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Opal ShoalhavenRACS ID: 2662

Approved provider: DPG Services Pty Ltd

Home address: 43 Brinawarr Street BOMADERRY NSW 2541

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 03 November 2020.

We made our decision on 22 September 2017.

The audit was conducted on 15 August 2017 to 16 August 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

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




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep MetHome name: Opal Shoalhaven Date/s of audit: 15 August 2017 to 16 August 2017RACS ID: 2662 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

Home name: Opal Shoalhaven Date/s of audit: 15 August 2017 to 16 August 2017RACS ID: 2662 3

Audit ReportName of home: Opal Shoalhaven

RACS ID: 2662

Approved provider: DPG Services Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 15 August 2017 to 16 August 2017 submitted to the Quality Agency.

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

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

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

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

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 15 August 2017 to 16 August 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Details of homeTotal number of allocated places: 75

Number of care recipients during audit: 59

Number of care recipients receiving high care during audit: 59

Special needs catered for: N/A


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

Interviews

Position title Number

Facility manager 1

Clinical nurse 2

Registered nurse 2

Physiotherapist 1

Physiotherapy aide 1

Visiting area health service clinical nurse consultant

1

Care staff 4

Lifestyle and activity staff 3

Head chef 1

Catering staff 1

Maintenance officer 1

Cleaning staff 2

Laundry staff 1

Care recipients and/or representatives 14

Sampled documents

Document type Number

Care recipients’ files 8

Summary and/or quick reference care plans 8

Medication charts 9

Personnel files 5

Continuous improvement logs 15

Complaints 3

Compliments 6


Document type Number

Position descriptions 7

Staff duties lists 3

Staff incident reports 7

Hazard incident reports 2

Maintenance request logs 15

External service agreement 1

Care and accommodation agreements 2

Other documents reviewedThe team also reviewed:

Accident and incident reports, medication incidents, behaviour incidents, with data collation and reporting

Activity and lifestyle documentation including: leisure and lifestyle assessments, leisure and lifestyle care plan and care recipient social profile, activities calendars, individual visits records, activity participation records

Advanced care directives

Allied health referral, assessment and care planning documentation

Behaviour assessment tools, behaviour management and monitoring tools, referral to external specialists, assessment of triggers and plans implemented

Care recipients' information package, handbook and agreements

Care recipient leave register, visitor attendance register

Cleaning schedules and work instructions

Clinical documentation including: care plans, monitoring and evaluation of care documents, assessment and treatment records, smoking assessments, risk assessments, bedrail assessment and authorisations, referral to external specialists, hospital discharge documents, vital signs charting, weight monitoring, advance care planning documents and specialised nursing care documents; clinical monitoring records and observation monitoring records; and palliative care records

Continence management including management plans, daily bowel monitoring records and continence aid allocation lists

Dietary preference assessments, catering documents and notices regarding preferred diets and food allergies

Education documentation: education calendars, education training attendance records, educational resource information, staff mandatory training requirements, staff competency assessment information, education and training reports

Documentation guides

Fire safety and emergencies documentation: inspection records, annual fire safety statement, emergency evacuation diagrams, emergency procedures manual, evacuation


details of care recipients, emergency evacuation signage, emergency procedures guide flipchart

Food safety: food safety program, food safety monitoring records, care recipients’ dietary requirements and food preference information and menu

Human resource management documentation: employment documentation, staff roster, employment engagement checklists, employee orientation and induction program, human resource matrix documentation, staff appraisals, employee orientation handbook, staff information register

Information system documentation including: policies and procedures, flowcharts, meeting minutes, case conference records, memoranda, handover record, handbooks and information packages, communication diaries, memorandum folders, notices, survey results, contact lists, organisational information, vaccination records

Maintenance documentation: preventative maintenance schedules, maintenance and approved supplier register, maintenance service reports and warm water temperature check records, external service agreement documentation, contractor site induction and orientation checklists, pest control reports, legionella species reports

Medication management documents, diabetic medication delivery tools, assessments and monitoring records

Meeting minutes – staff, care recipients and others

Nutrition and hydration management including: individual dietician review, special diets, thickened fluids and nutritional supplements, menu choice forms, care recipient food and beverage preferences and allergies, and weight monitoring charts

