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Hopevale Aged Hostel RACS ID 5177 31 Thiele Street

HOPE VALE QLD 4895

Approved provider: Hope Vale Aboriginal Council

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for one year until 30 October 2014.

We made our decision on 06 September 2013.

The audit was conducted on 06 August 2013 to 07 August 2013. The assessment team’s report is attached.

The accreditation period will provide the home with the opportunity to demonstrate that it is capable of monitoring systems, evaluating the effectiveness of actions taken and continuing to meet the Accreditation Standards. We will continue to monitor the performance of the home including through unannounced visits.

Home name: Hopevale Aged Hostel Date/s of audit: 06 August 2013 to 07 August 2013 RACS ID: 5177

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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 Accreditation 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.

Expected outcome Accreditation Agency decision




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


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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.


decision




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.


decision




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


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Audit Report

Hopevale Aged Hostel 5177


Introduction This is the report of a re-accreditation audit from 06 August 2013 to 07 August 2013 submitted to the Accreditation 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 Accreditation 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


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 06 August 2013 to 07 August 2013. The audit was conducted in accordance with the Accreditation Grant Principles 2011 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: Jill Winny

Team member/s: Lynette Harding

Approved provider details


Details of home

Name of home: Hopevale Aged Hostel

RACS ID: 5177

Total number of allocated places:

20

Number of residents during audit:

11

Number of high care residents during audit:

2

Special needs catered for:

DHA ATSIC Category

Street/PO Box: 31 Thiele Street State: QLD

City/Town: HOPE VALE Postcode: 4895

Phone number: 07 4060 9242 Facsimile: 07 4060 9254

E-mail address: [email protected]


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

Number Number

Facility Manager/Registered Nurse

1 Residents 6

Assistant Manager 1 Staff (care, catering and cleaning)

5

Director of Social Services 1

Sampled documents

Number Number

Residents’ files 11 Medication charts 11

Personnel files 5

Other documents reviewed The team also reviewed:

Activities participation record

After hours lockdown procedure

Allied health folder

Application for respite/short term admission

Assessment charts

Assessment of residents ability to self-medicate

Audit folder and calendar

Certificate of food business licence

Cleaning schedules

Clinical documentation folder

Clinical observation matrix

Comments and complaints folder

Consent forms

Dangerous drug register

Dialysis schedule

Dietary plan/profile

Education and training folder

Education calendar

Fire and safety equipment maintenance logs

Food safety program

Handbooks - resident and staff

Health signing sheets


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Incident reports – medication and client/staff/visitor

Induction checklists

Infection log

Information brochures

Leisure and lifestyle calendar

Maintenance folder and schedules

Material safety data sheets

Minutes of meetings folder

Nurse initiated medication list

Orientation and employment folder

Peritonitis treatment procedure

Plan for continuous improvement

Police checks

Policy and procedures manual

Position descriptions and duties lists

Recruitment policies and procedures

Referral form

Resident evacuation list

Resident initial data base

Resident meeting calendar

Residential care agreements

Residents’ information package and surveys

Staff rosters

Temperature monitoring logs

Weekly handover sheet Observations The team observed the following:

‘Have your say’ forms

Activities blackboard

Activities in progress

Archives storage room

Emergency assembly areas

Equipment and supply storage areas

Fire fighting and emergency equipment

Interactions between staff and residents

Internal and external living and working environment

Meal preparation and service


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Menu cards

Personal protective equipment in use

Storage of medications


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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 Hopevale Aged Hostel (the home) has a continuous improvement system to identify improvement opportunities and to monitor performance against the Accreditation Standards. The home utilises a range of processes to capture suggestions for improvement including resident and staff meetings, the feedback system, audits, surveys and one-on-one discussion with residents/representatives and staff. Monitoring of improvements is achieved through monthly reviews of the improvement plan conducted by the Facility Manager. Staff, residents and representatives are able to make suggestions for improvements and management is open and responsive to improvement ideas and suggestions. Improvement activities implemented by the home over the last six months in relation to Standard 1 Management systems, staffing and organisational development include:

