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Uniting Care Hawkesbury Village

RACS ID 0222 23 Chapel Street

RICHMOND NSW 2753

Approved provider: The Uniting Church in Australia Property Trust (NSW)

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 31 December 2017.

We made our decision on 21 November 2014.

The audit was conducted on 21 October 2014 to 23 October 2014. The assessment team’s report is attached.

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

Home name: Uniting Care Hawkesbury Village RACS ID: 0222 2 Dates of audit: 21 October 2014 to 23 October 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Uniting Care Hawkesbury Village 0222


Introduction

This is the report of a re-accreditation audit from 21 October 2014 to 23 October 2014 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.

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 21 October 2014 to 23 October 2014.

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

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

Assessment team

Team leader: Rosemary Chaplin

Team members: Jennifer Denham

Maria Weekes

Approved provider details


Details of home

Name of home: Uniting Care Hawkesbury Village

RACS ID: 0222

Total number of allocated places:

134

Number of care recipients during audit:

131

Number of care recipients receiving high care during audit:

109

Special needs catered for: Dementia specific unit

Street/PO Box: 23 Chapel Street

City/Town: RICHMOND

State: NSW

Postcode: 2753

Phone number: 02 4588 2700

Facsimile: 02 4588 2750

E-mail address: [email protected]

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Service manager 1

Clinical care manager 1

Hostel clinical care coordinator 1

Registered nurses 5

Physiotherapist 1

Dietician 1

Occupational therapist 1

Palliative clinical nurse consultant 1

Dementia clinical nurse consultant 1

Property manager, West South region 1

Catering operations manager 1

Hotel services manager 1

Health Safety and Well Being Operations manager 1

Chaplain 1

Learning and Development Facilitator 1

Clinical Nurse Educator 1

Care recipients 13

Representatives 10

Volunteer Coordinator 1

Administration assistant 1

Catering staff 5

Laundry staff 2

Cleaning staff 4

Care staff 9

Project manager 1

Contract manager 1

Chef manager 1

Handyman/external cleaner 1


Category Number

Fire officer 1

Recreational activities officers 2

Pastoral care worker 1

Sampled documents

Category Number

Care recipients’ files including assessments, care plans, progress notes, allied and medical officers’ documentation, hospital transfer and specialists’ documentation

15

Advanced care directives 10

Individual toileting schedules, falls prevention and manual handling charts in care recipients’ rooms

10

Bowel charts 20

Wound monitoring logs 9

Medication profiles and charts on electronic medication management system and hard copy

20

Blood glucose monitoring charts 6

Personnel files 5

Blood pressure monitoring charts 10

Other documents reviewed

The team also reviewed:

Memories are made of this’ folder

Activity records, attendance sheets, evaluations, photographic records, care recipients’ social, cultural and spiritual assessments and birthday list

Asset register report

Audit schedule and audit results

Circulars and alerts folder

Cleaning schedule and cleaning manual

Code of conduct booklet

Communication diaries at nurses stations and in kitchens, handover sheets, medical officers communication folders, allied health communication folders and books and pharmacy communication folders

Compliments, comments and complaints register


Continuous improvement plan

Contract management folder and supply agreements

Dietician’s spreadsheet with care recipients dietary requirements and identified risks, enteral feeding charts, care recipients’ dietary preferences and nutritional needs assessments, dietary requirements lists, allergy/ dislikes lists, care recipients requiring nutritional support lists and allergy alerts in kitchens

Education and training needs analysis, education matrix 2013/2014, ‘Learning Campus’ - online learning platform, learning and development attendance forms and evaluations, mandatory training report on the in-service sessions conducted at Hawkesbury Village January – July 2014, self-directed learning package for care service employees – ‘Promoting an environment free of abuse and managing reportable assault in residential aged care’, service learning plan, training calendar, Uniting Care orientation program timetable, Western region learning and development calendar 2013

Email correspondence to the service manager regarding planned education 31 October for staff in anaphylaxis and the use of epipens and in-service notice

Emergency and disaster manual

Gastro outbreak folder September 2014

Hazard reports

Incidents and accident reports and data base

Infection control data

Job descriptions and duty statements

Maintenance data base records

Mandatory reporting file

Medication refrigerators’ temperature monitoring charts, schedule 8 drug registers,

Meeting minutes 2013-2014 (including meetings for resident and friends, general staff , recreation activity officers, registered nurses and medication advisory meetings)

Meeting schedule

Memorandums including memorandum regarding call bell response times 4 August 2014 and 16 September 2014 and transcribing medication orders on blood glucose charts 22 October 2014

