2.8 Painmanagement

Thisexpectedoutcomerequiresthat“allcarerecipientsareasfreeaspossiblefrompain”.

Team'sfindings

ThehomemeetsthisexpectedoutcomeHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 16

Carerecipientsareasfreeaspossiblefrompain.Nursingstaffcompleteinitialpainassessmentsidentifyingcarerecipientspastandcurrentpainexperiencesandcommenceappropriatetreatments.Staffcompleteassessmentandchartingforcontinuingpainandusethisinformationtodevelopaplanofcare.Processesincludemonitoringofcarerecipientswhoareunabletoverbalisetheirpainsymptomsandareviewforanyneworalteredpain.Carerecipientshaveindividualisedpainprogramsdirectedbyanonsiteoccupationaltherapistinconsultationwiththeclinicalstaffandthecarerecipient’sgeneralpractitioner.Staffdescribedarangeofcomfortmeasurestheyusetoalleviatecarerecipients’painincludingheatandmassagetherapy,diversion,repositioningandmedication.Managementmonitorforeffectivenessofcareusingcarereviews,medication,auditsandfeedback.Carerecipientsandrepresentativessaidtheyaresatisfiedwiththemanagementofcarerecipients’pain.

2.9 Palliativecare

Thisexpectedoutcomerequiresthat“thecomfortanddignityofterminallyillcarerecipientsismaintained”.

Team'sfindings

ThehomemeetsthisexpectedoutcomeCaremanagementsystemsandstaffpracticesensurethedignityandcomfortforcarerecipientsnearingtheendoftheirlife.Endoflifewishesareincludedinassessmentandcareplanningandthenursepractitionerisassistingcarerecipientstocompleteadvancedcareplans.Whenindicatednursingstaffreviewcareanddevelopapalliativecareplaninconsultationwiththecarerecipient,representativesandotherhealthprofessionals.Palliativecarestrategiesincludesymptommanagement,comfortmeasures,paincontrolandaddressingemotionalandspiritualneeds.Staffconsultwithexternalpalliativespecialiststoassistwithadviceandcarewhenrequired.Staffdescribedempatheticcareforterminallyillcarerecipientsincludingconsiderationofpreferences,dignity,comfortandspiritualcare.Carerecipientsandrepresentativesaresatisfiedwiththespiritualandpalliativecareavailableforcarerecipients.

2.10 Nutritionandhydration

Thisexpectedoutcomerequiresthat“carerecipientsreceiveadequatenourishmentandhydration”.

Team'sfindings


Carerecipientsreceiveadequatenourishmentandhydration.Assessmentsandcareplansidentifyallergies,detailsofrequiredassistivedevices,personalandculturalpreferencesandclinicalneeds.Communicationprocessesensurecateringinformationreflectscarerecipients’needsandpreferences.Staffassistcarerecipientsatmealtimesandprovideadaptivecutleryandcrockeryencouragingindependence.Referralsystemsensurethedietitianandspeechtherapistmonitorscarerecipientswithdietaryandswallowingconcerns.Staffweighcarerecipientssecondmonthlytomonitorforanysignificantorunexplainedweightvariationandasmallnumberofcarerecipientsreceiveadditionalnutritionalsupplements.Monitoringofnutritionandhydrationoccursthroughaudits,weightanalysisandstakeholderfeedback.Carerecipientsandrepresentativesspokepositivelyofthemealsprovided,sayingtheyalmostalwaysenjoythefoodofferedandtheycanhavesubstitutemeals,avarietyofdrinksandsnacksastheywish.

2.11 Skincare

Thisexpectedoutcomerequiresthat“carerecipients’skinintegrityisconsistentwiththeirgeneralhealth”.


Team'sfindings


Carerecipients’skinintegrityisconsistentwiththeirgeneralhealth.Initialandongoingassessments,includingariskassessmentprocess,identifycarerecipients’skincareneedsandpreferencesandcontributetothedevelopmentofthecareplan.Skincareinterventionsincludepressurerelievingdevices,specifichygieneandskinmoisturisingstrategies,mobilityreviews,positionchangesandnutritionalstrategies.Woundcareincludesappropriatewounddressings,documentationandevaluationofcareandconsultationwiththewoundcarespecialistwhenrequired.Thewoundcarespecialistevaluatesallpressure-relievingaidsforsuitabilityandoptimumpressurerelievingfunction.Staffconfirmedsufficientsuppliesofwoundcareproductsandavailabilityofeducationresourcesforskincaremanagement.Audits,stakeholderconsultation,incidentandcareplanreviewsmonitortheeffectivenessofcare.Carerecipientsandrepresentativesaresatisfiedcarerecipientsreceiveappropriateskincareconsistentwiththeirgeneralhealth.