To ensure residents and representatives have access to current information management reviewed the contents of the resident handbook and the resident agreement. Management advised that the new handbooks and agreement reflect practices and policies of the home which were not previously included. The new handbooks and resident agreements are in use for all new respite and permanent 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 home meets this expected outcome The organisation has mechanisms to ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. Through memberships to peak industry and professional organisations updates and information on changes are accessed and processes ensure the home receives current information. The Facility Manager is responsible for ensuring service delivery complies with regulatory requirements. Requirements are communicated to the staff with changes to current information being discussed at meetings, verbally at handover and at education/training sessions. Changes are implemented when required. In response to changes and updates, policies and procedures are reviewed to ensure currency is maintained. Compliance is monitored by the Facility Manager and Assistant Manager, via audits and observation of staff practice.


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Examples of regulatory compliance relating to Standard 1, Management systems, staffing and organisational development include:

Stakeholders were informed in advance of the Aged Care Standards and Accreditation Agency re-accreditation audit visit

The home has a system to monitor and record professional staff registrations

Systems to maintain current police certificate checks for staff and volunteers

Records of staff attendance at mandatory training sessions 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively by providing ongoing education and training. The training needs of staff are identified through observing and monitoring staff practice, conducting performance appraisals and interest shown by staff in attending internal and external training sessions. Education and training records are maintained for individual staff. Support is available to staff to upgrade their qualifications and staff are informed of available education opportunities through the education schedule, notices and meetings. Education and training is provided via a range of formats including the Aged Care Channel, meetings, self directed learning packages and face to face tool box presentations. Management and staff receive mandatory training on commencement at the home to ensure they are appropriately skilled and qualified. Staff attend education sessions relating to the Accreditation Standards and understanding and meeting legislative requirements. 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 The home meets this expected outcome The home has a comments and complaints system that captures comments, suggestions and complaints from residents, staff and other interested parties. Information relating to internal and external complaint mechanisms is provided through the residents’ information package on entry, discussions at fortnightly resident meetings and in brochures/posters displayed at the home. ‘Have your say’ forms used for written complaints/suggestions are readily available and management has an open door policy for those wishing to use a less formal approach. Comments and complaints are considered and acted on according to the home’s complaint management policy and procedures. Residents and staff are aware of the comments and complaints processes and indicated they are able to raise issues and concerns with management if/when required.


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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 home meets this expected outcome The home’s philosophy of care, mission statement and objectives are displayed in the entrance foyer of the home. This information is also documented in the resident and staff 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 home meets this expected outcome The home’s staffing levels and skill mixes are determined by management in accordance with residents’ current care needs. The home follows the Approved Provider/Local Council policy and procedures for recruitment and selection. New staff are assigned to ‘buddy’ shifts and printed duties lists, procedure manuals and ‘Staff Induction Handbook’ are available to guide staff. Management has mechanisms to ensure coverage for all shifts and a registered nurse is rostered on site or on call at all times. Management obtain feedback from residents/representatives and staff to monitor sufficiency of staffing across the service types. Staff indicated they have sufficient time to complete their required duties. Residents confirmed they are satisfied with the responsiveness of staff and adequacy of care and services. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The home has policies and processes to facilitate the purchase, use, storage, maintenance and management of appropriate goods and equipment required for quality service delivery. Corrective and preventative maintenance programs are in place to ensure that all equipment is regularly checked and serviced. Audits and environmental inspections are undertaken to ensure that goods and equipment are maintained at sufficient levels and are correctly stored. The home has established processes for the ordering of supplies including chemicals, paper and clinical goods. Stocks of goods and equipment are adequate, repairs are made in a timely manner, and management is responsive to requests for additional supplies and equipment. A stock rotation process exists and items are stored in locked storage areas.