Menu

Nurses registrations

Orientation training program

Performance appraisals


Police checks

Policies and procedures

Quality improvement projects folder

Regulatory Compliance Standards and Guidelines Alerts and Guidelines Summary table

Report on disaster table top exercise conducted at Hawkesbury Village May 2013

Resident admission pack, resident agreement and resident handbook

Resident newsletter

Resident shower list, bed and chair alarm list, sight charts, and monthly weights lists

Routine and preventative maintenance schedule

Staff handbook

Staff information package

Staff roster

Strategic Plan booklet 2014-2018

Temperature monitoring records for food refrigerators, freezers and meals

Vaccination folder for staff and residents

Various signed consent forms

Volunteer folder and handbook.

Observations

The team observed the following:

‘Café Latte’ – room for care recipients and representatives with computer, tea/coffee making facilities, lounge

Activities in progress

Activity resources available to care recipients and staff , welcome packs for care recipients, photographic records of activities, monthly activities calendar and church services notice displayed

Annual Fire Safety Statement

Archives for current resident’s secondary files and archive room

Care recipients individual catering requirements lists available in kitchen

Chapel


Charter of resident rights and responsibilities displayed

Chemical storage area

Clean and dirty linen areas

Cleaning store and equipment

Clinical instruction and resources available to staff

Colour coded equipment (mops, cloths, cutting boards)

Complaints mechanisms including information, forms and brochures on display, advocacy rights brochures, locked suggestion boxes

Computer stations for care staff

Contaminated waste bin

Epinephrine auto injector storage and signage in the nursing home treatment room

Equipment and supplies in use and in storage (including clinical, continence, manual handling, pressure and mobility equipment)

Evacuation box with resident information

Fire safety equipment and emergency evacuation signage

Hair dressing salon

Hand washing facilities

Hawkesbury Village dining forms

Interactions between staff and care recipients

Kiosk, staffed by volunteers

Laundry

Living environment - internal and external, including residents’ rooms, communal living, lounge areas and gardens (including herb and vegetable garden)

Main kitchen and serving kitchen

Material safety data sheets

Meals and snacks service to care recipients

Medication storage including locked cupboards, trolleys and medication refrigerators, emergency medication supplies and medication rounds in progress

Menu displayed in dining rooms

Noticeboards for staff, care recipients, family and friends and volunteers


NSW Food Authority licence

Personal protective equipment and colour coded equipment

Public phone

Report writing schedule folders at nurses stations

Snack and drink vending machine

Spills kit

Staff amenities

Story boards for care recipients

Suggestion boxes

Utility rooms

Vision, Purpose and Values displayed

Visitors. Contractors and Community Visitors sign-in book.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

The home actively pursues continuous improvement across all four Accreditation Standards through audits, meetings, forms to capture comments and complaints, education, hazard and accident/incident reporting. Management inform care recipients/representatives of changes made at the home. Care recipients/representatives are welcome to make suggestions and give feedback. Staff are familiar with the systems for managing continuous improvement and are encouraged to communicate their suggestions for improvement. Results of improvements are communicated through meetings or in information displayed on notice boards. Continuous improvements are evaluated from completing audits and analysing the results of data.

Examples of improvements in relation Accreditation Standard One include:

The batteries on the battery-powered medication trolleys were not keeping their charge, resulting in increased effort needed from staff to push the trolleys. Four new battery- powered medication trolleys were purchased. Staff feedback on the trolleys has been positive as the medication trolleys are easier to manoeuvre.

A staff satisfaction survey identified that the scheduling of in-service sessions in the afternoon was unsuitable for staff. The learning and development team conducted a trial of in-service sessions in the later morning. Staff attendance at in-service sessions increased as a result of the earlier scheduling. This earlier scheduling of education sessions has now been implemented permanently, where possible.

In response to increased care needs of care recipients in Blaxland Court, four additional care hours were rostered on every evening shift. As a result, care staff are able to give more attention to care recipients and facilitate a safer environment.

Uniting Care Ageing has implemented an electronic medication management system across the organisation. This has resulted in a quicker medication round and fewer medication errors. Staff feedback on the system has been positive.


1.2 Regulatory compliance

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

Team’s findings


The home has systems to identify relevant legislation, regulatory requirements, professional standards and guidelines. The home receives updates and information pertaining to regulatory compliance through a peak body and subscription to a legislative update program. The home also receives information through notices from government departments and agencies, attendance at external meetings and education sessions. Staff are informed of regulatory requirements, current legislation and guidelines. Mechanisms include policies and procedures, notice boards, training sessions and meetings.

