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Marycrest HostelRACS ID: 5078

Approved provider: St Vincent's Care Services Ltd.

Home address: 411 Main Street KANGAROO POINT QLD 4169

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 17 November 2020.

We made our decision on 24 October 2017.

The audit was conducted on 21-23 August 2017 and 12-13 September 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: Marycrest Hostel Date/s of audit: 21-23 August 2017 and 12-13 September 2017RACS ID: 5078 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: Marycrest Hostel Date/s of audit: 21-23 August 2017 and 12-13 September 2017RACS ID: 5078 3

Audit ReportName of home: Marycrest Hostel

RACS ID: 5078

Approved provider: St Vincent's Care Services Ltd.

IntroductionThis is the report of a Re-accreditation Audit from 21-23 August 2017 and 12-13 September 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 21-23 August 2017 and 12-13 September 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of four 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: 153

Number of care recipients during audit: 141

Number of care recipients receiving high care during audit: 141

Special needs catered for: Degenerative neuro-cognitive conditions


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

Interviews

Position title Number

Administration assistant 1

Care recipient/representative 23

Care support worker 11

Clinical manager 2

Facility manager 1

Food services coordinator 1

Housekeeping/hospitality 8

Lifestyle officer 4

Maintenance officer 1

Menu monitor 1

Music therapist 1

Pastoral care worker 1

Physiotherapist 1

Registered staff 7

Speech pathologist (external) 1

Student 4

Support services manager 1

Volunteer 1

Sampled documents

Document type Number

Care recipients’ files 22

Medication charts 16


Other documents reviewedThe team also reviewed:

Activities calendars and participation records

Allied health referrals and documentation

Asset register

Audits and reports

Care management system – electronic

Care recipient agreement

Care recipients’ handbook and information book

Catering management system – electronic

Chemical register

Cleaning schedules

Clinical focus assessments, treatment plans and monitoring charts

Clinical indicator data and reports

Communication books/diaries

Compliments and complaints records

Contractor information – electronic system

Controlled drug registers

Credentialing register (including criminal history check reports)

Daily staff sheet

Dietary requirements and nutritional supplement records

Document register – electronic

Duties list folder

Education and training records

Emergency contacts list

Employee handbook

Evacuation list

Feedback forms

Fire and emergency folder

Fire/smoke detection and firefighting equipment inspection and maintenance records

Food safety program

Food, goods and equipment temperature monitoring records

Handover notes

Human resource management checklists

Incident forms

Infection data and analysis


Maintenance request books and electronic system (including preventative maintenance schedule)

Mandatory reporting register

Memoranda

Menu

Minutes of meetings

Newsletter

Nurse-initiated medication list

Outbreak management information

Personal clothing report

Pest control records

Pharmacy documentation

Plan for continuous improvement

Policies, procedures and guidelines

Position descriptions

Preferred supplier list

Reaccreditation self-assessment

Residential medication management reviews

Restraint assessment, authorisation and monitoring records

Restraint report

Risk management system – electronic

Rosters

Safety data sheets

Service agreements

Signature register

ObservationsThe team observed the following:

Activities in progress

Administration and storage of medications

Advocacy and complaints agencies’ brochures on display

Charter of care recipients’ rights and responsibilities on display

Chemical storage

Daily menu displayed

Emergency exits, lighting and egress routes

Equipment, goods and supply storage areas

Falls prevention, mobility and dexterity aids in use

Feedback form lodgement box – locked


Fire panel

Fire/smoke detection and firefighting equipment and inspection tags

Gym facility and equipment

Hand washing facilities and gel dispensers

Interactions between care recipients, staff and visitors

Internal and external living and working environments

Maintenance workshop

Midday meal, setting, service and practices

Morning and afternoon tea service

Noticeboards and whiteboards

Outbreak kit

Personal protective equipment in use

Physiotherapy class in progress

Safety signage

Shift handover in progress

Short group observation

Sign in/out registers

Vision, mission, values and commitment to quality statement on display

Waste disposal


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

Marycrest Hostel (the home) has a continuous improvement system that monitors performance against the Accreditation Standards and identifies improvement opportunities across all standards. Opportunities for improvement are identified through written and verbal care recipient and staff feedback, meetings, audits, quality indicator data collection and analysis. The Facility Manager (FM) is responsible for managing continuous improvement activities at the home including that actions are undertaken, recorded and evaluated as planned. Communication of continuous improvement activities occurs through meetings and memoranda and improvement activities are tracked and summarised in the home’s continuous improvement plan. Staff and care recipients are satisfied the home actively pursues continuous improvement.

Examples of improvements related to Standard 1, Management systems, staffing and organisational development include:

Following feedback from a care recipient’s representative regarding communication between staff on different shifts, the home reviewed handover processes. In order to ensure sufficient handover time, shifts times were adjusted so that registered staff and care staff all commence morning shift at 6.00am (registered staff previously commenced at 6:30am). This provides a 30 minute overlap with the night duty staff and the registered nurse provides a handover to all staff prior to commencement of their shift. Staff and management reported satisfaction with these changes and the improved communication the handover provides.

Following the introduction of an electronic clinical documentation system in August 2016, management reported improved ability to communicate with staff. Electronic alerts can be sent to all staff and/or groups of staff as appropriate and these are required to be read when a staff member logs onto the electronic system. Management reported this allows them to provide more timely and effective communication that the previous written memoranda system.

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 organisation has systems and processes to identify changes in relevant legislation, regulatory requirements, professional standards and guidelines. Systems are managed at organisational level by the Support Office, with relevant information communicated to the FM. Actions such as policy and procedure changes and staff education occur as required in response to regulatory changes. Compliance with legislation is monitored through audits and supervision of work practices. There are systems to inform care recipients/representatives of re-accreditation audits and to ensure all staff have a current criminal record check which they have passed.

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 an education program which ensures management and staff have appropriate skills and knowledge to perform their roles effectively. Education needs of staff are identified through the appraisal process, staff requests, mandatory training requirements, audits and care recipient feedback. Education is provided in groups, one to one sessions, and through electronic self-directed learning packages. Education attendance is monitored and evaluation of education is undertaken. Staff are supported to complete external training applicable to their role. Ongoing knowledge and skill needs of staff are monitored through performance appraisals, analysis of data, and observation of practice Staff are satisfied with the training and development opportunities available to them at the home and have the knowledge and skills appropriate for their roles.

In relation to Standard 1, Management systems, staffing and organisational development, orientation education and annual mandatory education is provided as required.

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".


Care recipients/representatives have access to the home’s internal comments and complaints system and to external complaints and advocacy mechanisms. The home provides relevant information to care recipients, their representatives and other stakeholders through a variety of communication channels including care recipient entry processes, the residential care agreement, care recipient handbook, meetings, and via external complaints management and advocacy brochures. Care recipients are invited to raise issues at meetings and/or privately with management and staff. Staff orientation includes information relating to comments and complaints processes. Compliments/complaints and suggestions for improvement are reviewed by management and logged. Complaints are investigated and action taken to resolve issues; implement improvement actions where necessary; provide feedback, and identify trends. Care recipients/representatives and staff are familiar with the mechanisms available to initiate a suggestion or raise a concern and are satisfied that management is responsive to their suggestions and responds to their requests in a 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 has documented the organisation’s vision, mission and values and commitment to quality. These are displayed in the foyer of the home and included in written information such as handbooks.

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 systems and processes to ensure staff are appropriately skilled and sufficient to provide services in accordance with these standards. Recruitment processes are managed by the FM and include selection criteria, interview processes and pre-employment criminal checks. New staff receive orientation to the organisation and the home which includes mandatory requirements and competencies. Buddy shifts are provided and policies and procedures, duty guidelines, position descriptions and task lists are available to direct staff in their roles. The performance of staff is monitored through audits, observation of practice, feedback mechanisms, monitoring of clinical indicator data and the performance appraisal system. Rosters are planned in advance and modified in response to planned and unplanned leave and to reflect changes in care recipient needs. A registered nurse is on site at all times. Organisational processes ensure staff have current registration if appropriate and a current criminal record check. Care recipients/representatives are satisfied staff have the skills and knowledge required to meet their needs and that requests for assistance are responded to in a timely manner.