2.12 Continencemanagement

Thisexpectedoutcomerequiresthat“carerecipients’continenceismanagedeffectively”.

Team'sfindings

ThehomemeetsthisexpectedoutcomeCarerecipientsreceivecontinencecareappropriatetotheirneeds,effectivelymanagingtheircontinenceexperience.Processesincludecontinenceassessments,managementplans,identificationandsupplyofappropriateaidsandregularcontinencecarereview.Continencecarestrategiesincludereferraltoacontinenceadviser,establishingvoidingpatterns,dietaryandmedicationinterventions,mobilitystrategiesandtoiletingplans.Nutritionplansincludedietarymeasuresforeffectivebowelmanagement.Staffmonitorforinfectionsimplementingappropriatemanagementstrategies.Careplanreviewsandauditsensuresufficientandappropriateaidsareavailableandthattheprogramismeetingtheneedsandpreferencesofcarerecipients.Carerecipientsandrepresentativesaresatisfiedstaffmanagecarerecipients’continenceissuesdiscreetlyandrespectfully.

2.13 Behaviouralmanagement

Thisexpectedoutcomerequiresthat“theneedsofcarerecipientswithchallengingbehavioursaremanagedeffectively”.

Team'sfindings


Theneedsofcarerecipientswithresponsivebehavioursaremanagedeffectively.Initialandongoingassessmentsidentifycarerecipients’behaviourpatternsandincorporatescopeforadditionalmonitoringandreviewasnecessary.Careplansincludeconsiderationoftriggersforthebehaviourwheneverpossibleandarereviewedtwomonthlyandwhenrequired.Medicalpractitionersandnursingstaffassessandregularlyreviewanypracticewithpotentialforrestraint.Staffconsultwithbehaviouralandpainmanagementspecialists,dementiaresponseteamsandadvisorygroupsasrequired.Staffsaidtheyareawareofthetriggersassociatedwithbehavioursandweobservedstaffprovidingcare,demonstratingtheyunderstoodcarerecipients’needs.Thehomemonitorstheeffectivenessofthecarethroughaudits,reviewofbehaviourincidents,carereviewsandfeedback.Carerecipientsandrepresentativesaresatisfiedtheneedsofcarerecipientswithresponsivebehavioursaremanagedeffectively.


2.14 Mobility,dexterityandrehabilitation

Thisexpectedoutcomerequiresthat“optimumlevelsofmobilityanddexterityareachievedforallcarerecipients”.

Team'sfindings


Carerecipients’optimumlevelsofmobilityanddexterityareachieved.Anonsiteoccupationaltherapistisactivelyinvolvedintheassessmentanddevelopmentofpersonalisedprogramsforcarerecipientsensuringoptimallevelsofmobility,dexterityandriskminimisation.Careplansincludestrategiestopromoteindependenceandminimisefallrisks.Appropriatetransferequipment,assistivedevicesandmobilechairsareavailable.Educationprogramsprovidetrainingforincidentmanagement,manualhandlingandsafetransfertechniques.Audits,careplanreviews,observationandstakeholderfeedbackmonitortheeffectivenessofcare.Carerecipientsandrepresentativesaresatisfiedwiththecareprovidedtomaintaincarerecipients’mobilityanddexterity.

2.15 Oralanddentalcare

Thisexpectedoutcomerequiresthat“carerecipients’oralanddentalhealthismaintained”.

