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Wesley Heights Nursing Home

RACS ID 2655 47 Birkley Road

MANLY NSW 2095

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 19 October 2018.

We made our decision on 25 August 2015.

The audit was conducted on 14 July 2015 to 17 July 2015. The assessment team’s report is attached.

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

Home name: Wesley Heights Nursing Home RACS ID: 2655 2 Dates of audit: 14 July 2015 to 17 July 2015

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

Wesley Heights Nursing Home 2655


Introduction

This is the report of a re-accreditation audit from 14 July 2015 to 17 July 2015 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 14 July 2015 to 17 July 2015.

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

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

Assessment team

Team leader: Christine Logan

Team member: Helen Hill

Approved provider details


Details of home

Name of home: Wesley Heights Nursing Home

RACS ID: 2655

Total number of allocated places:

60

Number of care recipients during audit:

54

Number of care recipients receiving high care during audit:

54

Special needs catered for: N/A

Street/PO Box: 47 Birkley Road

City/Town: MANLY

State: NSW

Postcode: 2095

Phone number: 02 9977 7366

Facsimile: 02 9977 1787

E-mail address: Nil

http://www.comlaw.gov.au/Details/F2011L00821


Audit trail

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

Interviews

Category Number

Residential operations manager 1

Service manager 1

Deputy director of nursing 1

Human resource manager 1

Continuous quality improvement co-ordinator 1

Admissions officer 1

Manager learning and development operations 1

Clinical nurse educator 1

Learning and Development Facilitator 1

Hospitality services manager 1

Chaplain 1

Clinical pharmacist 1

Physiotherapy contractor 1

Physiotherapists 2

Care recipients/representatives 12

Registered nurses 3

Care staff 7

Contracts and procurement coordinator 1

Leisure and lifestyle coordinator 1

Recreational activity officers 2

Manager maintenance 1

Maintenance supervisor 1

Laundry client service manager 1

Laundry area supervisor 1

Catering operations manager 1

Laundry staff 1

Cleaning staff 2

Catering staff 2


Sampled documents

Category Number

Care recipients’ files 8

Agreements 6

Medication charts 8

Personnel files 6

Other documents reviewed

The team also reviewed:

Approved supplier list, contractor agreements and contracts, contractor insurance records and police checks

Care recipient enquiry, admission and welcome pack.

Catering documentation (menu, dietitian reviews, dietary analysis sheets and food preferences, food safety manual)

Cleaning schedules, checklists, contract cleaning folder, cleaning schedule

Clinical Indicator documentation and compulsory reporting register

Clinical care documentation including assessments, care plans, progress and medical officers notes, continence and catheter management; behaviour, wound and pain management; nutrition and hydration preferences, requirements and weight monitoring; diabetic management including blood glucose level parameters; observation charts and case conference records

Comments and complaints; have your say forms, advocacy brochures

Consolidated register for reportable assaults and missing care recipients

Continuous improvement documentation; continuous improvement plan, summary of achievements, quality indicators, audit schedule, audits and surveys. Contracts and agreements, pest control records, service provider reports

Education system documentation (education calendar, mandatory education register, attendance records, orientation programs, online education program, toolbox talks)

Food services; NSW food authority certificate, meal feedback card, menu, food safety program, meal satisfaction survey, nutrition, hydration forms

Home’s self-assessment report for re-accreditation

Human resource management: police check register, professional staff registrations, rosters, position descriptions and duty lists

Incident data electronic records


Infection data and trending information, waste management, infection control audit, infection control report

Information system documentation: meeting agendas, minutes and schedules, policy and procedures folder, memos, newsletters, staff handbook, care recipient’s handbook, electronic communication systems, care recipients’ lists

Medication management documentation including; controlled drug register, pharmaceutical review’s, electronic medication management tablet with medication profile’s, medication charts and administration records

Preventative and reactive maintenance documentation

Quality system documentation: compliments and complaints matrix, audits, audit schedule, continuous improvement plans and summary of improvements

Work health and safety documentation

Observations

The team observed the following:

Activities calendar displayed and activities in progress

Re-accreditation notices displayed

Archive room

Australian Aged Care Quality Agency re-accreditation audit notice displayed

Charter of care recipients’ rights and responsibilities

Chemical store

Cleaning operations

Complaint information posters and brochures (internal and external), suggestion boxes

Daily menu displayed

Dining rooms at meal times (the serving and transport of meals, staff assisting care recipients with meals and beverages).