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


The home has processes to ensure there are stocks of appropriate goods and equipment available for service delivery. Key staff are responsible for the monitoring and ordering of supplies through the home or corporate ordering systems and preferred suppliers. Equipment needs are identified through staff requests, identification of care recipients’ needs, audits and asset management processes. The home has procedures for assessing risk, trialing, purchasing and replacing equipment. A preventative maintenance schedule and corrective maintenance processes ensure equipment is serviced on a regular basis by the Kangaroo Point campus maintenance supervisor and team in tandem with external contractors when required. Staff identify and remove unsafe equipment for modification or repair; such equipment is returned to use only if/when safe and functional. Goods are checked on receipt, rotated and securely stored. Staff are provided with instruction on the correct use of equipment and supplies. Care recipients/representatives and staff are satisfied there are appropriate goods and equipment available for service delivery.

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



The organisation and home have established processes to manage information. Information is disseminated to staff, care recipients/representatives, external service providers and other stakeholders through policies and procedures, electronic and written documentation and communication, and staff education and training. Information is also transmitted through noticeboards, meetings, staff handover processes, handbooks and correspondence. Staff have access to information relevant to their position and changes to care recipients’ needs are communicated to them in a timely manner. Electronic information is secured by passwords, with restricted access depending on the role in the organisation, and regularly backed up to prevent loss of information. There is a system to archive information appropriately. Care recipients are satisfied with internal communication processes and have access to information about care and service delivery.

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".


There are processes to ensure that externally sourced services are provided in line with the home’s needs and service requirements. The organisation’s corporate office develops contracts/service agreements that specify the organisation’s and home’s expectations and requirements including quality, criminal history checks, relevant licences, insurance details and education/training for staff where necessary. Designated staff are responsible for the monitoring of external providers to ensure the ongoing currency of agreements, police certificates, insurance and relevant licensing/registrations. Monitoring processes ensure consistent quality in service delivery; action is taken when deficiencies are identified. Care recipients/representatives, staff and management are satisfied with the quality 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 Improvement, for information about the home’s continuous improvement systems and processes.

Examples of improvements related to Standard 2, Health and personal care, include:

Following the introduction of a continence management team, the home has created a dedicated continence link nurse role. Management and staff reported that as a result of this role continence supplies are being managed more effectively and there is a greater continuity as one person now has oversight of continence supplies.

In April 2017 the home commenced Medication Advisory Committee (MAC) meetings specific to the home as previous meetings were held with the adjoining hospital and the content was not always relevant to the home. Management reported the meetings are more focused and topics discussed are pertinent to the home.

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 information about the home’s regulatory compliance systems and processes.

In relation to Standard 2, Health and personal care, the home has systems in place to ensure staff maintain current registration if required. Procedures are in place to ensure reporting occurs in the event of unexplained absences of care recipients.



Refer to expected outcome 1.3, Education and staff development, for information about the home's systems and processes in relation to staff education.

In relation to Standard 2, Health and personal care, the home provides a range of learning opportunities for staff including recent education on continence management, safe swallowing, dementia care, nutrition needs of the elderly and tracheostomy management.


Staff are satisfied with the training and development opportunities available to them at the home and have the knowledge and skills appropriate for their roles.

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


The home has mechanisms to ensure care recipients receive clinical care that is appropriate to their needs and preferences. Care needs are identified on entry and on an ongoing basis through review, consultation with the care recipient and/or their representative and assessment processes. Individual care plans are developed by qualified staff and reviewed regularly. There are processes to ensure staff have access to current information to inform care delivery including care plans, progress notes and handovers. Care recipients' clinical care needs are monitored, evaluated and reassessed through incident analysis, reviews and feedback. The home regularly reviews and evaluates the effectiveness of the clinical care system and tools used. Changes in care needs are identified and documented; where appropriate, referrals are made to medical officers or health professionals. Staff provide care consistent with individual care plans. Care recipients/representatives are satisfied with the clinical care being provided.

