essendon aged care · 2018-12-14 · essendon aged care racs id 4304 10 fletcher street essendon...

Essendon Aged Care

RACS ID 4304 10 Fletcher Street

ESSENDON VIC 3040

Approved provider: Menarock Aged Care Services (Templestowe) Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 17 August 2017.

We made our decision on 01 July 2014.

The audit was conducted on 20 May 2014 to 21 May 2014. The assessment team’s report is attached.

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

Home name: Essendon Aged Care RACS ID: 4304 2 Dates of audit: 20 May 2014 to 21 May 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Essendon Aged Care 4304


Introduction

This is the report of a re-accreditation audit from 20 May 2014 to 21 May 2014 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, resident lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 20 May 2014 to 21 May 2014.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 1997.

Assessment team

Team leader: Nicola Walker

Team member: Stephen Koci

Approved provider details


Details of home

Name of home: Essendon Aged Care

RACS ID: 4304

Total number of allocated places:

60

Number of residents during audit:

52

Number of high care residents during audit:

52

Special needs catered for: Nil

Street: 10 Fletcher Street

City: Essendon

State: Victoria

Postcode: 3040

Phone number: 03 9375 2933

Facsimile: 03 9370 0828

E-mail address: [email protected]

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Management and administration staff 5

Registered and enrolled nurses 4

Care staff 2

Lifestyle staff 2

Catering, cleaning, laundry and maintenance staff 6

Allied health contractors 3

Residents 3

Representatives 5

Sampled documents

Category Number

Residents’ files 11

Resident agreements 5

Medication charts 6

Personnel files 5

Other documents reviewed

The team also reviewed:

Accreditation assessment signage

Audit schedule, results, analysis and response documentation

Call-bell and staff communication system records

Cleaning and laundry schedules and records

Competency assessments, electronic learning system and staff education records

Complaint investigation forms

Dietary information, menus and residents’ preferences

Education and training needs analysis, matrix and training program

Environmental monitoring documentation


Fire equipment service records, evacuation lists and emergency procedure manual

Food safety documentation and training records

Incident reports, analysis and monthly summaries

Job descriptions and duty lists

Kitchen cleaning and temperature records

Lifestyle documentation and monthly program

Maintenance schedules, documentation and records

Mandatory reporting register

Material safety data sheets

Meal service and resident assistance

Memoranda

Minutes of meetings and meeting schedule

Newsletters

Nurse registrations

Occupational health and safety documentation and risk assessments

Plan for continuous improvements and continuous improvement forms

Police check registers – payroll and non-payroll staff

Policies and procedures

Quality plans, quality program and activity records

Reportable assaults log

Resident handbook

Resident of the day schedule and worksheets

Restraint risk management and authorisation documentation

Risk assessments, authorisations and clinical management plans

Staff rosters

Service provider register and service provider evaluations

Skin protection equipment and hip protectors in use

Staff information handbook


Clinical care coordination documentation.

Observations

The team observed the following:

Activities in progress

Annual essential safety measures report on display

Archive room and register

Cleaning in progress

Doctors communication processes

Electrical safety systems

Equipment and supply storage areas

External and internal living environment

Firefighting equipment and evacuation plans

Gastroenteritis outbreak and blood spill kits

Hand hygiene facilities and personal protective equipment

Information boards

Interactions between staff and residents

Kitchen dietary records and information displays

Laundry operations

Lunchtime meal service

Meal preparation

Mobility aids and transfer equipment

Resident weight and nutrition management processes

Security systems including video surveillance

Sensory assessment pack

Shredder for confidential document destruction

Staff room

Storage of general, drugs of addiction and refrigerated medications


Suggestion box, continuous improvement and external complaint service forms on display

Supervision of residents who smoke and smoking area

Twenty minute observation in dining room

Vision and mission statements on display.


Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of 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 findings

The home meets this expected outcome

The organisation has a continuous improvement system that demonstrates improvements in management, staffing and organisational development. The systems for residents and representatives include continuous improvement forms, separate resident and relative meetings, surveys and informal feedback. The system for staff includes forms, surveys, direct feedback, audits and meetings. Continuous improvements are identified, documented on a plan for continuous improvement and are monitored and evaluated via the home’s quality control system. Management provide feedback about continuous improvement to residents, representatives and staff through direct feedback or at meetings. Residents, representatives and staff advised they are satisfied that continuous improvement occurs at the home.