Pain assessment tools for verbal and non-verbal assessment of pain, pain management monitoring charts, referral to external specialists

Physiotherapy assessments, mobility assessments, falls risk assessments, mobility care plans, manual handling guidelines

Quality management system: Mission, Vision and Values statements, organisational chart, audit schedules, audit results and reports, clinical indicator reports, plans for continuous improvement, compliments and complaints, monthly infection data reports

Regulatory compliance documentation: incident management reporting system includes reportable incidents, staff criminal records checks, NSW Food Authority Licence, professional registration records, electrical equipment inspection register and consent forms for the collection and handling of private information

Self-assessment report for re-accreditation

Specialised nursing records including: diabetes management plans, catheter care, peritoneal dialysis, wound and pain management

Wound assessment and management records, referral to and review by wound specialists

Work health and safety system documentation: incident and hazard reports, work health and safety documentation, safety data sheets, risk assessment documentation, workplace health and safety inspection checklists

ObservationsThe team observed the following:

Activities in progress and associated resources and notices

Dining environment during midday meal service including staff supervision and assistance


Equipment and supplies in use and in storage such as lifting equipment, manual handling aids, mobility equipment, pressure relieving mattresses and aids in use and in storage; linen, clinical stores and continence aids

Fire panel, fire-fighting equipment, emergency exits, emergency evacuation diagrams, emergency response guide flipcharts, emergency evacuation kits, annual fire safety statement and fire safety plans

Infection control including: outbreak supplies, spill kits, sharps disposal containers, hand-washing facilities, waste disposal, hand sanitiser dispensers around the home, general and contaminated waste disposal systems, colour coded cleaning equipment and personal protective equipment

Internal and external complaint mechanisms and feedback processes, feedback form box

Interactions between staff, care recipients and representatives including meal service and short group observation in the home

Living environment – internal and external

Medication administration across the home; secure storage of medication

Notices advising stakeholders of the dates for the re-accreditation audit on display

Noticeboards and posters, notices, brochures and forms displayed for care recipients, representatives and staff

Nurse call system in operation

Secure storage of confidential care recipient information

Short group observation in lounge area

Sign in/out registers

Staff work practices and work areas

The Charter of Care Recipients' Rights and Responsibilities displayed


Assessment informationThis 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 developmentPrinciple:Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The home utilises a continuous improvement system which includes a quality management system and performance review mechanisms. Improvements are identified through a number of avenues including care recipient and representative meetings, staff meetings, audits, surveys, and review of clinical data. The home also utilises surveys, benchmarking, suggestions, incidents and staff performance appraisals. Part of this system includes ensuring compliance with the Accreditation Standards through the audit program. The home uses these indicators along with other input from stakeholders to identify opportunities for improvement and to develop improvement plans. Care recipients, representatives and staff reported they have opportunities and are encouraged to participate in the home’s continuous improvement activities.

Examples of recent improvements in relation to Accreditation Standard One include:

Management identified the need to improve its care documentation system and as such a new computerised care documentation system was introduced. The purpose of this improvement was to improve the efficiency and effectiveness of the home’s care assessment and care planning processes relating to care recipients’ clinical needs and leisure and lifestyle requirements. Management advised the system has resulted in the home more effectively meeting the physical and mental health needs of care recipients as well as their leisure and lifestyle needs.

Management identified the need to review some staff duties and workflows within particular sections of the home so care recipients’ physical and mental health needs can be promoted and achieved at a more efficient and effective level. Consequently new working arrangements for particular staff was introduced. Management stated the new working arrangements have led to a higher level of quality care.

Management identified the need to put in place a more efficient system whereby the care manager could readily monitor care recipients’ care needs on a regular basis to identify any health or related issues that needed investigation and/or action. Consequently a dashboard reporting tool was introduced which monitors care recipients’ health care needs and issues and identifies any areas or issues requiring further investigation and action by the care manager.


1.2 Regulatory complianceThis 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”.


The home has systems to identify and ensure compliance with changes in relevant legislation, professional standards and guidelines. The home accesses relevant information through the organisation’s subscription to legislative update services and membership with a peak body. The home receives information from government departments and accesses the internet and other sources. Management communicates changes to staff by documentation, staff meetings and staff education sessions. Compliance with regulatory requirements is monitored through audits, skills assessments, staff appraisals and observations by management.