Team'sfindings


Carerecipients’oralanddentalhealthismaintained.Assessments,careplansandregularevaluationsidentifycarerecipients’dentalstatus,preferredcareoptionsandthelevelofassistancerequired.Nursingstaffandthemedicalpractitionermonitororalanddentalhealthreferringcarerecipientstoalliedhealthspecialistssuchasthedietician,speechtherapistanddentalserviceswhenrequired.Adentalclinicvisitedrecentlycompletingdentalchecks,hygienecareandsimpletreatments.Staffassistcarerecipientstoattendexternalservicesformorecomplicatedtreatments.Dentalcareequipmentischeckedregularly,readilyavailableandreplacedaccordingtoaseasonalschedule.Careplanreviewsensuredentalcareandpreferencesareaddressedeffectively.Carerecipientsandrepresentativesaresatisfiedwiththeassistancecarerecipientsreceivetomaintaintheiroralanddentalcare.

2.16 Sensoryloss

Thisexpectedoutcomerequiresthat“carerecipients’sensorylossesareidentifiedandmanagedeffectively”.

Team'sfindings

ThehomemeetsthisexpectedoutcomeCareprocessesaddresstheeffectiveidentificationandmanagementofcarerecipients’sensorylosses.Assessmentandcareplanningidentifycarerecipients’sensoryneedsforvision,hearing,communication,sensation,tasteandtactileexperiences.Careplansdetailthelevelofassistancerequired,careofaidsandstrategiestooptimisesensoryfunction.Staffnotifythemedicalpractitionerofanyconcernsandreferraltospecialistssuchasaudiologistsandoptometristsoccurs.Lifestyleactivitiesincludearangeofsensoryenhancingopportunitiessuchasinteractivelifestyleevents,music,massageandtactiletherapies.Monitoringsystemsincludeauditsandstakeholderfeedback.Carerecipientsandrepresentativesaresatisfiedwiththesupportgiventocarerecipientstoenhancetheirsensoryexperiences.


2.17 Sleep

Thisexpectedoutcomerequiresthat“carerecipientsareabletoachievenaturalsleeppatterns”.

Team'sfindings


Sleepmanagementstrategiesassistcarerecipientstoachieveandmaintainnaturalsleeppatterns.Assessmentsidentifycarerecipients’usualsleeppatternspreferencesfordayandnightrest.Careplansdetailpreferencesforretiring,wakingandstrategiestopromotesleep,suchasattendingtophysicalcareneeds,leavingalighton,painmanagementandspecificcomfortmeasures.Staffdemonstratedknowledgeofcarerecipients’individualsettlingroutinesanddayrestrequirements.Managementmonitorcarerecipients’sleeprequirementsbyauditsandstakeholderfeedback.Carerecipientsandrepresentativesaresatisfiedstaffrespectandaccommodatecarerecipients’preferencesforsleepandrest.


Standard3-Carerecipientlifestyle

Principle:

Carerecipientsretaintheirpersonal,civic,legalandconsumerrights,andareassistedtoachievecontroloftheirownliveswithintheresidentialcareserviceandinthecommunity.



Team'sfindings


RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard3Carerecipientlifestyleare:


Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines,aboutcarerecipientlifestyle”.

Team'sfindings


RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.Thehomehasprocessestoguidemanagementandstaffintheeventofacompulsoryreportingincident,however,weidentifiedononeoccasionmanagementdidnotapplytheseguidelineseffectively.Whenweraiseditwithmanagement,theytookstepstoreporttheincidenttotheappropriateregulatoryauthorities.

OtherexamplesofregulatorycompliancerelatingtoStandard3Carerecipientlifestyleinclude:

Duetothesuccessofthehome’screativelymanagedentertainmentprogramwheremanagementhasattractedqualityactsfromacrossAustralia,includingKarmalandTomBurleson,theboardofgovernorshavecommitteda$50000budgeteachyeartoensurethecontinuityofprofessionalentertainers.Entertainmentandcabareteveningsareverywellattendedbycarerecipientsandtheoccasionisenhancedwiththechefpreparedthree-coursemealtosuitthesetting.Tosupportcarerecipientswithlowvisionthelifestyleprogramisnowprovidedinlargeprint.Themenuboardinthediningroomandtheday’sactivitiesarewritteninlargefontforallcarerecipientstosee.Staffsaidthishasincreasedcarerecipients’independenceandparticipationinactivities.

Therearepoliciesandproceduresavailableinrelationtoprivacyandconfidentialityofcarerecipientandstaffinformation.TheCharterofcarerecipients'rightsandresponsibilities-residentialcareisdisplayed.Carerecipientsand/ortheirrepresentativesreceivearesidentialagreementuponentrywhichoutlinesobligations,rights,services,responsibilitiesandfees.