Equipment and supplies storage areas and equipment in use

Fire safety equipment, fire board, emergency flip charts, evacuation plans, annual fire statement and emergency evacuation pack

Infection control equipment: infection outbreak kit, signage, hand wash stations, hand sanitiser dispensers, colour coded cleaning and catering equipment, spill kits, sharps containers and personal protective equipment

Interactions between staff, care recipients and visitors

Internal and external complaints forms on display, confidential box for lodgement


Laundry

Living environment and grounds

Meal preparation and storage areas

Medication management including storage, controlled drug cupboard, medication trolleys, medication blister packs, medication refrigerators and medication round

Mobility aids and care recipients being assisted with mobility

NSW Food Authority licence

Palliative care kit

Care recipient and staff noticeboards

Secure storage of care recipient information

Short small group observation

Staff practices and interactions with care recipients, visitors and other staff

Vision, purpose and values statement displayed

Visitors register and security measures


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

Wesley Heights Manly actively pursues continuous improvement as demonstrated by examples provided of improvements across the four Accreditation Standards. Information for improvement relating to Accreditation Standards One, Two, Three and Four is gathered through various activities including audits and meetings and discussed at the quality committee. An audit report is developed if any issues require action and these matters are recorded on the home’s quality plan. Feedback on continuous improvement activities is provided through the home’s meetings, verbally and on notice boards. Staff and care recipients and their representatives stated management are responsive to their comments and suggestions for improvement and were able to identify recent improvements at the home. Staff discuss possible improvements amongst themselves or at staff meetings and feel comfortable to raise improvements directly with the service manager if needed.

Examples of improvements and results of continuous improvement specifically relating to Accreditation Standard One include:

In a survey completed at a staff forum it was decided to implement a staff monthly award system to recognise outstanding service. Staff nominate other staff who have provided extra-ordinary service or activities for care recipients. This is an opportunity to recognise the quiet achiever. On a quarterly basis at their monthly meetings, registered nurses nominate the care staff, care staff nominate registered nurses and Work Health and Safety committee members nominate at their meetings. Since the introduction, feedback indicates that this has had a positive outcome giving a sense of pride in staff member’s work performance and recognition of a ‘job well done’.

During the Uniting Care’s training program review, it was decided to introduce a safety leadership program. This resulted in the service manager and the deputy manager attending a three day training program for managing safety and safe behaviours in the workplace. This has ensured managers have key skills for providing a safe environment for care recipients and staff and the management team report they feel adequately skilled in this area.

The manager had received informal feedback from representatives that information is not always readily available to them. It was decided that an entail data base be set up for those who have internet availability. Representatives are now asked as part of the entry


process for email addresses. Multiple family members now receive the newsletters electronically and have access to other important information. Representatives are also responding with a thank you to management for providing this. Staff are also receiving minutes to meeting via email and expressed that they find this very useful.

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 a system to identify changes to legislation and regulations. These are provided corporately through the organisation and through information updates from industry bodies and government departments. The home’s policies and procedures are reviewed and updated if required. Changes are communicated to staff via the meetings, memos noticeboards. Information is disseminated to care recipients as required.

Examples of regulatory compliance relating to Standard One include:

Criminal history checks for staff, volunteers and contractors are monitored.

Information is provided to care recipients and their representatives and staff about internal and external complaints mechanisms.

Notices advising care recipients and their representatives and staff of the re- accreditation audit were displayed prominently throughout the home.