Examples of regulatory compliance relating to Accreditation Standard One include:

The organisation conducts reviews of all policies and procedures on a regular basis to ensure all relevant legislation, regulatory requirements, professional standards and guidelines are appropriately documented.

Procedures for monitoring the currency of criminal history record checks for staff and contractors are in place. Interviews and documentation confirmed that these have been completed and are current.

The organisation and home have a system whereby external contractors’ registrations and insurances are checked to ensure they are current.

Information brochures on the Aged Care Complaints Commissioner are available within the home.

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


The home has systems that ensure staff have appropriate knowledge and skills to perform their roles. Calendars of education sessions are developed which detail mandatory training sessions and education of interest or importance to various staff members. Learning packages are provided and some of these packages are skills based. Education and training requirements are identified through staff performance appraisals, internal audits and staff requests. Management and staff are supported to attend internal and external courses. Participation records are maintained and reviewed by management when planning future education programs. Staff interviews indicated they are provided with training as part of the home’s orientation process and have access to on-going education.

Examples of education and staff development relating to Accreditation Standard One include:

The home regularly undertakes induction and orientation sessions for new staff.

Calendars of education sessions have been developed through a consultative needs analysis between management and staff.

Staff receive training on a wide range of topic areas relating to the Accreditation Standards.


1.4 Comments and complaintsThis expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".


Information about internal and external complaint mechanisms is provided to care recipients and/or representatives on the care recipient’s entry to the home. This information is contained in the care recipient information enquiry/information pack. Information is also communicated on a regular basis through care recipient and representative meetings and information on display in the home. Staff are made aware of these mechanisms through policies and procedures and staff meetings. Feedback forms are available within the home. Brochures about external complaint mechanisms are also on display. Staff demonstrated they have knowledge and understanding of the complaint handling process and of their role in assisting care recipients to raise issues if necessary. Review of complaints and feedback as well as other relevant documents indicates that management responds to issues raised in an effective and timely manner.

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


The home’s vision, mission and values are available in a number of documents including handbooks for care recipients and staff. The home’s vision, mission and values form a part of the staff induction program and are discussed with staff.

1.6 Human resource managementThis 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".


The home has a system that aims to ensure there are enough staff with appropriate skills and qualifications to meet care recipients’ care and lifestyle needs. The organisation together with the home’s management team review staffing requirements to ensure sufficiency of human resources. Recruitment procedures ensure the best possible match between candidates and roles are achieved. Staff are provided with position descriptions and there are systems in place for staff orientation, education and performance management. Performance appraisals are conducted and results are fed into the home’s human resource management system. Observations, documentation and care recipient interviews showed there are sufficient staff with the appropriate knowledge and skills to perform their roles effectively.

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



The home has stocks of goods and equipment that support quality service delivery. Specific staff are designated to maintain adequate stock levels and ensure such stock meets the required quality standards. The home has systems to guarantee the integrity of the stock, and stock is rotated as required. Equipment needs are identified through staff requests, audits, asset replacements and acquisition programs. The home has preventative and reactive maintenance programs. Maintenance request reports are maintained and action is taken in an efficient and effective manner to deal with any requests or preventative maintenance tasks. Emergency maintenance requirements are dealt with in a timely manner. Staff are satisfied with the amount of supplies and quality of the equipment available to ensure the provision of quality care and services.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The home has an information management system that provides relevant information to stakeholders. The home’s communication system includes meetings, handbooks for staff, information pack for care recipients, newsletters, policies and procedures, noticeboards, staff handovers and a clinical documentation system. The home utilises these communication channels along with management’s open door policy to disseminate information and to collect feedback. The information management system governs the collection, processing, accessing, reporting, storage, archiving and destruction of information and records. The home has policies covering relevant regulatory requirements for management of information and records including confidentiality and privacy matters. Access to confidential information and records is controlled and limited to authorised staff. Observations demonstrated that care recipient and staff files are stored securely. Staff confirmed they receive and have access to relevant information that allows them to perform their roles effectively. Care recipients and representatives stated they are well informed regarding care recipients’ needs and all other matters appropriate to them.