Team'sfindings


Thehomehasasystemtomonitorandensurestaffhavetheknowledgeandskillstoenablethemtoeffectivelyperformtheirrolesinrelationtocarerecipientlifestyle.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard3Carerecipientlifestyleinclude:

3.4 Emotionalsupport

Thisexpectedoutcomerequiresthat"eachcarerecipientreceivessupportinadjustingtolifeinthenewenvironmentandonanongoingbasis".

Team'sfindings

ThehomemeetsthisexpectedoutcomeManagementandstaffprovidesupportforcarerecipientstoadjusttotheirnewenvironmentwhenmovingintothehomeandonanongoingbasis.Carerecipientsand/orrepresentativesreceivepreadmissionandentryinformationpacksandmanagementprovidesaninformativetourofthehome.Staffencourageandassistcarerecipientstopersonalisetheirroomsandrepresentativesareinvitedjoininactivitiesandmaintaincloserelationships.Careandlifestyleassessmentsidentifycarerecipients’emotionalneedsandcontributetothedevelopmentofasupportivecareplan.Regularcareplanreviewscaptureanychangesandactivitystaffscheduleindividualempathetictimewithcarerecipients.Whilemostcarerecipientsinterviewedagreedorstronglyagreedtherearestafftheycantalktowhensadorworried,oneinfiveresponseschoseaneutralresponsesayingtheywouldrathercallontheirfamilyifneeded.Representativesspokehighlyoftheemotionalsupportprovidedtocarerecipientsatentryandonanongoingbasis.

3.5 Independence

Thisexpectedoutcomerequiresthat"carerecipientsareassistedtoachievemaximumindependence,maintainfriendshipsandparticipateinthelifeofthecommunitywithinandoutsidetheresidentialcareservice".

Team'sfindings


Staffassistcarerecipientstomaximisetheirindependence,maintaincommunitycontactsandcontinuewiththeirpersonalandsocialfriendships.Assessmentandcareplanningprocessesidentifycarerecipients’cognitive,mobilityanddexteritylevels,anyrisktakingbehavioursandpreferencesforsocialinteraction.Staffassistcarerecipientstovoteinelections,managetheirfinancesandcontinuewithcommunityactivitiesaccordingtotheircapabilitiesandpreferences.Specialisedequipment,aidsandutensilsencourageindependenceandauditsensuretheenvironmentisfreeofhazards.Allcarerecipientsinterviewedaspartoftheconsumerexperiencereporteitheragreedorstronglyagreedthey

10tipsforcaringforapersonlivingwithdementiaelderrightsadvocacyprotectingelderpeoplefromabuserespectingchoices.


areencouragedtoasmuchaspossibleforthemselves.Representativesarehighlysatisfiedwiththeassistancecarerecipientsreceivetopromotetheirindependenceandlifestyleopportunities.

3.6 Privacyanddignity

Thisexpectedoutcomerequiresthat"eachcarerecipient’srighttoprivacy,dignityandconfidentialityisrecognisedandrespected".

Team'sfindings


Eachcarerecipient’srighttoprivacy,dignityandconfidentialityisrecognisedandrespected.Managementinformsstaffoftheirobligationsatorientationandprivacyinformationisincludedinemploymentandeducationprograms,staffhandbookandbrochures.Carerecipientsresideinsingleroomswithprivateensuitesandcanlocktheirroom.Careplansrecordcarerecipients’wishes,preferencesandincludeconsentfortheuseoftheirrecordsandpublicationofidentifyinginformation.Filesarestoredsecurelyandhandoveroccursprivately.Weobservedstaffmaintainedcarerecipientsprivacyanddignitybyknockingondoorspriortoenteringroomsandaddressingcarerecipientswithcourtesyusingtheirpreferredname.Audits,observationsandfeedbackmonitorstaffpracticeandrespectforcarerecipients.Carerecipientsandrepresentativesinterviewedallsaidstaffmostlyoralwaystreatthemwithdignityandrespectcarerecipientprivacy.

3.7 Leisureinterestsandactivities

Thisexpectedoutcomerequiresthat"carerecipientsareencouragedandsupportedtoparticipateinawiderangeofinterestsandactivitiesofinteresttothem".