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 organisation has systems to ensure that management and staff have appropriate knowledge and skills to perform their roles effectively. Staff have an orientation program on commencement of employment and ongoing education in a range of subjects. Mandatory education is given to staff and monitored to ensure all staff have attended. Education needs are identified through an annual education needs analysis, staff appraisals, audits, competency skills assessments, observation and feedback. Throughout the year education sessions are added to the education calendar as needs and opportunities arise and are identified. Education is provided via face to face teaching, internet educational programs, toolbox talk and external providers. An online learning campus is also available which offers online opportunities for staff to learn at their own pace. At the conclusion of each session, staff are encouraged to complete evaluation forms. All sessions have records of staff attendance and staff confirmed they have education to ensure they perform their jobs effectively. Care recipients and their representatives expressed satisfaction with the knowledge and skills of staff.

Examples of education for staff and management in relation to Accreditation Standard One include:

Leadership skills

Organisational change

Making the most of complaints

Aged Care Funding Instrument

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 organisation has systems to ensure all care recipients, their representatives, and other interested parties have access to internal and external complaints’ mechanisms. The care recipients and relatives’ handbook and agreements provide details of complaints and comments mechanisms, and detailed posters and brochures are on display. Care recipients are reminded of the complaints mechanisms at meetings and ‘have your say’ forms are accessible throughout the facility with suggestion boxes. Care recipients regularly use emails directly to the service manager to raise any concerns. Management have an open door policy to encourage care recipients and representatives to raise issues. Management maintain a record of issues raised through the continuous improvement process and feedback is offered individually. Management and staff monitor trends in complaints and discuss outcomes at


relevant meetings. Care recipients and their representatives said they feel comfortable in making suggestions or complaints and are satisfied with the responses made.

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 vision, purpose, and values statements that are documented and displayed throughout the home and in handbooks to all stakeholders. The commitment to quality is reflected in these statements. The commitment to quality is documented in policy and procedure documents pertaining to quality management.

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 a system to ensure there are sufficient appropriately skilled staff to ensure that services are delivered in accordance with standards and the residential care service’s vision, purpose and values. The manager advised care recipients changing care needs as well as staff feedback on workloads are used as key indicators in identifying the staffing level needs in the home. The manager advised that they have the flexibility to increase staffing levels to meet any changes in a care recipient’s behaviour or care which might require closer supervision or assistance. A casual pool of staff provide coverage for all leave and staff advised that all absences were replaced. The organisation ensures all relevant checks such as police checks are undertaken before the new staff member commences duty. New staff members are partnered with experienced staff as part of the orientation process. Care recipients and their representatives expressed their satisfaction with the care provided and spoke very highly of the caring nature of the staff.

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 has systems in place to ensure appropriate stocks of goods and equipment are available at all times. Observations, interviews and review of documentation demonstrated appropriate stocks of goods and equipment, food, furniture and linen are achieved. Stock rotation processes, budgeting, purchasing through preferred suppliers ensures this ongoing program is effective. Staff and care recipients and their representatives confirmed there is


sufficient and suitable equipment for their use. All maintenance requirements are carried out in an appropriate time frame by maintenance staff at the home.

1.8 Information systems

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

Team’s findings


Information is disseminated to staff through a variety of avenues including information displayed on notice boards, email, discussions at the regular staff meetings and education sessions. Information is relayed to care recipients and their representatives through information on various noticeboards, care recipient meetings and email. Documentation is archived on-site, stored securely and destroyed according to the policies and procedures of the organisation. This system enables files to be retrieved as needed. Information retained on the computer system is routinely backed-up on an external server. Access to data retained on the home’s computers is password protected.

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


All externally sourced services are provided in a way which meets the home’s needs and quality goals. Documents reviewed showed the organisation has a system to identify preferred suppliers of goods, equipment and services and to review major or regular suppliers’ performance. Contracts and/or service agreements are in place with suppliers of services such as pharmacy services, food services and physiotherapy services. Systems which ensure maintenance requests are completed and contractor requirements are monitored by the regional maintenance manager, maintenance supervisor and onsite maintenance staff.