An example relating to Accreditation Standard One includes that the home has conducted criminal record checks for all staff as per legislative requirements.

1.3 Education and staff development

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

Team’s findings


The home has a planned approach to education and development to ensure that staff have the appropriate knowledge and skills to perform their roles effectively. There is a comprehensive education program in place determined by training needs analyses, head office directives, staff and stakeholder feedback, changes in legislation, observation and best practice research. The internal education system includes online orientation training, mandatory training and self-directed learning modules. This is supported by in-service sessions as well as external opportunities for further education. The organisation supports staff to obtain or upgrade their formal qualifications. Competency assessments are carried out annually or more frequently if necessary. Records of attendance at education and training programs are maintained and reviewed to monitor attendance. Care recipients interviewed are of the view that staff have the skills and knowledge to perform their roles effectively.

Examples of education that has occurred relevant to Standard One, Management systems, staffing and organisational development, include:

Communication and customer service

Professional portfolio development

Documentation requirements during infection outbreaks.


1.4 Comments and complaints

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

Team’s findings


The home has a system that allows access to internal and external complaints mechanisms. Care recipients/representatives said they feel comfortable raising issues of concern with staff and management. They stated that when they raise concerns their issues are actioned in a timely manner. Complaints and comments are captured by a system that includes internal feedback, complaints and suggestion forms, resident and relative meetings, audits and verbal feedback. Information in the resident handbook outlines the system for expressing any comments and complaints and includes contact details of external complaints mechanisms. Brochures including those from external complaints bodies are displayed in public areas throughout the home.

1.5 Planning and leadership

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

Team’s findings


The home has documented the vision, purpose and values statements at an organisational level and has communicated these to care recipients, representatives and staff. The resident handbook contains the vision, purpose and values statements and they are displayed in the home. The vision, purpose and values statements are also part of the staff orientation process.

1.6 Human resource management

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

Team’s findings


The home has appropriately skilled, sufficient and qualified staff. There is a system to manage human resources that includes policies and procedures, staff appraisals, job descriptions, selection and recruitment processes, appropriate rostering and an education program. Staff said they generally have sufficient time to complete their duties. The home offers additional shifts to staff and has access to casual staff to cover staff absences when needed. The care recipients/representatives are very satisfied with the personal and clinical care provided to care recipients.


1.7 Inventory and equipment

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

Team’s findings


The home ensures that there are stocks of appropriate goods and equipment to provide a quality service through systems of monitoring stock supply, maintenance and a purchasing system. Care recipients/representatives and staff said they are satisfied with the provision of stock and the maintenance of equipment. A system using audits and regular stocktaking processes assists in monitoring stock supply. A routine and preventative maintenance program ensures that all equipment is regularly checked and serviced.

1.8 Information systems

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

Team’s findings


The home has systems to manage the creation, usage, storage of information and where required its destruction. There is a backup process for the computerised system and computers are password protected. There are mechanisms in place to record and disseminate information. These include meeting minutes, memorandums, handover and noticeboards. Policy and procedure manuals and job descriptions clearly outline correct work practices and responsibilities for staff. Management keep all staff and resident records locked to ensure security of access and maintain confidentiality of information. Care recipients/representatives receive information when they come to the home from meetings, family conferences and newsletters. All personal information is collected and stored securely and there are procedures for archiving and disposing of documents in accordance with privacy legislation. Staff and care recipients/representatives interviewed said they are kept well informed at the home.

1.9 External services

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

Team’s findings


Externally sourced services are provided at a standard that meets the home’s needs and goals. The home monitors the performance of external contractors to ensure that externally sourced services are provided to meet its needs and quality goals through a system of feedback from care recipients/representatives, staff and regular audits. Service agreements are entered into with contractors for the provision of services and all external service providers are required to have current licences, insurance and comply with relevant legislation and regulatory requirements. Staff told us that they are satisfied with the products and services from external suppliers.


Standard 2 – Health and personal care

Principle: 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.



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about the system used to actively pursue continuous improvement.

Examples of improvements in relation Accreditation Standard Two include:

Following an observation that care recipients were finding it difficult to get out of chairs, a weekly strength and balance class (‘Move it or lose it’) was introduced. Objective measures showed an improvement in strength. Care recipient attendance at the class has increased from 10 to 20, with care recipients reporting they enjoy the class.

In response to weight loss by some care recipients and the ineffective use of nutritional supplements, a weight and nutritional supplement management program was instigated. This program included a schedule of care recipients to be weighed daily and weekly, a review of care recipients requiring nutritional supplements, and staff training. More than half of care recipients identified as being at risk of poor nutrition either maintained or gained weight. Additionally, two new care recipients were identified as being at risk of poor nutrition.