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' specialised nursing care needs are identified through assessment processes on entry to the home. Care is planned and managed by appropriately qualified staff. This information, together with instructions from medical officers and health professionals is documented in the care plan. Specialised nursing care needs are reassessed when a change in care recipient needs occurs and on a regular basis. Staff have access to specialised equipment, information and other resources to ensure care recipients' needs are met. Specialised nursing care is delivered by appropriately qualified staff consistent with the care plan. Care recipients/representatives are satisfied with how care recipients' specialised nursing care needs are managed.

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”.


The home has systems to ensure care recipients are referred to appropriate health specialists/services, such as podiatry, optometry, audiology, dentists, dietitian, speech pathology, geriatrician and palliative care specialists, in accordance with their needs and preferences. Health specialist directives are communicated to staff and documented in the care plan and care is provided consistent with these instructions. Staff practices are monitored to ensure care is in accordance with the care recipients' needs and preferences. Staff support care recipients to attend external appointments with health specialists. Care recipients/representatives are satisfied referrals are made to appropriate health specialists of their choice and staff carry out their instructions.


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


The home has systems to ensure care recipients' medication is managed safely and correctly. There are processes to ensure adequate supplies of medication are available and medication is stored securely and correctly. Medical officers prescribe and review medication orders and these are dispensed by the pharmacy. Medications are administered by staff who have received training in relation to this. Documented medication orders provide guidance to staff when administering or assisting with medications. Procedural guidelines provide clarification surrounding safe medication practices. The home's monitoring processes include reviews of the medication management system and analysis of medication incident data. Opportunities for improvement in relation to the medication management system are identified and addressed. Care recipients/representatives are satisfied care recipients' medications are provided as prescribed and in a timely manner.

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


Care recipients' pain is identified through assessment processes on entry to the home and as needs change. Specific assessment tools are available for care recipients who are not able to verbalise their pain. Care plans are developed from the assessed information and are evaluated to ensure interventions remain effective. Medical officers and allied health professionals are involved in the management of care recipients' pain. The home's monitoring processes identify opportunities for improvement in relation to pain management systems and processes. Staff assess care recipients' verbal and non-verbal indicators of pain and implement appropriate actions, including utilising a range of strategies to manage comfort levels. Care recipients/representatives are satisfied care recipients' are as free as possible from pain.

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


The home has processes to ensure the comfort and dignity of terminally ill care recipients and to provide support for their representatives and those involved in their care. Palliative care information, includes emotional, cultural and spiritual wishes as well as pain and symptom management, is collected in consultation with care recipients and their representatives and documented in a pastoral care plan. Referrals are made to medical officers, palliative care specialist teams and other health specialist services as required. There is a supportive environment which provides comfort and dignity to the care recipient and their representatives. Staff practices are monitored to ensure the delivery of palliative care is in accordance with the pastoral care plan. Representatives of care recipients who recently received end of life care were appreciative of the care provided in supporting the care recipient's needs and preferences.


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


Care recipients' nutrition and hydration requirements, preferences, allergies and special needs are identified and assessed on entry. Care recipients' ongoing needs and preferences are monitored, reassessed and care plans updated. There are processes to ensure catering and other staff have information about care recipient nutrition and hydration needs. Staff monitor care recipients' nutrition and hydration and identify those care recipients who are at risk. The home provides staff assistance, equipment, special diets and dietary supplements to support care recipients' nutrition and hydration. Staff have an understanding of care recipients' needs and preferences including the need for assistance, texture modified diet or specialised equipment. Care recipients/representatives are generally satisfied care recipients' nutrition and hydration requirements are met. Care recipients/representatives are generally satisfied care recipients' nutrition and hydration requirements are met; however, one care recipient receiving a special diet was dissatisfied with the options available to them.