1.9 External servicesThis 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".


The home’s externally sourced services are arranged primarily by way of specified contract agreements. There is a designated process whereby specific criteria must be met in relation to services to be supplied and references and insurance and criminal history record checks are current. All major contracts are reviewed regularly through feedback by the organisation and the home as considered appropriate. Contractor non-performance is recorded and actioned immediately if urgent or at the time of reviewing the contract. To enable staff to contact an appropriate contractor/supplier, lists are maintained at the home and updated as required. Staff are informed of appropriate matters relating to the provision of externally sourced services.


Standard 2 – Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



Refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement system.

Examples of specific improvements relating to Accreditation Standard Two include:

A review of the home’s medication management practices associated with schedule 8 drugs identified non-compliance with the home’s medication policies and procedures and legislative guidelines for high care aged care facilities. Consequently a number of improvements were made to how schedule 8 drugs are stored and managed. These improvements include appropriate storage of schedule 8 drugs, schedule 8 drugs are packed separately from other medications and the administration practices of schedule 8 drugs by staff have been improved. Management advised improvements implemented has assisted to ensure compliance with required medication policies and procedures.

Management identified the need to improve the processes whereby care recipients’ pain is assessed and monitored. As such the home introduced a new system for pain assessment and monitoring through the use of a pain flow chart as well as provided education session for care staff on what type of questions to ask care recipients about their pain. Also the home utilises the Abbey Pain Scale for those care recipients who may not be able to clearly articulate their needs. Management advised the improvements made has assisted to ensure care recipients are as free as possible from pain.

An audit concerning implementation of the home’s care recipient post fall’s policy and procedure identified staff were not always implementing required practices. Consequently education sessions were held for staff on implementing required policies and practices and registered nurses now set up appointments post any care recipient having a fall whereby observations and assessments can be carried out. Management stated now all falls are being appropriately monitored by the facility manager and/or care managers according to the home’s policy and procedure and appropriate care interventions implemented.

2.2 Regulatory complianceThis 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”.


Refer to expected outcome 1.2 Regulatory compliance for details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, and professional standards and guidelines.


Examples of regulatory compliance relating to Accreditation Standard Two include:

The home monitors registered nurses’ registrations.

The home monitors the registrations of visiting health professionals to ensure they are current.



Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education relating to Accreditation Standard Two include:

Behaviour management, continence management, nutrition and hydration, medication management, palliative care, insulin and diabetic management, skin integrity, understanding weight loss.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


Care recipients residing within the home receive appropriate clinical care. Their preferences are assessed from pre-entry through to the development of the care plan and regular evaluation of care. Family care conferences are documented and changes communicated to care staff. This occurs as the care recipient’s needs change and is routinely reviewed each four-months or as changes occur. The assessment process is guided by the home’s policies and procedures. Assessment of care, implementation of the plan and evaluation of interventions are attended by registered nurses. Variations to the plan for care recipients are discussed in an environment of collegial support and teamwork. There are registered nurses on duty in the home across 24 hours. Care recipients and representatives interviewed said care recipients’ clinical care was appropriate to their needs.

2.5 Specialised nursing care needsThis expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.


Care recipients and representatives are consulted regarding specialised nursing needs and plans are in place to direct this care. The home provides policies and procedures to guide staff in the delivery of specialised nursing care. Specialised nursing care is delivered by registered nurses, in consultation with care recipient’s chosen doctor and other specialised services when required. Protocols and communication systems are in place to ensure follow up of specialised nursing needs such as pathology and x-ray results, pain management effectiveness, dietetic involvement, catheter care, wound and diabetes management. Parameters are set by the doctor for blood glucose monitoring consistent with the care recipient’s plan for management of diabetes. Care recipients and representatives said they are happy with the management of these care needs.


2.6 Other health and related servicesThis expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.


Documentation shows the home refers care recipients to external health professionals and any changes to care following these visits are implemented in a timely manner. Allied health professionals are accessed via a referral system, through the care recipient’s preferred doctor. Pathology services, psycho-geriatrician, mental health and other allied health services visit the home using the external referral process. Representatives and care recipients report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Implementation of specialists’ recommendations is followed up by registered nurses. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care recipients’ care are implemented.