To improve pain and symptom management, three new syringe pump drivers were purchased. This has resulted in improved care to care recipients receiving palliative care, reduced hospitalisations for complex pain management and increased quality of life for care recipients.

In response to an observation that wounds were healing slowly, a wound management program was undertaken. This program included a review of all wounds, design of a wound swab protocol, instigation of a weekly wound regime (including a more even distribution of staff workload), as well as the research and implementation of new wound care products. This program has resulted in an increased wound healing rate, with staff being happier with the revised workload.

Following an increase in the number of care recipients identified at high risk of falls, six bed and chair alarms were purchased. This equipment allows improved monitoring of care recipients at risk of falling.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about the health and personal care systems.

Staff practices observed demonstrated that staff are performing their duties in accordance with the home’s policies and procedures. All registered nurses have current registration. Medication administration is managed in accordance with legislative guidelines and the home’s policies and procedures.



Team’s findings

The home meets this expected outcome.

The home has systems to ensure the staff have the appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. Management uses those systems to identify and implement a range of educational measures relevant to Standard Two, Health and personal care.

Examples of education and training attended by staff in relation to Standard Two include:

Pain management

Palliative care

Simple wound care

Diabetes management

2.4 Clinical care

This expected outcome requires that “care recipients receive appropriate clinical care”.

Team’s findings


The home has systems to ensure care recipients receive appropriate clinical care. A comprehensive program of assessment is undertaken when a care recipient moves into the home and a care plan is developed using a computerised care management program. Care recipients and/or their representatives are consulted in the assessment and care planning process including through case conferences. Documentation review confirms allied health


professionals and medical officers are involved in the planning and delivery of care recipients’ clinical care. Appropriately skilled staff develop and review care plans on a regular basis and when care recipients’ identified needs and preferences change. Medical officers review care recipients regularly and as requested. Care recipients are referred to specialist medical and allied health services as required. The organisation’s dementia and palliative care clinical nurse consultants are available if required to provide support to care recipients. A range of care based audits, clinical indicators and care recipient surveys are used to monitor the quality of care. Care staff are provided with current care recipient clinical care information through handovers, communication diaries, care plans and progress notes. Staff report they have appropriate equipment, resources, education and supervision to ensure care recipients receive appropriate clinical care. Staff interview demonstrates they are knowledgeable about the care requirements and preferences of individual care recipients.

Care recipients/representatives are satisfied with the clinical care the care recipients receive.

2.5 Specialised nursing care needs

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

Team’s findings


The home has systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. Specialised nursing care needs such as catheter management and complex pain management are assessed and documented on care plans when care recipients move into the home. Changes are documented in the progress notes, clinical charts, specialist forms and charts and in the care plans. Care plans are regularly reviewed and evaluated in consultation with care recipients and/or their representatives. Registered nurses attend care recipients’ specialised care in the hostel and the nursing home sections of the home. Observation and interview confirms equipment is supplied as necessary to meet identified needs. External nursing specialist services are accessed as required including wound care and palliative nurse specialists.

Staff informed us they have appropriate training, resources, equipment and support to provide specialised nursing care for care recipients. Care recipients/representatives are satisfied with the specialised nursing care provided for care recipients.

2.6 Other health and related services

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

Team’s findings


The home has systems to assist staff to identify, assess and refer care recipients to appropriate health specialists in accordance with the care recipient’s needs and preferences. Review of documentation including care recipients’ files demonstrates care recipients are referred to medical specialists and other allied health professionals such as the dietician, speech pathologist, podiatrist, behaviour management specialists, physiotherapist and audiology and optometry services as required. External providers of specialist services visit care recipients in the home or care recipients are assisted to attend appointments outside the


home. Care recipients/representatives informed us they are satisfied with the referral process and are consulted regarding referral to health specialists.

2.7 Medication management

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

Team’s findings


The home has systems to ensure care recipients medication is managed safely and correctly. Medication needs and preferences are assessed on entry to the home and as care recipients’ needs and preferences change. Registered nurses and competency tested certificate III and certificate IV care staff administer medication which is prescribed by medical officers and dispensed by a pharmacist using a blister package system. Care recipients’ medications are regularly reviewed by medical officers and the pharmacist. The home has a medication advisory committee which meets to communicate such issues as legislative requirements and current best practice. Review of the electronic medication charts confirms care recipients’ identifying information is documented clearly including photographs, name, date of birth and allergies. Observation and staff interview demonstrates medication is stored safely in locked areas and dispensed in accordance with the home’s policy. Review of documentation confirmed that medication incidents are recorded and addressed appropriately. Care recipients who wish to manage their own medications are able to if assessed as safe to do so. Care recipients informed us they are satisfied with their medication management.