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1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The home has processes to manage information effectively and ensure its security and confidentiality. Policies and procedures guide staff practices for the collection and management of information. Monitoring of clinical information is carried out by the Facility Manager who is a registered nurse. Access to residents’ and staff files is restricted and they are stored in a secure cabinet; archived material can be retrieved readily and back-up systems are in place for computer records. Handover processes communicate residents’ care information to care staff and all staff are kept informed with one-to-one directions, meetings, meeting minutes and notice boards. Residents have meetings, noticeboards and other correspondence to keep them informed. Resident and staff feedback indicate communication of information is timely and effective. 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 The home meets this expected outcome The home identifies external service requirements based upon resident, operational and legislative requirements and has established contracts through the Approved Provider/Local Council with major suppliers including chemical products, clinical supplies, paper goods and incontinence aids. Due to the remote location of the facility, independent contractors provide air-conditioning, plumbing, electrical repair and fire safety maintenance services through external service agreements with the Approved Provider/Local Council. Queensland Health provide clinical and allied health services direct. The home obtains staff and resident feedback to monitor the performance of external service providers. Management liaise with external providers and/or Council to address any dissatisfaction with services or supply of stock. Residents and staff are satisfied with the quality of services provided by external service providers.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information relating to the home’s continuous improvement systems and processes. In relation to Standard 2 Health and personal care, staff record resident falls, skin tears, medications, behaviours and wounds and this information is then collated and analysed for trends. Residents and staff are satisfied that the home actively promotes and improves residents’ physical and mental health. Improvement activities implemented by the home over the last six months in relation to Standard 2 Health and personal care include:

As a result of a better practice initiative the home has developed medication and skill set training to provide guidelines for care and lifestyle staff. The training focuses on a new care model of managing residents’ medications and basic care needs. As a result of the up skilling, residents requiring medications during the day are now able to participate in the homes’ outings. Management indicated four of five staff have completed the training.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Professional registrations for all nursing staff are accessed prior to commencing employment at the home and are checked annually. The home implements processes and relevant protocols to ensure medication management is safe and unexplained absences of residents are reported. Compliance with legislation is monitored through the audit process, staff and resident feedback and observation of staff work practices.


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2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s systems and processes to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. In relation to Standard 2 Health and personal care, examples of training and education undertaken by staff include the following:

Understanding asthma

Diabetes management

Drugs in the elderly

Medication management skills and competencies

Understanding Epilepsy

Dementia

Palliative care

Effective communication 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Residents receive clinical care that is appropriate to their individual needs and preferences. The home has established processes to assess residents care needs on entry to the home and on an ongoing basis. Care plans are developed and reviewed by the Registered Nurse in consultation with the resident/representative, staff, allied health professionals and information gathered from assessments. Daily care needs are evaluated, monitored and reviewed by the Registered Nurse through progress notes, staff handover and clinical incident data. Changes are communicated to staff and care plan adjustments made as required. Communication and referral between allied health professionals for residents’ individual care needs is appropriate and timely. Staff demonstrate an understanding of individual resident care needs and preferences and are satisfied with the communication processes to inform them of change in care needs. Residents are satisfied with the clinical care provided. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Residents receive specialised nursing care that is appropriate to their individual needs and preferences. The specialised nursing care needs of residents are identified through


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assessment and care planning processes conducted on entry to the home and as required. The Registered Nurse oversees the provision of specialised nursing care in consultation with medical officers, allied health practitioners and specialist services as required. Specialised care needs currently provided include peritoneal dialysis, variable dose medication, oxygen therapy and blood glucose monitoring. Ongoing care and monitoring of care needs is generally conducted through observation, discussion with residents, review of residents’ records, and feedback from staff and health professionals. Residents are satisfied with the specialised nursing care needs provided by the staff at the home.