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


Care recipients' skin care requirements, preferences and special needs are assessed and identified, in consultation with care recipients and/or representatives. Care plans reflect strategies to maintain or improve care recipients' skin integrity and are reviewed regularly. Skin care needs are monitored, evaluated and reviewed as required. Referral processes to other health specialists are available if a need is identified. The home's monitoring processes identify opportunities for improvement in relation to skin care; this includes a process for documenting and analysing incidents relating to skin integrity. Staff promote skin integrity through the use of moisturisers, pressure relieving devices, pressure area care and safe manual handling techniques. Care recipients/representatives are satisfied with the assistance provided to maintain skin integrity.

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


Care recipients' continence needs and preferences are identified during the assessment process and reassessments occur as required. Strategies to manage care recipients' continence are documented in the care plan and regular evaluation occurs to ensure strategies remain effective. Care staff have an understanding of individual care recipients' continence needs and how to promote privacy when providing care. Changes in continence patterns are identified, reported and reassessed to identify alternative management strategies. Equipment and supplies such as continence aids are available to support continence management. The home's monitoring processes identify opportunities for improvement in relation to continence management; this includes the collection and analysis of data relating to infections. Care recipients/representatives are satisfied with the support provided to care recipients in relation to continence management.


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


The needs of care recipients with challenging behaviours are identified through assessment processes and in consultation with the care recipient, their representative and/or allied health professionals. Individual strategies to manage behaviours are identified and documented in the care plan and are regularly evaluated to ensure they remain effective. The home's monitoring processes identify opportunities for improvement relating to behaviour management; this includes the collection and analysis of behavioural incident data. Staff have an understanding of how to manage individual care recipients' behaviours, including those care recipients who are at risk of wandering. Care recipients/representatives are satisfied with the responsiveness of staff and support of care recipients with behaviours which may impact on others.

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


The home has processes to ensure care recipients achieve optimum levels of mobility and dexterity. Care recipients are assessed by a physiotherapist and registered nursing staff and are referred to the medical officer as needed. Regular education is provided to staff to enable them to effectively assist care recipients with manual handling procedures, their exercise program and to maintain and/or improve their mobility and dexterity in accordance with planned care. Assistive equipment for mobility and dexterity such as walking aids and specific dietary utensils are provided to promote independence in accordance with care recipients’ needs. Falls incidents are reported and prevention strategies are implemented such as hip protection, low beds and sensor equipment to monitor care recipients requiring staff assistance to mobilise. The effectiveness of strategies for promoting mobility, dexterity and rehabilitation is regularly evaluated. Care recipients/representatives are satisfied with the support provided for achieving optimum levels of mobility and dexterity.

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


Care recipients' oral and dental health needs are identified through assessment processes and in consultation with the care recipient and/or their representative. Care strategies are documented on the care plan and are regularly evaluated and reviewed to ensure care recipients' changing needs are met. The home's monitoring processes identify opportunities for improvement in relation to oral and dental management systems and processes, including clinical monitoring processes and consultation. Equipment to meet care recipients' oral hygiene needs is available. Staff provide assistance with oral and dental care and where necessary referrals are made to health specialists such as dentists. Care recipients/representatives are satisfied with the assistance provided by staff to support care recipients to maintain oral and dental health and referrals when required.


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


Sensory losses are identified through assessment processes and in consultation with care recipients and/or their representative. Care plans identify individual needs and preferences and are reviewed regularly. Care recipients are referred to health specialists, such as audiologists and optometrists, according to assessed need or request and are assisted to attend appointments as required. The home's monitoring processes identify opportunities for improvement in relation to how sensory loss is managed, including clinical monitoring processes and consultation with care recipients, representatives and health professionals. Staff receive instruction in the correct use and care of sensory aids and are aware of the assistance required to meet individual care recipients' needs. Care recipients/representatives are satisfied with the support provided to manage care recipient sensory needs.