2.8 Pain management

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

Team’s findings


The home has systems to ensure all care recipients are as free as possible from pain. A range of pain assessment including assessments used for care recipients living with dementia is undertaken by nursing staff and the physiotherapist to identify care recipients’ pain. Care plans are developed for each care recipient including individualised interventions. Interventions used to assist care recipients to manage their pain include application of heat packs, gentle exercise, medication and massage therapy. The pain management program includes massage by the occupational therapist to relieve and to minimise care recipients’ pain. Pain management measures are evaluated for effectiveness and care recipients are referred to their medical officers or pain management specialists if required. Care recipients/representatives informed us they are satisfied with the way care recipients’ pain is managed.


2.9 Palliative care

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

Team’s findings


Care recipients who are terminally ill are regularly assessed in consultation with their representatives and medical officer to ensure their comfort and dignity is maintained. On entry to the home care recipients are offered an opportunity to provide information regarding end of life wishes and advanced care directives. Interviews demonstrate staff are aware of maintaining the respect and dignity of care recipients who are terminally ill, and of supporting their families. The organisation’s palliative care clinical nurse consultant assists with care planning and staff education. The home liaises with the local palliative care team if extra support is needed for care recipients receiving palliative care. Music and aromatherapy are utilised in conjunction with medical and nursing interventions to maintain comfort. Care recipients’ emotional and spiritual needs and preferences are included in the care planning for terminally ill care recipients. We observed supplies of equipment used for palliative care including specialised pressure relieving equipment, electric beds and ceiling hoists.

2.10 Nutrition and hydration

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

Team’s findings


The home has systems to ensure care recipients receive adequate nourishment and hydration including initial and ongoing assessments of care recipients’ needs and preferences. Care plans are developed and reviewed regularly and as required. The dietician identifies care recipients at risk of weight loss and malnutrition by monitoring monthly weight records. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements such as any modified textured meals via a dietary needs folder, beverage and diet lists and the care recipients care plan. Care recipients have input into menu planning through resident meetings, the food forum, comments and complaints mechanisms and informal discussions with staff. Observation confirms the menu is displayed for care recipients in the dining areas of the home. Care recipients/representatives informed us they are satisfied with the catering services provided.

2.11 Skin care

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

Team’s findings


The home has systems to ensure that each care recipient’s skin integrity is consistent with their general health. Care recipients’ skin integrity is assessed when they move into the home through the initial assessment process. Ongoing assessment occurs regularly and as care


recipients’ needs and preferences change. Care staff confirm they monitor care recipients’ skin integrity as part of daily care and report any changes to the registered nurse for review and referral as appropriate. Complex wound management is carried out by registered nurses. Wounds are assessed regularly using comprehensive wound assessments and logs. Skin tears and infections are recorded and data is analysed by management. A podiatrist and hairdresser attend the home on a regular basis. A range of skin protective devices are available, if needed, including pressure relieving mattresses, hip protectors, skin emollients and protective bandaging. These are available to all care recipients and are consistent with individual care plans and identified care recipient needs. Care recipients/representatives informed us they are satisfied with the way staff provide skin care and the range of equipment available to them.

2.12 Continence management

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

Team’s findings


The home has systems to ensure care recipients’ continence is managed effectively. Clinical documentation review and interviews with staff confirms continence management strategies are developed for each care recipient, if required, following initial and ongoing assessment. Staff informed us they assist care recipients with their toileting regime, monitor skin integrity and receive training and supervision in the management of continence and the use of continence aids if necessary. The home has sufficient stock of continence aids in appropriate sizes to meet care recipient needs. Care recipients/representatives informed us they are satisfied with the management of continence. Staff were observed being considerate of care recipients’ privacy and dignity at all times.

2.13 Behavioural management

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

Team’s findings


The home has systems to effectively manage care recipients with challenging behaviours. In consultation with care recipients and their representatives assessment and monitoring is undertaken on entry to the home and on an ongoing basis as care recipients’ needs and preferences change. Challenging behaviours, triggers that lead to challenging behaviours and successful interventions are identified and documented on care recipients’ care plans.