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 meets this expected outcome Residents are referred to appropriate health specialists in accordance with their individual needs and preferences. The health needs of residents are identified on entry to the home and referral to appropriate health specialists is undertaken in a timely manner. A team of allied health professionals make scheduled visits through the local medical clinic and can be contacted for additional advice and telephone support when needed. The outcome of referrals, including instructions for ongoing care, are documented and retained in residents’ records. Staff are aware of the referral process and are satisfied they are informed of outcomes resulting from referrals. Residents are satisfied referral to appropriate health specialists are made in accordance with their needs and preferences. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Residents’ medication is managed safely and correctly in accordance with their individual needs and preferences. The home has effective systems to identify residents initial and ongoing medication management needs. The Registered Nurse and competent care staff assist with medications which are predominantly managed via a packaged system. Medications are stored in a locked trolley within an air conditioned room. Residents’ medication charts contain photographic identification, allergies and specific instructions for administration. Evaluation of the medication system is conducted through the monitoring of internal medication incidents and internal auditing processes. Residents are satisfied that their medication is managed safely and correctly. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome Residents receive assistance with pain management that ensures they are as free as possible from pain. Each resident is assessed for pain upon entry to the home, through regular care reviews or when pain is indicated. Residents’ preferences in relation to pain management are documented in care plans to guide staff practice. Strategies to ensure residents remain as free as possible from pain include; analgesia, change of position,


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exercise/movements, physiotherapy, comfort touch and heat packs. Staff have received education in pain management which includes the use of verbal and non-verbal assessment tools and are aware of pain management strategies for individual residents. Residents are satisfied with the way their pain is managed. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome Residents receive palliative care that is appropriate to their individual needs and preferences. Residents’ wishes regarding terminal care needs are discussed upon entry and when required in consultation with residents/representatives. Requests are respected and facilitated wherever possible in consultation with a medical officer and with family and community involvement. The local pastor and staff at the home provide emotional and spiritual support to residents and their families during the end stages of life. Residents are satisfied that staff are caring and would be respectful of their wishes and preferences in ensuring their care needs are met. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome The home has processes to identify residents’ nutrition and hydration needs on entry to the home and an ongoing basis. Residents’ weights are monitored monthly and more frequently for those residents with complex care needs such as dialysis. Variations are noted and acted upon through referrals to the medical officer and/or a dietitian. Residents’ dietary information is communicated to catering staff via individual dietary profiles and displayed on boards in the kitchen to guide staff. Dietary supplements are available for residents when a need is identified. Increased monitoring of residents’ food and fluid intake is undertaken when there is a change in a resident’s health status. Residents are satisfied they receive sufficient food and fluids in accordance with their needs and preferences. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The skin integrity and individual needs of residents including cultural preferences is assessed on entry to the home or when care needs change. Care staff monitor residents’ skin integrity during hygiene routines and through the delivery of care. Care plan interventions to maintain residents’ skin integrity include the regular application of emollients and other skin care products. When residents’ skin is compromised a wound treatment regime is completed identifying any specific treatment and interventions and a wound management assessment is completed to document interventions and progress of wound healing. Residents are satisfied with the care they receive to maintain their skin integrity.


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2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome The home has processes to manage residents’ continence effectively. Care staff assist residents to maintain their continence in response to required need for example; during extended periods of dialysis treatment, as a result of episodes of incontinence. Where needs are identified, assessments for the use of continence aides are undertaken. Staff monitor bowel patterns of residents on a daily basis and are aware of their individual continence needs and preferences. Residents are satisfied with the assistance staff provide to meet their hygiene 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 Assessments of each resident’s behavioural needs are undertaken upon entry to the home to enable appropriate care planning. Individual strategies are documented in the resident’s care plan and reviewed by the Registered Nurse each month as resident of the day or in response to change. The Registered Nurse monitors the effectiveness of care strategies in consultation with staff who have been provided with instruction in regards to managing challenging behaviour. Staff outlined care for individual residents and demonstrated that preventative strategies are in place and effective in minimising the occurrence of challenging behaviours. Residents are satisfied with the behaviour management in place at the home and that other residents do not disturb them. 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 The home meets this expected outcome Residents receive assistance to maintain mobility and dexterity that is appropriate to their individual needs and preferences. Residents’ mobility and dexterity requirements are assessed on entry to the home and on an ongoing basis through care planning and reviews. Where needs are identified residents are referred to allied health professionals such as a physiotherapist, medical officer and/or podiatrist for additional support and advice on use of appropriate mobility aids. Residents transfer requirements are documented on care plans and staff are familiar with the individualised needs of the residents. Residents are satisfied with their mobility and dexterity.