Examples of continuous improvement in Standard 1 include:

Following an audit management reviewed and updated the call bell system at the home to include direct paging to staff via portable communication devices. Staff report the callbell system has improved and assisted them to assist residents in a timely manner.

Following a review of education available to staff, management introduced a range of new education sessions and formats. Management report they introduced a television based education service, introduced ‘quick’ informal education sessions and spoke to staff about which education sessions they would like to attend. Management report they have noted an increase in education attendance and staff report they receive training to assist them to care for residents.


1.2 Regulatory compliance

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

Team’s findings


The organisation has a system in place for identifying relevant legislation and regulatory requirements and ensuring compliance with professional standards and guidelines.

Management receives regulatory information via a legal update service and through membership of industry bodies. Management then discuss relevant regulatory compliance information at the home’s regular meetings. Residents and representatives said they receive information about to regulations through meetings, verbally or via written communication.

Staff said they receive information at meetings, from memoranda, posted on noticeboards and via updates to policy and procedures.

Management monitor compliance with regulations relevant to management systems, staffing and organisational development through audits, staff competency assessments and observations. There are staff and service provider credential and police check processes place.

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 findings


Management has a comments and complaints mechanism that is accessible to residents, representatives’ staff and other stakeholders. The home’s mechanisms of access include continuous improvement forms, meetings and an ‘open door’ policy. Information on the home’s complaint mechanisms is set out in the residents’ handbook. Brochures about the external complaints service are available to residents and representatives. All complaints go directly to management and are actioned in a timely manner;residents and representatives get feedback directly or at meetings. The organisation has processes for the handling of confidential complaints. Residents, representatives, and staff confirm their knowledge about the home’s comment and complaints processes and feel comfortable to raise any concerns.

1.3 Education and staff development

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

Team’s findings


Management identify staff education and training needs through a variety of means including staff appraisals, survey and analysis, analysis of audit results, incident reviews, changing


resident needs and requests by staff. Management ensure staff have appropriate skills and knowledge through assessment of staff competencies, an extensive auditing system and through direct observation. Management develop an annual staff training program which includes mandatory education, electronic-learning opportunities and education sessions based on identified staff development needs and requests. Management and staff confirm the type, frequency and availability of education meets their needs. Residents and representatives are satisfied staff have the appropriate knowledge and skills to deliver quality care.

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

selected policy and procedures education

mentoring and one-on-one support

regulatory compliance.

1.5 Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings


The organisation has documented its vision, mission and commitment to continuous improvement. We observed the home’s vision and mission displayed throughout the home and documented in residents’ and staff information handbooks.

1.6 Human resource management

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

Team’s findings


The organisation has processes to ensure the recruitment of appropriately skilled and qualified staff for the delivery of care and services to residents. A formal recruitment process is followed by management and management monitors qualifications and credential information. New staff complete a formal orientation program that includes ‘buddy shifts’ to assist them in adjusting to their new roles. All roles have position descriptions to guide staff and staff sign employment contracts. Rosters identified management maintain staffing levels over all shifts and a registered nurse is rostered on all shifts. Permanent and casual or contract staff fill roster vacancies. Residents, representatives and staff are satisfied with current staffing levels at the home.


1.7 Inventory and equipment

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

Team’s findings


There is an effective system at the home to ensure appropriate stocks of goods are available and equipment for quality service delivery. An ordering system ensures adequate equipment and stock levels at all times and storage areas are accessible, clean and secure. Monitoring of equipment availability and safety occurs and the preventative maintenance program ensures equipment remains in good working order. Staff said they have sufficient equipment and supplies to undertake their roles effectively and are involved in the trial and testing of new equipment. Residents and representatives are satisfied there are sufficient goods and appropriately maintained equipment.

1.8 Information systems

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

Team’s findings


Management has information management systems to provide information that includes meetings, minutes, resident handbooks, notice boards and activity calendars. The systems to inform staff include orientation, meetings and minutes, staff information handbook, noticeboards, policy and procedures, memoranda and clinical files. Clinical notes and resident and staff files are securely stored. Old files are stored on site in a secure archive room and staff have access to a shredder. Residents and staff confirm their satisfaction with access to information and with the communication mechanisms at the home.