Care plans are regularly reviewed and evaluated for effectiveness. Care recipients are referred to their medical officer and behaviour management specialists including the organisation’s dementia clinical nurse consultant for clinical review and assessment when necessary. Staff receive ongoing training and we observed their interactions with care recipients who exhibit challenging behaviours to be consistent with interventions documented in the care recipients’ care plans. Care recipients/representatives are satisfied with the management of care recipients with challenging behaviours and informed us they are not disturbed by these care recipients.


2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


The home has systems to ensure that optimum levels of mobility and dexterity are achieved for all care recipients. Care recipients’ mobility and dexterity needs and preferences are assessed on entry to the home an on a regular basis or as needs change. The physiotherapist develops individual exercise, falls prevention and mobility programs for care recipients with identified needs. Documentation review and interviews with staff confirm all care recipients are assessed on moving into the home for mobility, dexterity and transfers, falls’ risk and pain management. The physiotherapy and exercise programs are implemented by the physiotherapist, physiotherapy assistant and activity staff. Programs are regularly reviewed and evaluated by the physiotherapist and registered nurses. Staff are trained in falls prevention, manual handling and the use of specialist mobility and transfer equipment. Assistive devices such as mobile frames, mechanical lifters and wheelchairs are available if required. All falls’ incidents are documented and the data is analysed. Any care recipient who falls is referred to the physiotherapist for review and any follow up required. Care recipients/representatives informed us they are satisfied with the management of care recipients’ mobility and dexterity needs.

2.15 Oral and dental care

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

Team’s findings


The home has systems to ensure care recipients’ oral and dental health is maintained. A review of documentation shows that care recipients’ oral and dental health is assessed when they move to the home and individual care plans are regularly reviewed and evaluated to meet changing needs. Diet and fluids are provided in line with the care recipient’s oral and dental health needs and preferences and specialist advice for care recipients with swallowing problems is sought if needed. Dental appointments and transport are arranged in accordance with care recipients’ needs and preferences, if required. Staff have received education in oral and dental care. Care recipients/representatives informed us staff provide assistance with care recipients’ oral and dental care as required or as requested.

2.16 Sensory loss

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

Team’s findings


Initial assessment of care recipients’ sensory loss is identified when they move into the home. Management strategies are implemented, regularly reviewed and evaluated in consultation with the care recipient and referral to specialist services is arranged as needed. External optometry and hearing services are accessed as needed. The team observed the environment


to have good lighting, including natural light, and that rooms and corridors are spacious and uncluttered to promote care recipient safety. Staff informed us they use a variety of strategies to manage sensory loss, including appropriate equipment and support to promote independence. Care recipients/representatives informed us staff are attentive to their individual needs, including the care of glasses, hearing devices and if needed assistance to move around the home.

2.17 Sleep

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

Team’s findings


Care recipients’ sleep patterns including day time rest and known strategies to assist sleep are assessed when they move into the home and their care plans are regularly reviewed and evaluated by appropriately qualified staff. Care recipients’ preferences for rising and retiring are respected and accommodated by staff. A review of documentation and discussions with staff show care recipients are offered comforts such as soft music, heat packs, aromatherapy, snacks, warm milk, and any other support to assist them achieve natural sleep patterns. Disturbances in sleep patterns are monitored and referred to the medical officer as needed. Lighting and noise levels are subdued at night. Care recipients informed us they are satisfied with the management of their sleep and the night time environment.


Standard 3 – Care recipient lifestyle

Principle: 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.



Team’s findings



Examples of improvements in relation Accreditation Standard Three include:

Following refurbishment of a thoroughfare, the area has been turned into a coffee lounge. A coffee vending machine (dispensing free coffee) was purchased, and seating was provided. The area is now used as an additional meeting space by care recipients.

It was observed that care recipients were not able to attend the chapel service held in the morning and were resting in their rooms when the afternoon service was held. The morning service was scheduled to a later time in the morning and the afternoon service was cancelled. There has been an increase in the number of care recipients attending the morning service, with care recipients reporting that they prefer the later time.

As a way of getting to better know the care recipients in Blaxland Court, a project (‘Memories are made of this’) was undertaken to create folders of their lives. Individual folders were compiled on each care recipient, outlining their background, family members and work history. It is used by care staff to reminisce with care recipients. Representatives appreciate the project.

A doll’s house was donated to the facility. A weekly activity was designed, enabling care recipients to reminisce about their childhood. This activity is popular with the care recipients.

The pianola in the Richmond Room was not working. It was repaired and new pianola rolls were purchased. Care recipients enjoy the entertainment provided by the pianola.



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

Team’s findings


Refer to Expected Outcome 1.2 Regulatory compliance for information about the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about resident lifestyle.

An example of regulatory compliance relating to Accreditation Standard Three is that mandatory reporting is part of compulsory education undertaken regularly by all staff.