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


Management described and observation confirmed the safe and correct administration of medications. Staff were observed making appropriate checks, administering medication and assisting care recipients, while also keeping the medications within their safe observation. “As required” (PRN) medications are approved, and the effectiveness of the medication followed up by registered nurses. All medications are administered and oversighted by registered nurses in the home. Policies and procedures guide the safe delivery of medications. Meeting minutes’ show review of legislation changes, medication and pharmacy issues and medication reviews are completed by a consultant pharmacist. Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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


All care recipients are assessed for pain on entry to the home and as needed. Pain is also assessed as medication is administered and effectiveness monitored by care staff and registered nurses. The registered nurses provide feedback to the care recipient’s chosen doctor to ensure the comfort of care recipients. Allied health and care staff collaborate on the care recipient’s pain management strategies. Physiotherapy staff and registered nurses provide massage for pain relief, based on clinical assessment. Care recipients and representatives report care recipients are as free as possible from pain and staff respond in a timely manner to requests for pain control.

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



The comfort and dignity of terminally ill care recipients is maintained. There are records of care recipients’ preferred care at end of life and education programs are in place for staff of the home. The registered nurses consult with care recipients’ doctors and the care recipients/representatives where appropriate. Spiritual support is provided as needed. Staff ensure the care recipient’s wishes and comfort are observed while delivering palliative care. Interviews confirm care recipients trust the home’s staff with all aspects of their care.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Care recipients and representatives confirm they are satisfied with the home’s management of the nutrition, hydration and associated support needs. Meals are prepared according to a menu which has been reviewed by a dietician. Details of special dietary needs are documented on entry to the home and communicated to the kitchen staff. Preferences, meal consistency, special diets, supplements required and allergies are recorded on the dietary sheets available to catering and care staff. Care recipients confirmed they enjoyed the choice available and the meals are well balanced. Care recipients’ weights are monitored monthly and variations investigated and addressed. Dietary high calorie/high protein meals and nourishing supplements are available and are initiated as required. Snacks supplies and the choice of meals were observed to be provided to care recipients during the re-accreditation visit. Consultations occur with the care recipients’ doctor and/or a dietician and there are processes to vary the nutritional preferences of care recipients.

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


Care recipients and representatives confirm they are satisfied with the care provided to care recipients in relation to skin integrity. Skin integrity assessments and risk of impairment to skin integrity, are conducted on entry to the home and reviewed as necessary including at the three-monthly care review and evaluation. Risk assessment guides the pressure area care as care recipients’ mobility, nutrition status and cognition alter. Care recipients with specific skin conditions are closely monitored and treatments applied as directed by the care recipient’s chosen doctor. Referrals are made to specialist services as required. Wound monitoring and wound charts show regular review of wound management and improvement strategies. Pressure relieving equipment is available for those care recipients who are identified at risk of skin breakdown.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


Care recipients and representatives confirm continence needs for urine and bowel function are being met. On entry to the home the care recipient’s continence needs are assessed by staff obtaining the history from the care recipient, their representatives, doctor’s referral and


pre-entry assessments. Flow charts are initiated, voiding times and bowel evacuation patterns are recorded to enable assessments to be made. Care plans are developed and reviewed at regular intervals including consultation with care recipients and representatives. Staff continence education includes toileting programs, bowel management and the relationship to privacy, dignity and choice for care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behaviour management is identified by initial assessments and care plans are formulated. Management strategies include one-on-one and group activities with care staff and lifestyle staff. The programs are regularly reviewed in consultation with the care recipient, their representatives and other specialist services if consultation is required. Staff confirm they have received education in managing care recipients who express challenging behaviours through access to specialist health professionals and consult with these services as needed. Staff were observed to use a variety of management strategies and resources to effectively manage challenging behaviours. Care recipients and representatives were satisfied with the staff management of these situations and communication with families, regarding the interventions used to assist the care recipient and the impact of care recipients’ behaviours on other care recipients.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.


Each care recipient has their mobility and dexterity assessed by the physiotherapist, the registered nurse and the allied health team. Information is gathered from the care recipients, representatives, and pre-admission documents. Mobility information and the care recipient’s need for assistance are detailed in the care plan and programs are instigated by the physiotherapist to optimise care recipients’ mobility function. Care recipient mobility and movement are promoted through all care delivery. There is a range of aids to effectively and comfortably move care recipients. There is a system to indicate the level of assistance required with mobility described on the mobility plan and discussed at the care staff hand-over meetings. Care recipients and representatives said they are satisfied with the assistance and therapy provided to care recipients.