1.9 External services

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

Team’s findings


There are processes in place to ensure the provision of external services in a way that meets the residential care service’s needs and service quality goals. External services at the home include physiotherapy, podiatry, fire system testing, hairdressing and pest control. The organisation’s head office manages contracts with external providers and specifies the required standards, timeframes and regulatory requirements. The organisation has a ‘service providers’ register. Management formally reviews external services and monitors these through observations, audits and feedback direct from stakeholders about the quality of service to the home. Residents and representatives said they are satisfied with the home’s external services.


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.



Team’s findings


The home has a continuous improvement system that demonstrates improvements in resident health and personal care. The continuous improvement system is described in expected outcome 1.1 Continuous improvement. Residents advised they are satisfied they receive appropriate clinical care. Staff confirmed improvements have occurred in resident health and personal care.


Following a change in resident mix and a review of care needed for residents with challenging behaviours, management provided some additional support for staff. This included more education sessions, informal education and an opportunity for staff to discuss specific case studies to assist them with residents with challenging behaviours. Management report a decrease in incidents and staff report they have attended the education sessions.

Management have commenced collecting more detailed data in relation to the locations and times when residents fall. Management report from these data they have targeted interventions and have been able to supply staff with the information. Staff report they are aware of the information and make sure they follow the interventions to assist with falls prevention.



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

Team’s findings


The system used to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards is described in expected outcome 1.2 Regulatory compliance. Staff said they are informed about regulatory requirements by management.

Examples of responsiveness to regulatory compliance relating to Standard 2 include:

The organisation has processes to monitor the current registration of nursing staff.

The team observed medications stored and administered according to legislated processes.

There are systems and processes in the event of an unexplained resident absence.



Team’s findings


Management have a system in place to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to residents’ health and personal care. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development.

Recent education relating to Standard 2 Health and personal care includes:

28-day admission assessment process

behaviour management

catheter care

continence management

diabetes medications

pain management

Parkinson’s Disease medications

resident observations and vital signs assessments.


2.4 Nursing care

This expected outcome requires that “residents receive appropriate nursing care”.

Team’s findings


The home has an effective system to ensure residents receive nursing care appropriate to their needs and preferences. Nursing staff assess each resident’s clinical needs and preferences when they move into the home using evidence based assessment tools, information provided by other health professionals and discussions with the resident and their representatives. Nursing staff develop care plans and review these on a monthly basis to ensure they remain consistent with each resident’s needs and preferences. Care and nursing staff discuss and handover daily details about the ongoing or changing care needs of each resident between shifts and record relevant details in the progress notes. Senior nursing staff collect and analyse nursing incident data every month and prepare a monthly report. Management review the report and provide feedback to staff. Management conducts regular comprehensive audits to ensure a high standard of care, communication and documentation continues. Residents and their representatives are satisfied with the care and representatives are satisfied staff communicate relevant changes when residents’ nursing needs change.

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 findings


There is a system in place at the home to ensure appropriately qualified staff identify and meet residents’ specialised nursing care needs. Registered nurses, in conjunction with the resident’s doctor or other health care consultants assess each resident’s needs and preferences when they move into the home. They then oversee the development of an individual care plan and they review and update monthly or more frequently if required. Care plans reflect monitoring requirements, specific needs, equipment, resources, instructions and strategies to optimise care delivery. Residents and their representatives said they are satisfied with the way staff meet the specialised care needs of 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 findings


The home has an effective system to ensure prompt referral of residents with special needs to appropriate health specialists. The system includes identification of needs, consultation with the resident or representative, referral procedures and a process of information sharing and ongoing communication. Specialists include a gerontologist, dietitians, speech pathologists, podiatrists, optometrists, audiologists, physiotherapists, palliative care services, wound specialists and ‘outreach’ services provided by local hospitals. Health specialists record relevant information and recommendations in the progress notes and nursing staff update


resident care plans and instructions for staff as relevant. Residents and their representatives are satisfied with the way the home arranges referrals to relevant health specialists when required.