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


Care recipients' sleep patterns, including settling routines and personal preferences, are identified through assessment processes on entry. Care plans are developed and reviewed to ensure strategies to support natural sleep remain effective and reflect care recipients' needs and preferences. Care recipients experiencing difficulty sleeping are offered a range of interventions to promote sleep; where appropriate medical officers are informed of sleep problems. The environment is optimised to ensure it supports natural sleep and minimises disruption. Environmental and clinical monitoring processes identify opportunities for improvement in relation to sleep management. Staff support care recipients when normal sleep patterns are not being achieved. Care recipients/representatives are satisfied support is provided to care recipients and they are assisted to achieve natural sleep patterns.


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.




Examples of improvements related to Standard 3 Care recipient lifestyle include:

In response to increased care needs of care recipients, it was identified it was increasingly difficult to enable care recipients to attend and participate in mass on Sundays. In July 2017, the home commenced allocating a carer to attend mass and assist care recipients during mass as needed. Additionally the pastoral care staff attend mass every fortnight to assist as needed. As a result two priests who live at the home are assisted to participate in mass despite deteriorating health and other care recipients attending mass have assistance available if required.

As a result of increasing numbers of care recipients having portable electronic devices, the home introduced classes for care recipients wishing to learn more about how to use them. Lifestyle staff report these classes are well attended.

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”.



In relation to Standard 3, Care recipient lifestyle, compliance with legislation includes a system to ensure staff are aware of mandatory reporting guidelines.



Refer to expected outcome 1.3, Education and staff development, for information about the home's systems and processes in relation to staff education.

In relation to Standard 3, Care recipient lifestyle, the home provides a range of learning opportunities for nursing, care and lifestyle staff including annual education on mandatory reporting and recent education on advocacy services, and experiencing loss and grief. Staff


are satisfied with the training and development opportunities available to them at the home and have the knowledge and skills appropriate for their roles.

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".


Emotional needs of care recipients are assessed on entry to the home. Management, nursing and lifestyle staff welcome care recipients and their families and introduce them. Care recipients’ emotional needs are determined via nursing and lifestyle assessments and documented in notes and care plans. Avenues of emotional support include pastoral care, psychology, and volunteer services as well as support from care and lifestyle staff. Care recipients’ emotional needs are communicated to staff as required to ensure care recipients are provided with appropriate support on a daily basis and if/when critical episodes occur. Care recipients are encouraged to maintain friendships and contacts within the external community and to participate in life at the home at a pace that suits them. Care recipients/representatives are satisfied with the support provided in adjusting to life in the home and as required.

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".


Care recipients are encouraged and supported to maintain their independence at a level that is appropriate to their individual needs and abilities. Assessment processes identify care recipients’ needs and preferences in relation to physical, financial and social independence. The information gathered informs the care plans which direct staff. The home’s lifestyle options offer a range of activities designed to maximise physical strength and independence as well as social independence. Care recipients are assisted and encouraged to maintain friendships and participate in the life of the community within and outside the home. Care recipients are encouraged to use available aids such as spectacles and walking frames to maintain their independence. Most care recipients/representatives are satisfied with the support and encouragement given by staff to enable them to remain as independent as possible. One care recipient stated they feel staff could be more motivating in relation to encouraging care recipient independence.

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


The home maintains a supportive environment that protects care recipients’ privacy and dignity. Entry processes provide care recipients with information about their rights, including their right to privacy. Staff are informed of their responsibility to respect care recipients’ privacy and dignity and to maintain confidentiality regarding aspects of care requirements and personal information. Care recipients’ personal information is stored electronically and is


password protected. Most care recipients are satisfied staff are respectful of their privacy, dignity and individual preferences while providing care and services for them.