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2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Residents receive assistance to maintain oral and dental health that is appropriate to their individual needs and preferences including the provision of items to assist with oral care. The oral and dental status of residents is identified on entry to the home and on an ongoing basis. Care plans include the level of assistance required to maintain oral and dental hygiene. Residents’ are referred to relevant external health specialists in response to assessed needs and texture modification of meals is provided where oral and dental health is compromised. Staff are aware of ways to assist residents with oral hygiene and residents are satisfied with the level of support provided to them. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Residents receive assistance with the management of sensory loss in accordance with their individual needs and preferences. Information relating to the residents’ sensory needs including sensation, smell, taste, vision and hearing is identified on entry to the home and on an ongoing basis. Referral processes enable residents to attend specialist audiology and optometry appointments. Staff assist residents as required with the cleaning and application of sensory devices such as glasses and hearing aids. Residents’ sensory aids such as hearing aids and glasses are monitored and external services provide maintenance and required repairs. Care staff are aware of residents’ individual sensory needs. Residents are satisfied with staff assistance and with their access to health professionals such as hearing and eye specialists. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Residents receive support to achieve natural sleep patterns that is appropriate to their individual needs and preferences. Residents’ sleep patterns are identified through assessment processes including nightly and daytime rituals which are documented in care plans. Residents are accommodated in individual rooms and staff conduct regular checks overnight to identify residents who are awake or uncomfortable. Strategies to promote sleep include repositioning, toileting and a light snack if requested. Residents are satisfied with their ability to achieve natural sleep.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 3 Resident lifestyle, assessment documentation resident meetings and resident surveys are used to gather suggestions. Staff encourage and support residents and others to provide feedback and suggestions. Improvement activities implemented by the home over the last six months in relation to Standard 3 Resident lifestyle include:

Residents, staff and management identified an area requiring updating in the main outdoor communal area of the home. A local artist was commissioned by the home to design a mural to fill this area focussing on the spiritual and cultural needs of residents. Residents identified totems specific to their clans to be incorporated into the mural. Each resident also identified totems specific to themselves which have been laminated and placed on the doors of their rooms. Key words chosen by residents and management from the Charter of Rights and Responsibilities have also been incorporated into the mural. Residents, staff, management and communities members stated the mural reflects the spirituality of the home and area.

Recognising the remoteness of the home and the difficulty in having a physiotherapist visit as regularly as wanted, management, in conjunction with the medical officer and physiotherapist have developed an exercise program for residents that incorporates exercise equipment, soft balls and an interactive gaming device to merge exercise programs into the leisure and lifestyle program. Management indicated the purpose of purchasing equipment and the development of individual exercise programs enabled residents to keep active without the need of a physiotherapist visiting weekly.

3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home has systems in place to ensure requirements of legislation including, record keeping relating to residents’ privacy, security of tenure and alleged and suspected assaults are met.