2.7 Medication management

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

Team’s findings


The home has an effective system to ensure nursing staff manage each resident’s medications in a safe and appropriate manner. Pharmacies supply resident medications and a 24-hour service is available if required. Medications are stored securely and in accordance with legislative requirements. A consultant pharmacist undertakes bi-annual reviews of each resident’s medications and makes recommendations to the resident’s doctor as required.

Management conduct audits of the home’s medication system and audit results inform the staff education and continuous quality improvement processes. A medication advisory committee oversees medication safety at the home and promotes continuous improvement of the system. Staff feedback and ongoing education occurs to ensure staff are knowledgeable about medications and maintain optimum skill levels. Residents and their representatives are satisfied residents’ medication administration occurs in a safe and timely manner and in accordance with needs and preferences.

2.8 Pain management

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

Team’s findings


The home has an effective system to ensure residents are as free as possible from pain and discomfort. All residents undergo a comprehensive assessment when they move into the home and nursing staff develop a plan of care. Extended observation periods enable nursing staff to develop an understanding of the causes, quality, frequency and types of pain and discomfort experienced by a resident and implement appropriate management strategies.

Care staff communicate resident needs and experiences to nursing staff who consults the resident’s doctor and/or physiotherapist if necessary. Staff provide regular non- pharmacological pain management interventions, such as massages and heat packs for residents. This enables residents to be as free as possible from pain and discomfort and continue their daily routines and activities. Residents and representatives said they are are satisfied with the way staff optimise pain management.


2.9 Palliative care

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

Team’s findings


There is a palliative care program at the home to provide for the comfort and dignity of terminally ill residents. Senior nursing staff sensitively discuss end-of-life issues with residents and/or their representatives and document these to ensure staff are able to meet the needs of the resident and their family. The palliative care program aims to support each resident and their family’s needs and nursing staff regularly review and update the care plan as needs of the resident progress. Staff arrange for the involvement of religious personnel and an external palliative care service to provide additional support for residents and their families if required. Staff said they have access to appropriate equipment to assist in resident care during this time.

2.10 Nutrition and hydration

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

Team’s findings


The home has an effective system to ensure residents receive adequate nutrition and hydration. Nursing staff assess each resident’s nutrition and hydration status as well as food preferences and swallowing risks when they move into the home. Staff weigh residents monthly or more regularly if required and review the care plan monthly. Senior nursing staff refer residents to a speech pathologist or dietitian if residents are at risk of swallowing difficulties, poor nutritional and hydration status or experience weight changes. Staff at the home ensure meal presentation and the residents’ dining experience promotes dietary intake. They utilise strategies to ensure residents remain hydrated and risks associated with dehydration are minimised during heat-wave periods. Residents said they liked the food and representatives said they are satisfied with the way staff at the home meet residents’ nutrition, hydration and associated needs.

2.11 Skin care

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

Team’s findings


The home has a system to assess each resident’s skin care needs when they move into the home and nursing staff document strategies to minimise skin integrity risks in the resident’s care plan. Strategies include regular repositioning, limb protectors, pressure relieving equipment and use of emollient creams. A podiatrist visits residents at the home regularly and senior nursing staff assess injuries such as skin tears, pressure injuries, bruising and any skin trauma. Senior nursing staff oversee wound management and consult a wound care specialist if necessary. The home has processes to collate, analyse and review skin integrity data to


ensure expected standards of care continue. Residents and their representatives are satisfied with the way staff assist residents maintain skin integrity.

2.12 Continence management

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

Team’s findings


The home has a system to manage residents’ continence needs effectively. Care and nursing staff assess each resident’s toileting and continence needs when they move into the home and may implement extended assessments to collect detailed information over a period of several days. Senior nursing staff oversee continence care in in the home and consult a continence specialist if necessary. There is regular communication between care and nursing staff to ensure care plans and continence equipment remain consistent with resident needs. Residents and their representatives are satisfied with the way staff at the home meet residents’ continence needs.

2.13 Behavioural management

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

Team’s findings

The home meets this expected outcome.