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 offers lifestyle options that incorporate a range of interests and activities. Initial assessments gather information regarding past history including care recipients’ interests, family relationships and how they would like to spend their time as well as their current abilities and any barriers to participation. An individual care plan is developed and individual participation is recorded and monitored. A monthly activity planner depicting both small and large group activities is distributed to care recipients and is available on noticeboards and is electronically communicated to family. Feedback is sought at meetings and during one on one interaction regarding individual preferences for the continuation of current activities and suggestions for introduction of new activities. As well as regular activities, themed days and celebrations are held regularly to add variety to the program and to enable care recipients to celebrate events that are being celebrated within the community. Where group activities are not appropriate, one to one activities are provided by staff and/or volunteers. Care recipients are satisfied lifestyle staff provide encouragement and support for them to participate in a range of leisure interests and activities of interest to them.

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


Care recipients’ specific cultural and spiritual needs are identified through initial and ongoing assessment processes. Religious services are held at the home and representatives from various religions visit the home and provide religious services and spiritual care. Care recipients are assisted and encouraged to attend services as desired. Celebrations are held to mark days of cultural and religious significance. Care recipients’ cultural and spiritual needs are monitored by pastoral care staff through consultation with care recipients. Care recipients are satisfied their cultural and spiritual needs and preferences are respected 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 supported to participate in decisions about the services they receive. Individual choices are identified through initial and ongoing assessment processes, daily contact between staff and care recipients and via informal and formal feedback mechanisms. Staff respect and accommodate care recipients’ choices, encourage them to be involved in choice of times for daily hygiene cares and evening retiring times, meal choices, to attend/contribute to activities and other choices related to their life at the home. Registered


staff assess individual care recipient choices against risk indicators and the rights of other care recipients. Care recipients ability to be involved in decision processes are accessed in conjunction with their medical officer and when appropriate substitute decision makers are involved. Opportunities for care recipients to exercise their decision-making rights are monitored through care plan evaluations, care recipient feedback and case conferences. Care recipients are satisfied with choices offered in matters relating to the care and services they receive at the home.

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/representatives are supplied with written and verbal information regarding care and services prior to and/or on transition to the home and can access additional information via the home’s web page. The Approved Provider ensures appropriate updates to legislation are reflected in the home’s care agreement and literature provided to care recipients/representatives. The home manages transition across the home in consultation with care recipients/representatives and will assist care recipients to access alternative accommodation through liaison with other service providers and allied health professionals. Care recipients/representatives are aware of their rights and responsibilities and are satisfied care recipients’ tenure at the home is secure.


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.




Examples of improvements related to Standard 4, Physical environment and safe systems, include:

Due to an increase in feedback regarding delays to maintenance requests, in October 2016, the home employed a maintenance officer. This allows the home to manage its own maintenance needs rather than relying on the co-located hospital’s maintenance services. Management and staff reported improved response to maintenance requests as a result of this appointment and care recipients expressed satisfaction with having a familiar person attending to their maintenance needs.

The home introduced an electronic menu ordering system in January 2017. The system has all menu items, ingredients and care recipients’ allergies and dietary requirements pre-loaded. Portable electronic devices are used to record care recipient’s menu choices each day and the system ensures these meal choices are appropriate for their dietary needs. Management reported this has reduced the risk of care recipients choosing meals which are not suitable and allows meal alternatives to be offered and discussed when ordering from the menu.

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”.



In relation to Standard 4, Physical environment and safe systems, the home has systems and processes to ensure compliance with fire safety, workplace health and safety, infection control and food safety legislation and guidelines. A food safety plan is in place at the home.





In relation to Standard 4, Physical environment and safe systems, the home provides a range of learning opportunities for all staff including mandatory education on fire safety, infection control, manual handling and chemical training and recent education on food handling. Staff are satisfied with the training and development opportunities available to them at the home and have the knowledge and skills appropriate for their roles.