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


Each care recipient’s oral and dental health needs are assessed by the registered nurses on entry to the home. The care recipient’s needs, preferences and interventions are recorded on the care recipient’s care plan. The care recipients’ care plans are reviewed regularly and adjusted as necessary to meet their oral health needs. The home has access to dental services and arrangements are made for care recipients to attend external services. Staff


interviewed confirm their understanding of the oral care process and care recipients and representatives expressed satisfaction with this service.

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


Each care recipient’s sensory losses are assessed by the registered nurse through completion of the entry assessments and the specific sensory assessment tools. This occurs in consultation with the care recipient and their representative. The methods for communication and compensation for sensory losses are also located on the care plan. Strategies to assist care recipients who have declining cognition include speaking clearly and slowly, making eye contact, using simple statements and speaking with warmth, caring and using gestures as required. Care recipients and representatives interviewed said they are satisfied with the assistance provided to the care recipients.

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


Care recipients and representatives confirm care recipients are able to achieve natural sleep in the home. Information about the care recipient’s sleep patterns is entered in to their assessment and recorded in the care plan. Observations by care staff are recorded on assessment tools and in the care recipient’s progress notes to ascertain their normal sleeping pattern. Sleep patterns are reviewed each four-months and as required. Disturbance of care recipients is kept to a minimum at night. Activity is provided for those care recipients who go to bed late or rise early. Documents and interviews confirm staff receive education regarding the promotion of sleep.


Standard 3 – Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



Refer to expected outcome 1.1 Continuous improvement for the details of the home’s continuous improvement system.

Examples of continuous improvement relating to Accreditation Standard Three include:

Management identified the need to ensure there was appropriate information for lifestyle staff when taking care recipients on outings in case of an adverse event. Consequently an outing folder was created which contains care recipients’ summary care plans and medication requirements. The outing folder has assisted recreational activity staff to encourage and support care recipients to participate in a wider range of activities and activities of interest to them.

It was identified by recreational activity officers a wider range of activity programs needed to be developed to address the lifestyle needs of care recipients with different cognitive ability levels and create more social opportunities in a group situation. Consequently the home’s activity calendars now include art and music activities as well as the Namaste and end stage dementia sensory program. Twilight activities and evening games have also been incorporated into the calendar. Staff stated care recipients very much enjoy participating in these activities.

Management and recreational activity officers identified the creation of ‘Life Stories’ for care recipients which could be framed and hung above care recipients’ beds could be good tool to help staff connect and have discussions which are meaningful, familiar and pleasurable to care recipients. As such care recipients’ families are helping to create these ‘Life Stories’ providing information such as working backgrounds, interests, photos and favourite places.

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



Examples of regulatory compliance relating to Accreditation Standard Three include:

The “Charter of Care Recipients’ Rights and Responsibilities” is on display.

The care recipient agreements outline security of tenure and are based on applicable legislation.


The home has a system for compulsory reporting according to current legislation.



Examples of education relating to Accreditation Standard Two include:

Understanding grief and loss, providing appropriate emotional support, privacy and dignity, LGBTI training.

3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".


The emotional support needs of each care recipient are considered and supported on entry to the home. Pre-entry social and background information is provided to ensure a smooth transition to residential care for both the care recipient and their family. There is ongoing emotional support throughout the care assessment process and on an ongoing basis. This includes reference to adjusting to life within the home, general emotional support, language requirements, as well as an understanding of any personal losses. This initial period is further enhanced by social profiling and assessment of each care recipient’s health, care, social, cultural and spiritual needs to gain a holistic understanding of their individual needs. The lifestyle and activity team are available to provide support. Visiting hours are open and care recipients are encouraged, where possible, to participate in outings, maintain existing social connections and develop relationships with others within the home. Care recipients and their representatives were very positive during interviews in relation to the support they receive from staff.