The home has a system to manage residents who demonstrate challenging behaviours to express their unmet needs. Nursing staff assess residents’ behaviour patterns and characteristics when they move into the home and obtain further information from representatives and previous caregivers. Staff will also conduct extended periods of assessment and observation if indicated and document detailed reports of behaviour related issues in the progress notes. A detailed care plan reflects assessment findings and provides information instructions for care staff in relation to residents’ specific care needs and the strategies to meet these. Senior nursing staff consult with external specialist services for residents who require further review and management. Staff have access to education and resources to assist in supporting residents with challenging behaviours. Residents and representatives said they are happy with the way staff manage residents experiencing challenging behaviours when these occur.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


There is a system at the home to support residents achieve optimum levels of mobility and dexterity and maintain their independence. Senior nursing staff and a physiotherapist assess each resident’s mobility, dexterity and rehabilitation needs when they move into the home and develop a care plan. The care plan outlines equipment or support needs and is re- evaluated monthly. Physiotherapy, care and nursing staff provide pain management for residents and


encourage exercises to promote balance and strength. Equipment is available to assist residents with mobility and dexterity. Nursing staff assess residents for their risk of falling and implement strategies to manage this risk. Residents and their representatives said they are satisfied with the way staff at the home support residents’ mobility, dexterity and rehabilitation needs.

2.15 Oral and dental care

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

Team’s findings


The home has a system to ensure residents are able to maintain or improve their oral and dental health. Nursing staff assess each resident’s oral and dental health when they move into the home and develop a care plan. The care plan details the degree of assistance residents require to manage their own oral hygiene. Nursing staff evaluate the care plan every month or more frequently if care needs change. Residents have access to a domiciliary dental service that visits the home or staff assist residents to visit their own dentists if preferred. The home has dental and mouth care supplies available for residents, which include swabs, mouthwashes and toothbrushes. Residents and their representatives said they are satisfied with the way staff assist residents with mouth care and support their independence.

2.16 Sensory loss

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

Team’s findings


There is a system at the home for identifying and managing residents’ sensory losses across all five senses. A range of staff, including nurses, dietitians and lifestyle staff capture this information when residents move into the home. Staff arrange relevant specialists such as audiologists, optometrists and dieticians to visit residents in the home as required. The home has resources available to minimise the impact of sensory loss such as large print and talking books and the lifestyle program provides activities that highlight the different senses and compensate for sensory loss. Residents and their representatives are satisfied with the identification and management of resident’s sensory losses.

2.17 Sleep

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

Team’s findings


Staff assess each resident’s preferences and usual routine in relation to sleep and develop strategies to assist residents achieve natural sleep patterns. Initial and extended observational assessments ensure staff obtain a good understanding of each resident’s sleep patterns and identify any problems they are having. Nursing staff document resident preferences and care strategies in the care plan and evaluate this regularly to ensure it remains current. Staff at the home use a variety of methods to promote sleep and nursing staff consult with a resident’s


doctor if medication is required. Staff use strategies such as pain relief, music, warm milk and other comfort measures to assist residents get to sleep.


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.



Team’s findings


The home has a continuous improvement system that demonstrates improvements in resident lifestyle. The continuous improvement system is described in expected outcome 1.1 Continuous improvement. Residents, representatives and staff are satisfied with the home’s improvements in the area of resident lifestyle.


Following observations, management introduced new lifestyle activities in the late afternoon to assist residents living with dementia. Management report this program is tailored to specific residents, is flexible and involves hands-on activities. Staff report the program works well and residents enjoy it.

Following an increase in residents from similar cultural backgrounds, management investigated specific activities to appeal to these residents. Management report they contacted a local citizens group, engaged entertainers to visit the home and started to celebrated cultural events that have specific meaning to the residents. Staff report they are very aware of each resident’s background and try to provide events and activities they would enjoy.



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 findings


The system used to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards is described in expected outcome 1.2 Regulatory compliance. Residents and/or representatives confirm they are informed of residents’ rights and responsibilities.

Examples of responsiveness to regulatory compliance related to Standard 3 include:

The organisation has policies and procedures around confidentiality of resident information.

Policies and procedures are in place regarding reportable incidents such as elder abuse.

The home has systems to demonstrate compliance related to residential agreements.



Team’s findings


Management have a system to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to resident lifestyle. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development.

Recent education relating to Standard 3 Resident lifestyle includes:

relevant policies education

elder abuse and incident reporting

privacy and dignity.