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 comprises of five floors of a building which also houses another aged care residence, and is situated on the Kangaroo Point campus alongside a private hospital offering specialist clinical, palliative and radiology services. The living environment of the home and care recipient safety and comfort needs are assessed and reviewed through regular care recipient and staff meetings, audits, incident reports and hazard identification, risk assessments, maintenance requests and staff observation. Care recipients are accommodated in single rooms with private en-suite bathrooms or shared rooms with private bathroom. Care recipients are encouraged to personalise their rooms. The environment provides safe access to clean and well maintained internal and external communal recreation, lounge, and dining areas with appropriate furniture sufficient for care recipients’ needs. Handrails facilitate care recipient mobility. Maintenance requests are recorded and actioned in a timely manner by the on-site maintenance team who also implement a preventative maintenance program on buildings, infrastructure and equipment, with external contractors being utilised as required. Restraint is utilised for care recipients with an assessed need, and appropriate authorisation and monitoring is undertaken. The majority of care recipients/representatives are satisfied the home ensures a safe and comfortable environment according to the care recipients’ needs and preferences.

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


There are systems to support the provision of a safe working environment, including policies and procedures, staff training, routine and preventative maintenance and incident and hazard reporting mechanisms. Opportunities for improvement in the work health and safety program are identified through audits, inspections, supervision of staff practice, and analysis of incident and hazard data. Sufficient goods and equipment are available to support staff in their work and minimise health and safety risks. Staff receive training during orientation and on an ongoing basis about key elements of safety including manual handling, the use of equipment, chemical handling, infection control and incident and hazard reporting mechanisms. Staff practice is monitored to ensure safe work practices are followed and staff are provided with opportunities to have input to the home's work health and safety program. There are processes to manage the rehabilitation of injured staff to support their return to work. Staff are satisfied that management is actively working to provide a safe working environment.

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".



Fire, security and safety systems are maintained through policies, processes and practice protocols, programmed maintenance by qualified personnel and education processes. Monitoring processes include audits and visual inspections for the identification and reporting of risk, potential and actual hazards related to fire, security and other emergencies. The home has emergency response guidelines and diagrams available at key points in the home to support the management of adverse events such as a fire/smoke, bomb scare, intruder and loss of utilities. A care recipients’ evacuation list (updated on entry/exit), coupled with sign in/out registers and staff roster, assist with evacuation headcounts. Education processes include information provided at orientation and annually thereafter relating to emergency, disaster, fire safety and security procedures. There are procedures to ensure security (day and night) of care recipients, staff and site visitors – staff have access to police and emergency telephone numbers in the event of a security breach. Care recipients/representatives and staff are satisfied with the safety and security of the physical environment.

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


The home has an effective infection control program that includes staff training and access to personal protective equipment. Infection control protocols are available to staff and outbreak and spills kits are located centrally in the home. Processes exist to identify care recipients with infections, and monitor interventions and outcomes of treatments. The home has a food safety program which is externally audited to monitor compliance with food safety requirements and incorporates ongoing training and education for staff. Monthly infection statistics are reviewed to identify trends in infection rates and processes are to report outbreak information as required. There is a pest control program and procedures to manage hospitality support services such as catering, cleaning and laundry to minimise risks of cross infection. In addition, the home has programs to manage vaccinations, sharps, spills and waste. Staff and care recipients are encouraged to receive regular immunisations and processes exist to ensure appropriate reporting of notifiable infections.

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".


The majority of care recipients/representatives are satisfied with the catering, cleaning and laundry services provided. Care recipients’ dietary needs are assessed/identified including allergies, likes, dislikes and cultural preferences; care recipients’ specific requirements are documented to ensure their individual needs and preferences are met. The rotating menu is seasonal; issues relating to hospitality services are discussed at relevant meetings. The home has a cook fresh system with the capacity to cater for individual dietary needs and preferences. The cleaning program is conducted by an external contractor and includes duties lists and schedules to guide staff in the cleaning of care recipients’ rooms and the general environment. Manchester and personal clothing are laundered at a commercial laundry off-site – care recipients are encouraged to name personal clothing items to facilitate satisfaction with the laundry service. Regular stock-takes are conducted to ensure linen is


replaced as necessary. The effectiveness of hospitality services is monitored through feedback, meetings, audits and surveys.


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