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


The home encourages care recipients to maintain their independence by participating in activities and events both within the home and the community. Clinical assessments and care plans identify the care recipients’ level of independence and the amount of support they require to participate in lifestyle options of their choice. The physiotherapy program and social programs promote independence through the maintenance of movement, strength, balance and dexterity. There are also opportunities for care recipients to participate in activities within the home as well as the wider community through the continuation of external activities such as bus trips. The home provides access to a number of indoor and outdoor areas where they can entertain guests. Care recipients and their representatives expressed satisfaction that care recipients are assisted to achieve maximum independence, maintain relationships and participate in life within and outside the home.


3.6 Privacy and dignityThis expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".


Care recipients are supported to retain their right to privacy and dignity with policies and education to guide staff in this process. Information regarding their rights and responsibilities is on display and also given to each care recipient on entry to the home. Observation of staff practices showed these are consistent with the home’s privacy and dignity related policies and procedures. Care recipients said the staff care for them in a respectful manner. The home has secure information systems in place. Procedures, handbooks and education programs provide further information for staff regarding care recipients’ rights to privacy and confidentiality. Interviews with care recipients and representatives indicate that care recipients’ privacy, dignity and confidentiality are recognised and respected.

3.7 Leisure interests and activitiesThis expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".


The home supports care recipients to participate in a range of activities and social opportunities. Their preferences in relation to lifestyle are assessed through a social profiling process and care plans are aligned to care recipients’ cognitive and functional abilities, areas of interest and cultural and spiritual choices. The activity calendars are displayed on noticeboards. Opportunities are available for care recipients to discuss the programs regarding the frequency and continuation of activities. Those activities that attract the greatest interest include word games and reminiscing. Care recipients interviewed said they enjoy the activities and interactions.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


The home has systems which are responsive to cultural diversity. Information related to individual interests, customs, beliefs and cultural backgrounds, as well as spiritual needs is gathered from care recipients and their representatives to assist the design of individualised care plans. Activities reflect the relevant cultural and spiritual preferences and provision is made for the celebration of significant events where friends and family are encouraged to participate. Care recipients are actively encouraged and supported to maintain their spiritual links through attending services in the home. The home also facilitates contact with a number of other religious ministers as required. All staff have received education on culturally appropriate care specific to the care recipient population in the home. Care recipients and representatives were appreciative that the care recipients’ cultural and spiritual needs are recognised and supported.

3.9 Choice and decision-makingThis expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to


exercise choice and control over his or her lifestyle while not infringing on the rights of other people".


Care recipients are aware of, and feel supported in exercising, their individual right to freedom of choice and are encouraged to make decisions about their care delivery and lifestyle. Whenever possible, care recipients make choices about their daily routines such as outings, meal preferences, cultural and spiritual choices and lifestyle options. Care recipients are encouraged to personalise their room or the area around their bed with memorabilia from their life and wall decorations. They are also kept informed and given opportunities to provide input into their care, services and environment, through systems such as an ‘open door’ policy by management, case conferences, care recipient meetings, care recipient surveys and comments and complaints mechanisms. Care recipients and representatives indicate they are able to express views about the provision of care and services and that their comments are considered.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


Care recipients and representatives reported they are satisfied with the information the home provides to care recipients on entry regarding care recipients’ entitlements, details of tenure as well as the fees and charges. Designated staff members explain the care recipient accommodation agreement to care recipients and representatives prior to care recipients coming to live at the home. Care recipients and representatives are advised to seek independent legal and financial advice. The care recipient and relatives handbook which is provided to care recipients on entry contains information about the services available, privacy and confidentiality, processes for making complaints and care recipients’ rights and responsibilities. Management explained the process for room changes within the home and advised that agreement is always reached prior to any room changes occurring.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Refer to expected outcome 1.1 Continuous improvement for further information relating to the home’s continuous improvement system.

Examples of recent improvements in relation to Accreditation Standard Four include:

The organisation together with management identified the need to improve the home’s living environment for care recipients. Consequently a refurbishment program was developed and implemented which included installation of new flooring, new wardrobes, bathrooms being renovated, installation of new curtains and blinds, hanging of new pictures in the hallways and upgrading office areas. Management stated care recipients’ response to the enhancement of the home’s living environment has been very positive.

Management identified the need to put in place a more effective infection control program increasing the proportion of staff receiving vaccinations during the influenza season. As such the home organised for two onsite vaccination clinics for staff with the result this year approximately 80 percent of staff were immunised whereas in 2016 only 48 percent of staff were immunised.