Team'sfindings


Carerecipientsareencouragedandsupportedtoparticipateinawideanddiverserangeofactivitiesandtocontributetothedevelopmentofthelifestyleprogram.Staffconsultwiththecarerecipientorrepresentativetoidentifyleisureandactivitiesinterestsandincorporatethisinformationintoanindividualisedlifestylecareplan.Carerecipientsreceivethemonthlylifestylecalendartokeepintheirroomandpostersdisplayedthroughoutthehomeinformandencourageparticipationbycarerecipientsandvisitors.Lifestylestaffmaintainrecordsofparticipation,reviewcareplansregularlyandspendtimewithindividualcarerecipientstoensurenoonefeelslonelyorisolated.Thelifestyleprogramincludestheplacementofresourcesincommunalareasenablingcarerecipientstoself-initiateactivitiessuchasjigsawsorartisticendeavours.Specialcelebrations,visitingentertainers,eveningcabarets,outings,familybarbequesandsocialeventsaddtothediversityoftheprogram.Carerecipientsandrepresentativesaresatisfiedcarerecipientsareabletoparticipateinawidevarietyofactivitiesofinteresttocarerecipients.

3.8 Culturalandspirituallife

Thisexpectedoutcomerequiresthat"individualinterests,customs,beliefsandculturalandethnicbackgroundsarevaluedandfostered".

Team'sfindings



Managementensurescarerecipient’sindividualcustoms,beliefsandculturalbackgroundsarefosteredandvalued.Initialassessmentsandcareplansdocumentpreferencesincludingcelebratorydays,socialcontacts,culturalandethnicneedsandpalliativecarewishes.Specialeventsandsignificantdaysarecelebrated.MembersofreligiouscommunitiesvisitregularlyandcarerecipientshavetheopportunitytoreceivecommunionandattendprayersandservicesintheDelaneyChapelaccessedviaasmallpassagewayinthehome.Lifestylestafforganiseculturalandthemeeventsandmaintainaregisterofcarerecipientswhowishtocelebratespecialsignificanteventssuchasbirthdaysandanniversaries.Staffcanaccessculturalcarekitsandinterpreterswhenrequired.Carerecipientsandrepresentativesaresatisfiedcarerecipients’spiritualandculturalpreferencesarevaluedandsupported.

3.9 Choiceanddecisionmaking

Thisexpectedoutcomerequiresthat"eachcarerecipient(orhisorherrepresentative)participatesindecisionsabouttheservicesthecarerecipientreceives,andisenabledtoexercisechoiceandcontroloverhisorherlifestylewhilenotinfringingontherightsofotherpeople".

Team'sfindings

ThehomemeetsthisexpectedoutcomeTherightsofcarerecipientstomakedecisionsandexercisechoiceandcontrolovertheirlifestyleisrecognisedandrespected.Managementprovidescarerecipients,and/orrepresentativeswithinformationregardingrightsandresponsibilities,advocacyandcomplaintsandfeedbackmechanismsavailabletothem.Careandlifestyleplansdetailindividualpreferencesandstaffconsultwithcarerecipientsand/orrepresentativesregularlytoidentifyanychangesinpreferencesandsatisfactionlevels.Carerecipientsparticipateinchoiceregardingpharmacy,healthspecialists,lifestyleactivities,healthandpersonalcareandmenuoptions.Managementensureauthorisedrepresentativesactforcarerecipientswhoareunabletoparticipateindecision-making.Carerecipientsandtheirrepresentativesaresatisfiedstaffacknowledgeandrespectthepreferencesandchoicesofcarerecipients.

3.10 Carerecipientsecurityoftenureandresponsibilities

Thisexpectedoutcomerequiresthat"carerecipientshavesecuretenurewithintheresidentialcareservice,andunderstandtheirrightsandresponsibilities".