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 details of the home’s system for continuous improvement.

Examples of improvements and results of continuous improvement specifically relating to Accreditation Standard Two include:

As a result of the Government initiative to improve palliative care management and avoid the need to transfer to hospital, the home introduced a new process with a pathway that allows staff to have a holistic approach to all aspects of terminal care. The home encouraged advanced care planning and consultation so the care recipient can pre- determine the level of intervention they want and avoid the need to transfer to hospital. This enables care recipients to be cared for in an environment that they are familiar with and in a way they wish to be cared for. Management have received many acknowledgements of thanks and personal satisfaction with the way this has been managed.

The service manager identified that it would be beneficial for care recipients to have easy access to snack foods and introduced the availability of fruit and snacks twenty-four hours per day. This would also assist in managing weight loss and minimising behaviours. Fruit bowls and biscuit jars have been placed around the home for snacks and food items available for night meals as required. Monitoring of care recipients weights has indicated that night time snacks have had a positive improvement. Care recipients confirm that they are happy with the availability of fruit.

An audit of medication management identified that medication administration is restricted to specific times. Care recipients were not always happy to take their medication at that time. All care recipients’ medication requirements were audited and care recipients asked if that was their time of preference and with more flexibility around the time. This was then adjusted to suit and there has been better compliance with care recipients taking of medication since the introduction.



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 for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Two include:

The home can access to the Australian Health Practitioner Regulatory Agency (AHPRA) website to verify current registrations for allied health practitioners if required.

There is a system to manage unexplained absences of care recipients in accordance with regulatory requirements.

2.3 Education and staff development


Team’s findings


Refer to expected outcome 1.3 Education and staff development, for information on how the home ensures management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of recent education and training relevant to Accreditation Standard Two include:

Decision assist

Oral health

Medication management

Dementia care essentials

Palliative care


2.4 Clinical care

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

Team’s findings


Care recipients and their representatives gave examples of individualised clinical care appropriate to their needs and all were very satisfied with the care received at the home. There are systems in place to ensure each care recipient receives appropriate clinical care. Assessments of care recipients’ individual needs are carried out by a multi-disciplinary team when they move into the home. Care plans are developed in partnership with the care recipient and their representatives. They include information from the assessments and appropriate interventions with strategies for meeting the individual needs of the care recipient. Care plans are reviewed, updated and evaluated three monthly or when a change in the care recipient’s condition is identified. Registered nurses review care plans and oversee all care provision. Consultation with care recipients and their representatives includes case conferences which are conducted after moving into the home then annually. The care recipient’s medical officer of choice and other relevant health care specialists are regularly consulted to ensure ongoing needs are met.

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


Wesley Heights Nursing Home has a system to ensure that care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. When a care recipient is identified as requiring specialised nursing care, registered nurses oversee all aspects of assessment, care planning, provision and review. Links have been established to specialists and specialist advisers within the extended health care team who provide support, equipment and training when required. Observations revealed there is sufficient equipment and supplies to provide specialised nursing care. Documentation, staff, care recipients and their representatives confirmed that care recipients’ specialised nursing care needs are met.

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


A system is in place to ensure care recipients are referred to appropriate health specialists in accordance with their needs and preferences. The need for referral is identified by the registered nurses in consultation with the medical practitioner and/or care recipients and their representatives. Podiatrists, optometrist, dietitian and speech pathologist visit care recipients in the home as required. A ‘Communication Club’ aimed at enhancing care recipients’ communication skills is coordinated by a speech pathologist. Contracted physiotherapists assess new care recipients, develop care plans and provide therapy as required. Care


recipients and their representatives, staff and clinical documentation confirmed the home has an efficient and effective system for referral of care recipients to appropriate health specialists. Staff advised and care recipients confirmed that the home arranges referrals and transportation to appointments as necessary.