The organisation together with management identified the need for a more effective and efficient contractor management system when contractors are on-site. Consequently a new system is being trialled whereby all contractors on site will more effectively manage their designated responsibilities. This improvement will relieve administration and maintenance staff of particular duties and be a more cost effective process.

4.2 Regulatory complianceThis 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”.



Examples of regulatory compliance relating to Accreditation Standard Four include:

The home has current NSW Food Authority licence and the food safety system has been audited by the NSW Food Authority.

The home has a current annual fire safety statement on display.

The home provides safety data sheets with stored chemicals.




Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education relevant to Accreditation Standard Four include:

Fire safety and evacuation training, work health and safety, manual handling, infection control, food safety, incident reporting management system.

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


The home demonstrates that it is actively working to provide a safe and comfortable environment consistent with care recipients’ needs. The home is a single-storey building with various adjoining sections under the one roof with an internal garden courtyard. The sections include single and multi-bedded bedrooms with ensuite facilities together with dining and communal areas. The home is well illuminated with natural light. The home’s bedrooms have individually controlled air conditioning as do the common areas. There is a preventative and reactive maintenance program in place, including recording of warm water temperatures and regular inspections covering the environment are undertaken. Care recipients and representatives stated they are very satisfied with care recipients’ individual rooms and the communal living environment.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Systems and processes enable the home to demonstrate that management and staff are working together to provide a safe working environment that meets regulatory requirements. The home has processes for the identification and addressing of hazards and incidents. There is safe work practice and work health and safety education for staff. Chemicals are appropriately stored and safety data sheets and personal protective equipment is available at point of use. Staff demonstrated knowledge and understanding of workplace safety issues and responsibilities and we observed safe practices in operation.

4.6 Fire, security and other emergenciesThis 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".



The home has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire evacuation plans, emergency procedure documentation and exit signs are located throughout the home. Monitoring and maintenance of all fire and alarm equipment is undertaken by contractors and reports provided. Fire equipment is located throughout the home. Appropriately responding to emergency training is included in the orientation program and there are mandatory annual updates. Staff are aware of procedures to be followed in the event of an emergency. Emergency evacuation documentation is readily available which includes information detailing care recipients’ care needs and relevant contact information. Staff stated they are aware of and understand their responsibilities in the case of fire and other emergencies.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


There is an effective infection control program which minimises infections. A care recipient and staff immunisation program is implemented each year. The infection surveillance program includes monitoring, appropriate treatment and follow up review of any infections to reduce the likelihood of further infections. Infection control training and hand washing education are provided for staff during orientation, during mandatory annual education and as needed for all staff. Outbreak management plans and equipment are in place. The home has a food safety program and a pest control program. Personal protective equipment, spill kits and hand sanitising stations were observed throughout the building. Temperature monitoring and thermometer calibration programs are regularly recorded and cleaning schedules are followed throughout the home. Waste is disposed of safely and correctly. All staff interviewed had a good understanding of the importance of infection control.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Care recipients and representatives expressed satisfaction with the hospitality services provided at the home.

Care recipients’ dietary needs and choices are assessed and documented on entry to the home and details provided to catering staff. All food is cooked on site. There is a food safety program and the home has a current NSW Food Authority licence. The home has a seasonal menu with input from a dietitian. We observed food preparation and service and staff practices are according to the appropriate food safety guidelines, including infection control requirements. Appropriate staff have undertaken training in relation to appropriate food handling and infection control. Care recipients said they are satisfied with catering services provided.

The home presents as clean, fresh and well maintained. Cleaning staff perform their duties guided by documented schedules, work instructions and results of inspections. Cleaning equipment is colour coded and chemicals are securely stored. Staff are trained in the use of equipment, infection control, outbreak management procedures and work, health and safety. Staff demonstrated a good knowledge of infection control, manual handling requirements and safe handling of chemicals.

Laundry services are provided on site. Dirty laundry is collected in appropriate coloured linen bags and transported to the laundry area. There are procedures and work instructions for the


collection and handling of linen. Staff described the processes for the collection and transportation of dirty clothes and linen and distribution of clean linen and clothes to care recipients. Staff confirmed they receive training in infection control and safe work practices.