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3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. In relation to Standard 3 Residents’ lifestyle, examples of training and education undertaken by staff are listed below:

Mandatory reporting

Culturally appropriate care

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 The home meets this expected outcome Emotional support is provided to residents and their families upon entry and throughout their stay at the home. Residents’ choices, preferences and needs are identified through conversations with residents and their families, observation, staff feedback and review of resident records. Residents are encouraged to form friendships with other residents at the home and staff contact families and other key people in the community if the resident requires additional emotional support. The effectiveness of support given to meet the emotional needs of residents and their families is evaluated through verbal discussion with the resident and/or their families and through staff observations. Residents are satisfied with the emotional support provided by staff. 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 The home meets this expected outcome The home has processes to ensure the social, physical, and financial independence of residents are identified and communicated to staff. Residents’ independence is encouraged during care and social activities including the provision of equipment, transport and assistance with access to the local community. Residents are encouraged to visit family and friends if they so choose and the home will contact family members if requested. Residents are satisfied with the assistance they receive to maintain friendships and connection with family and the community.


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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 The home meets this expected outcome The home has processes to ensure each residents right to privacy, dignity and confidentiality is recognised and respected. The needs of residents are identified on entry to the home and reviewed on an ongoing basis through conversations with the resident/representative, observation, staff feedback and review of resident records. The care needs of residents’ are reported and delivered by staff in a dignified and respectful manner. Doors are closed during occasions of personal care, staff knock before entering residents’ rooms and demonstrate respect by addressing residents by their preferred names and titles. Information relating to residents is stored in a manner that maintains confidentiality. Residents are satisfied their privacy needs are respected and staff ensure their dignity is maintained. 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 The home meets this expected outcome Residents’ past and current interests are identified upon entry to the home and in response to changed needs. Staff, family and the local community provide support and encourage residents to participate in activities of interest either in an individual or group setting. Activities such as craft, fishing trips, shopping outings, group exercises and sport are written into a program which is adapted in response to spontaneous requests by residents. Local community groups, family and cultural groups visit the home on a regular basis. Residents are satisfied that activities can be initiated in response to their daily needs. 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 home meets this expected outcome Residents’ cultural and spiritual preferences and practices are identified on entry to the home in consultation with the residents/representatives. Pastoral care workers and visitors to the home provide emotional and spiritual support, religious services are held on site and attendance at external places of worship is encouraged and facilitated. Birthdays, anniversaries and days of cultural and religious significance are celebrated in accordance with residents’ preferences. Information is available to assist staff in meeting residents’ individual cultural and spiritual needs. Residents are satisfied that their cultural and spiritual needs and preferences are respected.


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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 The home meets this expected outcome The home has processes to support the individual choices and decision-making rights of residents in the planning and provision of care and to encourage active involvement. Residents’ preferences are identified and documented on care plans to guide staff during activities of daily living. Substitute decision makers are identified and residents receive a handbook including a copy of house rules and mechanisms to express concerns. Staff are aware of ways to support and respect resident choice in daily care routines, lifestyle choice and other services. Residents are satisfied with the choices offered and their involvement in decision-making processes. 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 home meets this expected outcome The ‘residential care agreement’ contains information relating to security of tenure, conditions and processes for terminating the agreement, fees, charges, and specified services provided. Additional information is provided through the residents’ handbook including ‘house rules’ and specific services and activities provided at the home. The agreement and handbook are discussed with prospective residents/representatives prior to entry to the home and notification of any changes to information is discussed with residents/representatives and provided in writing. The home has a consultative process if a change in accommodation is necessary for any reason. Residents are satisfied their stay in the home is secure.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement, for information about the home’s continuous improvement systems and processes. In relation to Standard 4 Physical environment and safe systems, audits, hazard and incident reports, resident and staff meetings and resident surveys are used to gather suggestions. Feedback is regularly recorded and evaluated from all monitoring activities. Staff encourage and support residents and others to provide feedback and suggestions. Improvement activities implemented by the home over the last six months in relation to Standard 4 Physical environment and safe systems include:

Following requests by residents’ for more access to garden space, the home has installed four raised garden beds. The garden beds were purchased in collaboration with local community groups and garden suppliers. Two garden beds have been planted with a variety of vegetables, one garden bed is yet to be planted and the fourth bed will be planted with flowers for the residents to enjoy. Residents have responded positively to the new garden beds and the possibility of home grown produce.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home has systems to ensure compliance relating to the physical environment and safe systems including fire, security and other emergencies, occupational health and safety and infection control. Compulsory fire training is provided for staff and the home has regular fire safety checks by approved contractors. There are reporting mechanisms for accidents, incidents and hazards. Staff are provided with, and use personal protective equipment appropriately. Material safety data is maintained for chemicals used within the home.