Team'sfindings

ThehomemeetsthisexpectedoutcomeCarerecipientsandtheirrepresentativesareprovidedwithinformationaboutcarerecipients'rightsandresponsibilities,thetermsandconditionsoftheirtenure,anylimitationstocareprovisionwithinthehome,feesandchargesandinformationaboutcomplaints,whentheyenterthehome.Thisisachievedthroughmeetingsatentry,asignedresidentialagreement,handbooksanddisplayoftheCharterofcarerecipients'rightsandresponsibilities-residentialcare.Changestocarerecipients'securityoftenureorrightsandresponsibilitiesarecommunicatedtocarerecipientsand/ortheirrepresentative.Ifachangeincarerecipienthealthrequiresaroomchangeortransfertoanotherhome,thisisdiscussedwiththecarerecipientand/ortheirrepresentative.Thehome'smonitoringprocesses,includingfeedback,meetingsandcarereviews,identifyopportunitiesforimprovementinrelationtocarerecipientrights,responsibilitiesandsecurityoftenure.Staffdemonstrateanunderstandingofcarerecipientrights.Carerecipientsandrepresentativesinterviewedaresatisfiedcarerecipientshavesecuretenurewithinthehomeandunderstandtheirrightsandresponsibilities.


Standard4-Physicalenvironmentandsafesystems

Principle:

Carerecipientsliveinasafeandcomfortableenvironmentthatensuresthequalityoflifeandwelfareofcarerecipients,staffandvisitors.



Team'sfindings


RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard4Physicalenvironmentandsafesystemsare:


Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines,aboutphysicalenvironmentandsafesystems”.

Team'sfindings


RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.

ExamplesofregulatorycompliancerelatingtoStandard4Physicalenvironmentandsafesystemsinclude:


Inresponsetomanagementobservationsofadatedandincreasinglycrampeddiningarea,aprojectwascommencedtocarryoutamajorrefurbishmentofthisarea.Thediningroomwasextendedthroughremodellingadjoiningareas,acontemporarywoodstylefloorcoveringwasinstalledthroughoutthediningroom,and,coffeebarinstalledacrossonewall.Retractableblindsreplaceddatedcurtains.Carerecipientsandrepresentativesspokepositivelyaboutthechange.Weobservedlargenumbersofcarerecipientsenjoyingthediningarea,whichalsoaccommodatesvisitingentertainers.Inresponsetostakeholderfeedback,managementimplementedamajorreviewofthecateringdepartment.Thisresultedinarestructureofthecateringstaffrosterandcateringpractices.Thechefnowworksfrom8amto6pmwhichenablesthecheftoplanandbepresenttooverseeeachofthethreemealsprovidedduringtheday.Thehomeimplementedafreshcookmenuforboththelunchandeveningmeals.Carerecipientsandrepresentativesspokehighlyaboutthequality,varietyandpresentationofmeals.

Chemicalsarestoredappropriately.Thereisasystemtoensurecompliancewithfiresafetyregulations.Thereareinfectioncontrolpoliciesandasystemformanagingandreportingoutbreaks.Managementhasafoodsafetyprogramthatisregularlyreviewed.



Team'sfindings


Thehomehasasystemtomonitortheknowledgeandskillsofstaffmembersandenablethemtoeffectivelyperformtheirroleinrelationtophysicalenvironmentandsafesystems.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard4Physicalenvironmentandsafesystemsinclude:

4.4 Livingenvironment

Thisexpectedoutcomerequiresthat"managementoftheresidentialcareserviceisactivelyworkingtoprovideasafeandcomfortableenvironmentconsistentwithcarerecipients’careneeds".

Team'sfindings


Thehome'senvironmentreflectsthesafetyandcomfortneedsofcarerecipients,includingcomfortabletemperatures,noiseandlightlevels,sufficientandappropriatefurnitureandsafe,easyaccesstointernalandexternalareas.Environmentalstrategiesareemployedtominimisecarerecipientrestraint.Thesafetyandcomfortofthelivingenvironmentisassessedandmonitoredthroughfeedbackfrommeetings,surveys,incidentandhazardreporting,auditsandinspections.Thereareappropriatepreventativeandroutinemaintenanceprogramsforbuildings,furniture,equipmentandfittings.Staffsupportasafeandcomfortableenvironmentthroughhazard,incidentandmaintenancereportingprocesses.Carerecipientsandrepresentativesinterviewedareallsatisfiedthelivingenvironmentissafeandcomfortable.

4.5 Occupationalhealthandsafety

Thisexpectedoutcomerequiresthat"managementisactivelyworkingtoprovideasafeworkingenvironmentthatmeetsregulatoryrequirements".