Team’s findings


The home has systems to ensure that staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. Management uses those systems to identify and implement a range of educational measures relevant to Accreditation Standard 3, Resident lifestyle.

Examples of education and development attended by staff in relation to Accreditation Standard Three include:

Grief and loss

Privacy and confidentiality

Person centred care

Sexuality in aged care.


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".

Team’s findings


The home has systems to ensure each care recipient is supported adjusting to life when they enter the home and on an ongoing basis. Pastoral, activity and care staff spend one to one time with care recipients during their settling in period and thereafter according to the care recipient’s needs. The entry process includes gathering information from care recipients and their representatives to identify care recipients existing care and lifestyle preferences.

Feedback regarding care recipients’ levels of satisfaction with the provision of emotional support is gained through meetings, audits and care recipient surveys. Care recipients/representatives expressed satisfaction with the level of emotional support and assistance staff provide to them on entry to the home and on an ongoing basis.

3.5 Independence

This 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".

Team’s findings


Care recipients are encouraged to entertain at the home and visitors and relatives are made to feel welcome when they visit. Staff facilitate care recipient participation in the local community, for example, through the arrangement of regular bus trips. Many community groups visit the home including entertainers, special interest groups and school children.

Care recipients have access to the internet including application software which enables contact with friends and family who are not able to visit often. Regular exercise and mobility programs assist care recipients to maintain their mobility levels and independence. Care recipients are able to decide whether they wish to remain on the electoral roll and assistance is provided to them with voting if they wish to do so. Observations and interviews confirm staff promote care recipients’ independence when assisting with their activities of daily living. Planned activities and concerts involve care recipients from all areas of the home and include residents from the co-located independent living units. Care recipients/representatives stated they are satisfied with the opportunities available to them to participate in the life of the community within and outside the home.


3.6 Privacy and dignity

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

Team’s findings


The home has systems to ensure each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Care recipients care plans and progress notes provide evidence of consultation regarding their preferences for the manner in which care is provided. Care recipient’s individual preferences are documented and known by staff. Care recipient records are securely stored and each member of staff has a unique log in password to access the computerised care management program. Observations confirm staff address care recipients in a respectful manner by their preferred names. Staff were observed to knock on care recipient room doors before entering. Care recipients/ representatives informed us they are satisfied with the way in which their privacy and dignity needs are met.

3.7 Leisure interests and activities

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

Team’s findings


The home has systems to ensure care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them. Lifestyle, leisure and social history assessments are undertaken on entry into the home. Care plans are developed and evaluated regularly. Recreational activity officers in consultation with care recipients and their representatives plan monthly activity calendars for each area of the home which include a variety of events and activities. One on one activities are included to cater for those who prefer not to attend group activities. The recreational activity officers document care recipient participation. Care recipients are consulted through care recipient meetings and surveys regarding the activity program. This information is evaluated to make improvements to the program on an individual and group basis. Care recipients informed us they enjoyed the activities and particularly enjoyed the sing-alongs, bus trips, bingo and reminiscing groups.


3.8 Cultural and spiritual life

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

Team’s findings


Care recipients are assessed on entry to the home for their individual customs, beliefs and cultural and ethnic backgrounds. The chaplain and pastoral care staff provide support to care recipients as required. Uniting Church and Catholic services are provided regularly for care recipients to attend if they wish to do so. Specific cultural days such as ANZAC day, Australia day, Christmas and Easter are commemorated with appropriate festivities. Each care recipient’s birthday is celebrated. Interviews confirm the pastoral, activity staff and care staff have knowledge of and respect for the care recipients’ individual backgrounds and beliefs.

Care recipients/representatives informed us they are satisfied with the cultural and spiritual life offered at the home.

3.9 Choice and decision-making

This 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".

Team’s findings


The home has systems to ensure care recipients participate in decisions about the services they receive and are able to exercise choice and control. Mechanisms providing this include case conferences, discussions with staff, meetings and surveys and through the comments and complaints processes. Care recipients informed us they are involved in decisions about their care routines and their participation in the activity program. Care recipients’ choice of medical officer and allied health services is respected. Care recipients have personalised their rooms with memorabilia and items of their choosing, including small pieces of furniture. Care recipients/representatives informed us they are happy with the level of choice and decision making offered.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Care recipients have secure tenure within the home. The admission officer assists care recipients/representatives to understand their rights and responsibilities including security of room tenure. Relevant information about security of tenure and care recipients’ rights and responsibilities is provided in the care recipients’ agreement and the handbook. This is discussed with prospective care recipients/representatives prior to and on entering the home. The Charter of Residents’ Rights and Responsibilities is displayed at the home and is included


in the care recipients’ handbook. Care recipients/representatives told us they are kept informed about matters of importance to them and they feel secure regarding residency within the home.


Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Team’s findings



Examples of improvements in relation Accreditation Standard Four include:

A hostel room is used to temporarily accommodate care recipients whilst their room is being refurbished. This room had a bathroom that was considered to be unsafe for care recipients. The bathroom was refurbished, resulting in increased safety for care recipients.

The floor surface in a thoroughfare was cold, noisy and unsafe for care recipients. It was recovered with a ribbed matting, resulting in a safer, more pleasant environment which is now being used as an additional meeting space. Care recipients have responded positively to the new floor covering.

Following care recipient feedback that some meals delivered to their rooms were not hot enough, three new catering transport trolleys were purchased. Care recipients appreciate the hotter meals.

As menu boards in the dining rooms were difficult to read and were visually unappealing, two new menu boards were purchased. The new boards are larger, more attractive and easier to read. Care recipients appreciate the new boards.


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

Team’s findings


Refer to Expected Outcome 1.2 Regulatory compliance for information about the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about the physical environment and safe systems.

Staff could describe their responsibilities in relation to safe work practices, in relation to infection control, food safety, fire and emergencies, work, health and safety and the importance of reporting accidents and incidents.




Team’s findings


The home has systems to ensure that staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. Management uses those systems to identify and implement a range of educational measures relevant to Standard 4, Physical environment and safe systems.

Examples of education and development attended by staff in relation to Accreditation Standard Four include:

Infection control

Food safety

Manual handling

WH&S

4.4 Living environment

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

Team’s findings


The home provides a living environment that is safe, comfortable and consistent with care recipients’ care needs. All care recipients are accommodated in a single room with en-suite. There are lounge and private areas inside the home and outdoor areas for care recipients and their families to enjoy. Care recipients are encouraged to personalise their rooms as much as possible. Maintenance of the environment occurs by the use of a preventative and routine maintenance program. The home conducts regular environmental audits and accident and incident data is analysed to monitor the safety of care recipients. Care recipients/representatives are pleased with the living environment.

4.5 Occupational health and safety

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

Team’s findings


Management is actively working to provide a safe working environment that meets regulatory requirements. Interviews with management and staff indicated that the home has systems to help ensure the provision of a safe working environment for staff, visitors and care recipients.


The home has systems to help promote work place safety and awareness that includes education during staff orientation and on an ongoing basis. Other mechanisms include manual handling training, discussion of work, health and safety issues at meetings, environmental audits, hazard reporting and incident and accident reports. Issues identified by staff through the work, health and safety system are followed up and actioned appropriately and in a timely manner.

4.6 Fire, security and other emergencies

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

Team’s findings


The home has systems to minimise fire, security and emergency risks. These include regular checks of equipment by staff and contractors and emergency and fire evacuation procedures. The home is equipped with fire warning and firefighting equipment, extinguishers and fire blankets, all of which are regularly checked and maintained. Staff confirmed they attend compulsory education for fire training and that management monitor their attendance. The home has an emergency plan to guide staff in the actions to implement if an evacuation is required. The home has appropriate security measures such as lockup procedures and keypad entry in some areas of the home to ensure care recipient safety.

4.7 Infection control

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

Team’s findings


The home has an effective infection control program with a system for identifying, managing and minimising infections. The program includes staff education, audits, discussion of infection issues at meetings and evaluation of resident infection data. Staff monitor temperatures in fridges and freezers, use and understand colour coded equipment and wear protective clothing when required. Adequate hand washing facilities are available throughout the home. There are formal cleaning schedules and processes for the removal of waste to maintain hygiene levels. Staff interviewed demonstrated an understanding of, and commitment to, infection control principles and guidelines. The home has equipment for handling an outbreak of infection. Staff described the strategies to prevent infections at the home.

4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Processes are in place at the home to ensure that hospitality services enhance the care recipients’ quality of life and the staff’s working environment. These processes include a food monitoring system, staff education, infection control guidelines and an audit schedule. Other mechanisms include a system for communicating resident food preferences and allergies,


temperature monitoring and the provision and maintenance of equipment related to hospitality services. A contractor is used to provide the catering services and meals are cooked fresh in the kitchen each day. All laundry is done on site. There is a system for the processing of clean and dirty laundry. Cleaning staff provide cleaning services and use colour coded equipment. Care recipients/representatives stated that they are pleased with the cleaning, catering and laundry service.

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