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4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information relating to the home’s education and staff development systems and processes. In relation to Standard 4 Physical environment and safe systems, examples of training and education undertaken by staff are listed below:

Handwashing

Fire safety

Regulatory compliance

Food safety

Manual handling

Infection control

Workplace health and safety

Hazard management 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 The home meets this expected outcome Residents are satisfied with the safety and comfort of the living environment. The home’s management are actively working to provide a safe and comfortable environment consistent with residents’ care needs. Residents are accommodated in single rooms with ensuite and are encouraged to personalise their room with familiar items such as photographs. There is easy and safe access to clean and well-maintained communal, private, dining and outdoor areas for residents. The home is secure, clean, clutter and odour free, and provides private seating areas available to residents and their families. A system for reporting hazards is available, preventative maintenance schedules are followed and any additional maintenance requirements are reported by staff or residents and are generally attended to by the Maintenance Officer and/or external contractors in a timely manner. Residents expressed satisfaction with the maintenance and comfort of the living environment.

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 The home meets this expected outcome The home has processes to assess the safety of the workplace through regular audits of the environment, hazard/risk management processes, incident and hazard reporting, staff


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education and competency assessments. All staff receive education on the home’s safety requirements at orientation and through annual mandatory training. The home has maintenance programs for equipment and buildings and these are monitored by the Facility Manager. Material safety data sheets are available in work areas and chemicals are stored securely. Staff accidents and incidents are reviewed, and staff demonstrated an awareness of how to report accidents, incidents, and hazards and perform their roles in a safe manner. 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 The home meets this expected outcome The home has an established procedure to ensure staff and residents are aware of what is required in the event of an emergency. Evacuation plans are displayed throughout the home, emergency procedures are located next to telephones, exits and assembly areas are clearly identified. Fire prevention and fire fighting equipment is assessed regularly by an external contractor to ensure it is working correctly. The home conducts fire safety training at the time of commencement and thereafter on an annual basis. Residents and staff are aware of their roles in an emergency situation and residents are satisfied they feel safe in the home. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has an infection control program to identify, document, manage and minimise infections. The program includes a food safety program, pest control schedule and outbreak management kit. Residents’ infection statistics are recorded and reviewed monthly by the Facility Manager. A colour coded cleaning and kitchen equipment process is followed and colour coded bags within skips direct care/laundry staff regarding resident clothing and linen. Hand washing instructions and protective equipment for staff are strategies implemented by management to reduce the risk of cross infection. Monitoring of safe food practices is evident in the kitchen. The home is equipped with hand washing areas and anti bacterial gel with instructions for use displayed throughout the home. Staff are aware of infection control measures, including the appropriate use of personal protective equipment, hand hygiene procedures and precautions to be taken. 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 The home meets this expected outcome Residents expressed satisfaction with the variety of food and drink offered and with the quantity, availability and frequency of meals and snacks. Cleaning services provide regular and frequent cleaning of resident rooms, the general living environment, common areas, staff areas and equipment. Cleaning staff demonstrated they use colour coded cleaning equipment such as mops and buckets which are regularly cleaned and use personal protective equipment in accordance with health and hygiene standards, in particular infection


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control requirements. The laundry service is scheduled to provide sufficient frequency of service for linen and personal items and residents confirmed their satisfaction with the service provided. Management actively seeks feedback from residents through regular second weekly meetings as well as satisfaction surveys. Residents advised they have the opportunity to provide feedback on all hospitality services at meetings and through one on one consultation with staff and management.

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