2.7 Medication management

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

Team’s findings


The home has an efficient and effective system which ensures care recipients’ medication is managed safely and correctly. Care recipients and their representatives reported they are satisfactorily assisted with their medication requirements. The system includes assessing care recipients’ medication needs on entry, consultation with care recipients and/or their representatives, liaising with the medical officer to arrange for medications to be ordered and regularly reviewed, and liaising with the pharmacist for the supply of medications. Medication is administered by medication trained care staff from individual single dose blister packs. A clinical pharmacist regularly reviews care recipients’ medication and a medication advisory committee meets bi-annually. The team observed all medications to be safely stored.

Policies and procedures and a system for reporting medication incidents are in place and medication audits are conducted. Care staff are assessed annually for competency in the administration of medications. This was confirmed by care staff and documentation.

2.8 Pain management

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

Team’s findings


There is an effective system to assess and manage care recipients’ pain. Staff and clinical documentation confirm that a pain management assessment and history of pain is carried out on all care recipients on moving into the home and as necessary, a pain management plan is implemented, documented and regularly reviewed. Further assessments are undertaken as required when the level of pain changes or strategies are no longer effective. The registered nurses oversee the assessment and management of care recipients’ pain and provide regular massage treatment. Both pharmaceutical and non-pharmaceutical pain relief is considered when planning pain management. Care recipients are referred to pain management specialists and clinics as necessary. A syringe driver is available to manage complex pain when required. Care recipients and their representatives confirm they are maintained as free from pain as possible and appreciate the massages from the registered nurses.


2.9 Palliative care

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

Team’s findings


Wesley Heights Nursing Home has a system in place to provide and maintain the comfort and dignity of terminally ill care recipients. Identification of palliative care wishes are recorded on entry to the home or reviewed at case conferences. Decisions regarding the management of the terminally ill are made in consultation with the care recipient, their family and medical officer. End of life care is provided by appropriately trained staff and the home has access to the community palliative care service for clinical support as needed. After completing training in the Program of Experience in the Palliative Approach the deputy director of nursing introduced a palliative care kit and oversees the care of terminally ill care recipients in consultation with the chaplain. Relatives are kept informed of the care recipient’s condition and family are welcome to stay on site in a guest suite or with the care recipient. Family members of a care recipient receiving palliative care praised the staff and chaplain for their care and support.

2.10 Nutrition and hydration

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

Team’s findings


There are systems to ensure care recipients receive adequate levels of nourishment and hydration. Care recipients’ nutritional and hydration needs, preferences and allergies are recorded and passed to the kitchen. Care recipients’ weight is monitored regularly.

Monitoring is increased and the care recipient is referred to a dietitian if there are nutritional concerns. Special diets and varied consistency of meals, including thickened fluids, are available as required. Nutritional drinks are provided as a dietary supplement to assist in reversing weight loss. Care recipients’ swallowing ability is assessed by a speech pathologist if there are concerns. Staff supervise and assist care recipients with their meals as necessary and adapted crockery and cutlery is also available. Care recipients, staff and review of documentation confirmed care recipients’ nutrition and hydration needs are assessed, documented and regularly reviewed and acted upon.

2.11 Skin care

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

Team’s findings


Wesley Heights Nursing Home has a system to ensure care recipients’ skin integrity is consistent with their general health. Staff and clinical documentation confirm care recipients have a skin assessment completed after moving into the home. Care recipients identified at


risk have skin integrity care plans with management strategies outlined. Care recipients’ skin integrity is monitored by staff who report any abrasions, rashes or abnormality to the registered nurses. A range of equipment and practices is utilised to assist in the maintenance of care recipients’ skin integrity such as special mattresses and pressure relieving devices, pressure area care, repositioning, protective bandaging and equipment and moisturising creams. A wound management chart documents the dressings required, frequency of treatment, evaluation and progress of healing is commenced for care recipients who have skin tears or wounds. The management of complex wounds is undertaken by the registered nurses. Care recipients and their representatives are satisfied with care provided to maintain skin integrity.