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 findings


Staff support residents in adjusting to life in the home and on an ongoing basis. Assessment of residents’ emotional support needs and preferences occur upon entry to the home and staff


develop care plans to meet each resident’s needs. Nursing and lifestyle coordinators review residents’ emotional support needs a regular basis and update therapy plans as required. Residents and representatives receive a resident handbook to assist their orientation to the home and lifestyle staff run a one-to-one visiting program to introduce new residents to other residents. Residents and representatives confirmed their satisfaction with the initial and ongoing emotional support residents receive at the home.

3.5 Independence

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

Team’s findings


Staff assist and support residents to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Initial and ongoing assessment and care planning processes identify, assess and plan for residents’ physical, social, cognitive and emotional needs. Strategies to maximise independence include regular exercise programs with the assistance of the physiotherapist, freedom of movement within the home, taking residents for walks, bus trips the use of individual mobility aids. The home has a visiting physiotherapist services. The home welcomes visitors and maintains contact with local schools. Residents and representatives confirmed they are satisfied residents’ independence is supported by the home.

3.6 Privacy and dignity

This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected".

Team’s findings


Staff respect residents’ right to privacy, dignity and confidentiality. There is a privacy policy in place. The home has single, double and triple rooms with shared and private toilets and showers. There is a large dining room and sitting area for residents to meet with friends and family. Staff describe appropriate practices to protect residents’ privacy and dignity including knocking on doors, not discussing private information in public areas, using curtains in shared rooms, using ‘dignity’ gowns when assisting residents with hygiene and calling residents by their preferred name. Residents and representatives confirmed and we observed that staff respect residents’ rights to privacy and dignity.

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 findings


Residents are encouraged and supported to participate in a wide range of interests and activities. Staff complete a social, religious, cultural and lifestyle assessment when residents'


move into the home and develop an individual diversional therapy care plan in consultation with residents and their representatives. Staff regularly review diversional care plans. The lifestyle program includes a wide range of activities that are advertised through a monthly calendar that is printed and distributed to all residents and displayed on the main noticeboard. Management obtain feedback about the program via meetings, direct feedback, continuous improvement forms, observations and through activity attendance records.

Residents and representatives confirmed they are satisfied with the lifestyle program and confirm the support of residents to participate in a range of activities at the home.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


The organisation values and fosters individual interests, customs, beliefs and cultural and ethnic backgrounds. Staff identify residents’ religious and cultural needs through the assessment process when residents move into the home. There is provision for church services for residents at the home catering for different religious affiliations. There are special days held throughout the year and staff have access to culturally specific services via the internet. Citizens groups also assist in meeting individual cultural needs as required.

Residents and representatives confirmed they are satisfied with the home’s response to residents’ cultural and spiritual needs.

3.9 Choice and decision-making

This expected outcome requires that "each 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 findings


There are processes in place that promote each resident’s right to exercise choice and control over their lifestyle. Residents and representatives are encouraged to participate in the assessment process by describing their needs to staff. The home conducts regular meetings with residents and representatives and provides continuous improvement forms to enable and encourage them to provide feedback on the home. Management have an ‘open door’ policy to ensure they are easily accessible if needed. Staff support residents to manage their own financial affairs and management have a ‘petty cash’ system in place at the home.

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


3.10 Resident security of tenure and responsibilities

This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities".

Team’s findings


The organisation has a system in place to ensure residents have secure tenure within the home and understand their rights and responsibilities. The resident’s handbook has Information about security of tenure and residents’ rights and responsibilities. The director of nursing discusses entry requirements and agreements with residents and representatives.

Any change of rooms will only occur after consultation with the resident and their representatives. The director of nursing is available to can clarify on an ongoing basis, any residents’ rights and responsibilities issues, security of tenure information or any financial questions. Residents and representatives confirmed that residents have secure tenure within the home and are aware of resident’s 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.



Team’s findings


The home has a continuous improvement system that demonstrates improvements in the physical environment and in the area of safe systems. The continuous improvement system is described in expected outcome 1.1 Continuous improvement. Staff confirm ongoing improvements occur at the home. Residents and representatives are satisfied with the safety and comfort of the home’s environment.


The home’s external food contractor identified an opportunity to improve the serving and presentation of meals for residents who require a texture-modified diet. A new product range uses a ‘moulding process’ so texture-modified meals are presented in a way that more closely resembles a non-modified meal. Management and staff report the meals look more appetising, taste nice and enhance the dining experience for residents.