Team'sfindings


Thereareprocessestosupporttheprovisionofasafeworkingenvironment,includingpoliciesandprocedures,stafftraining,routineandpreventativemaintenanceandincidentandhazardreportingmechanisms.Opportunitiesforimprovementintheoccupationalhealthandsafetyprogramareidentifiedthroughaudits,inspections,supervisionofstaffpractice,andanalysisofincidentandhazarddata.Sufficientgoodsandequipmentareavailabletosupportstaffintheirworkandminimisehealthandsafetyrisks.Staffhaveanunderstandingofsafeworkpracticesandareprovidedwithopportunitiestohaveinputtothehome'sworkplacehealthandsafetyprogram.Staffwereobservedtocarryouttheirworksafelyand

chemicalhandlingfireandemergencyunderstandingthecoronerinquestfindingonprincesschairsworkplacebullying.


aresatisfiedmanagementisactivelyworkingtoprovideasafeworkingenvironment.

4.6 Fire,securityandotheremergencies

Thisexpectedoutcomerequiresthat"managementandstaffareactivelyworkingtoprovideanenvironmentandsafesystemsofworkthatminimisefire,securityandemergencyrisks".

Team'sfindings


Policiesandproceduresrelatingtofire,securityandotheremergenciesaredocumentedandaccessibletostaff;thisincludesanemergencyevacuationplan.Staffareprovidedwitheducationandtrainingaboutfire,securityandotheremergencieswhentheycommenceworkatthehomeandonanongoingbasis.Emergencyequipmentisinspectedandmaintainedandtheenvironmentismonitoredtominimiserisks.Staffhaveanunderstandingoftheirrolesandresponsibilitiesintheeventofafire,securitybreachorotheremergencyandthereareroutinesecuritymeasures.Carerecipientsandrepresentativesinterviewedareawareofwhattheyshoulddoonhearinganalarmandsaidtheyalwaysfeelsafeandsecureinthehome.

4.7 Infectioncontrol

Thisexpectedoutcomerequiresthatthereis"aneffectiveinfectioncontrolprogram".

Team'sfindings


Thereisaneffectiveinfectioncontrolprogramtodetectandmanageinfections.Seniorstaffoverseeinfectioncontrolensuringinfectioncontrolpoliciesandrelevantinformationisavailabletoguidestaffpractice.Orientationandannualeducationprogramsincorporateinfectioncontrolandhandhygiene.Nursingstaffcompleteaninfectionrecordforcarerecipients’infectioneventsandrecordwhentheinfectionisresolved.Therearesuppliesofprotectiveclothingandequipmentandaprocessforthedisposalofsharpsandinfectiouswaste.Managementofferscarerecipientsandstafftheopportunitytoreceivethefluvaccinationeachyear.Foodsafety,pestcontrolprogramsandenvironmentalservicescomplywithlegislationandinfectioncontrolguidelines.Staffdemonstratedanawarenessandknowledgeofappropriateinfectioncontrolpracticesrelevanttotheirduties.

4.8 Catering,cleaningandlaundryservices

Thisexpectedoutcomerequiresthat"hospitalityservicesareprovidedinawaythatenhancescarerecipients’qualityoflifeandthestaff’sworkingenvironment".

Team'sfindings


Thehomeidentifiescarerecipients'needsandpreferencesrelatingtohospitalityservicesonentrytothehomethroughassessmentprocessesandconsultationwiththecarerecipientandtheirrepresentatives.Thereareprocessesavailablethatsupportcarerecipientstohaveinputintotheservicesprovidedandthemanneroftheirprovision.Thehome'smonitoringprocessesidentifyopportunitiesforimprovementinrelationtothehospitalityservicesprovided;thisincludesfeedbackfromcarerecipientsandrepresentativesandmonitoringofstaffpractice.Hospitalitystaffinterviewedsaidtheyreadilyhaveaccesstoinformationaboutcarerecipientpreferencesandinvitefeedbackaboutservicesprovided.Staffaresatisfiedthehospitalityservicesenhancetheworkingenvironment.CarerecipientsandrepresentativesHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 27

interviewedspokehighlyaboutthequality,varietyandpresentationofmeals.Carerecipientsandrepresentativesaresatisfiedwithcleaningandlaundryservices.


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