In response to identifies gaps in understanding, management have expanded chemical handling training. In addition to staff receiving chemical handling education from the chemical supplier, management also discuss material safety datasheets with staff to promote understanding. Management report the sessions discuss what information is in the sheets and what the terminology used in the sheets means. Staff said that they are better equipped to find relevant information quickly and can interpret the information more easily.



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

Team’s findings


The system used to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards is described in expected outcome 1.2 Regulatory Compliance. Staff confirm compliance with safe working practices within the home.

Examples of responsiveness to regulatory compliance relating to Standard 4 include:

Chemicals are stored in locked rooms within the home and relevant material safety data sheets are accessible.

The home has an externally audited food safety plan and has appropriate auditing of kitchen systems.

Ongoing monitoring of the safety of fire safety systems.



Team’s findings


Management have a system to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to physical environment and safe systems. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development.

Recent education relating to Standard 4 Physical environment and safe systems includes:

manual handling

infection control

fire and emergency training

safe chemical handling

the appropriate use of gloves in the home.


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 findings


Management are actively working to provide a safe and comfortable living environment for residents. Most residents have shared accommodation with access to an ensuite or shared bathroom. All residents have access to a comfortable communal area and private areas are available for residents if required. Maintenance staff ensure the living environment remains safe and well maintained and the home has an effective security system. The home is clean and maintained at a comfortable temperature. Residents are encouraged to personalise their rooms with their own furniture and personal items. Residents and their representatives said they are satisfied the environment is comfortable and homely and are satisfied with the safety and security of the building.

4.5 Occupational health and safety

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

Team’s findings


Management demonstrate it is working to provide a safe working environment to meet regulatory requirements. On commencement of employment, all staff undergo an orientation process that includes occupational health and safety training. Policies and processes guide staff to understand their responsibilities in relation to occupational health and safety.

Management monitor the effectiveness of its occupational health and safety procedures through the outcome of audits, review of incidents and suggestions raised via continuous improvement forms completed by staff. Management discuss and address any occupational health and safety issues at monthly staff meetings where occupational health and safety is a standing agenda item. The home ensures all equipment undergoes regular review as part of the preventative maintenance program and there is a system to remove broken or unsafe items from use and report them to the maintenance manager. Staff said they are able to recognise and report hazards and incidents and are satisfied they work in a safe environment.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".

Team’s findings


Management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. Management display emergency evacuation plans and there is clear signage of emergency exits that are free from obstructions. Fire training occurs regularly at the home and the home has an annual essential safety measures report relating to fire systems on display. External contractors service firefighting


equipment and chemicals are stored safely and securely. Staff secure the home in the evenings and there is backup lighting in case of a blackout. A workplace emergency procedure manual is accessible to all staff. Staff said emergency training regularly occurs at the home.

4.7 Infection control

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

Team’s findings


There is an effective infection control program at the home and policy and procedures inform and guide management and staff. Proactive infection control measures include a surveillance program, an influenza vaccination program, outbreak management plans and adequate supplies of personal protective equipment for gastroenteritis and other infectious outbreaks. Cleaning and laundry processes and staff practices follow recognised infection control standards. Senior nursing staff collect, review and analyse infection data for trends and monitor the completion of any infection control actions required. Residents and their representatives said they are satisfied staff demonstrate appropriate infection control practices.

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 findings


Management and contractors have a system to ensure the catering service at the home enhances each resident’s quality of life and where possible, meets each resident’s needs and preferences. Meals are prepared at the home and the kitchen utilises innovative strategies to improve the experience of residents who require a texture modified diet.

Catering staff have relevant resident information identifying specific nutrition and hydration requirements, food allergies, food preferences and choices. Schedules are in place to ensure cleaning tasks are completed and the team observed the living environment and resident rooms to be clean during the visit. An in-house service is responsible for laundering general linen and residents’ personal items and a labelling process reduces the risk of clothing becoming lost in the laundry process. Residents, representatives and staff are satisfied with the home’s catering, cleaning and laundry services.

essendon aged care · 2018-12-14 · essendon aged care racs id 4304 10 fletcher street essendon...

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