2.12 Continence management

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

Team’s findings


The home has a comprehensive system to ensure care recipients’ continence is managed effectively. Clinical documentation showed that the system includes an individual continence assessment when the care recipient moves into the home and the development of a care plan and where needed a toileting program which is regularly reviewed and evaluated.

Toileting regimes are maintained for as long as possible. A disposable continence aid system is used for care recipients with intractable incontinence and staff confirm there are always adequate supplies of continence aids of varying sizes available for care recipients. Staff advised that the supplier of continence aids are available for consultation and advice. Care recipients are assisted to maintain their bowel function in a number of ways, such as through high fibre diet, fresh fruit, exercise and medications, bowel movements are monitored to ensure these interventions are effective. Care recipients and representatives expressed satisfaction with the way care recipients’ continence is managed.

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 ensure the needs of care recipients with challenging behaviours are managed effectively. Clinical documentation confirmed behaviours of concern are identified then assessed. Challenging behaviours are monitored and management strategies with appropriate programs are implemented and regularly reviewed. We observed that strategies detailed in care plans for specific care recipients are effective. The home has access to specialised services including geriatricians and the dementia behaviour management advisory service (DBMAS). Observations and talks with staff, care recipients and their representatives indicate care recipients’ behavioural issues are treated with patience and understanding in an effective and efficient manner.


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


There is an effective system in place to ensure optimum levels of mobility and dexterity are achieved for all care recipients. Staff and documentation reviewed revealed all new care recipients are assessed by the physiotherapist for mobility, dexterity and manual handling requirements when moving into the home and when necessary. A falls risk assessment is also completed. Where indicated, the physiotherapist develops individualised programs which are provided by the care staff and physiotherapy aides and are regularly reviewed. There is a range of mobility aids and equipment to assist care recipients to move independently and staff to assist in moving care recipients safely. Care recipients and their representatives stated they are satisfied with the assistance they receive to maintain or improve their mobility and dexterity.

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 strategies in place to ensure care recipients’ oral and dental health is maintained. Review of clinical documentation showed care recipients’ oral hygiene is assessed, documented, regularly reviewed and acted upon. Staff are trained to supply ongoing oral and dental hygiene by observation, mouth care, either prompting or assisting care recipients to clean teeth and/or dentures. Care recipients are referred to specialist dental services or technicians as required and an onsite dental service is also provided. Staff demonstrated knowledge on oral care and care of dentures. Care recipients and their representatives confirmed that where necessary care recipients’ dentures are checked daily and/or care recipients are assisted to brush their teeth.

2.16 Sensory loss

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

Team’s findings


The home has a system in place to identify and effectively manage care recipients’ sensory losses. Assessments of care recipients’ sensory needs are undertaken when moving into the home and when there is a change in the care recipient’s condition. Staff and clinical documentation confirm care recipients are assessed for the identification of their sensory loss and needs. Care recipients who are identified as having sensory deficits, for example, require glasses or hearing devices, have management strategies documented in their care plans and are assisted to access services or equipment that will support them. Clinical documentation reviewed also showed that referrals are made to specialist services as required. Care


recipients and their representatives reported staff assist them where necessary with the care and maintenance of their glasses and hearing devices.

2.17 Sleep

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

Team’s findings


There are strategies in place to assist care recipients to achieve natural sleep patterns. The home identifies the care recipient’s usual and preferred sleeping patterns on admission and uses this information to assist in supporting the care recipient to develop a regular sleep pattern. Strategies implemented include management of environmental disturbances, continence and pain management programs. The introduction of 24 hour food boxes has assisted night staff to settle care recipients and promote natural sleep patterns. Care recipients and their representatives advised staff strive to maintain an environment that is conducive for them to achieve uninterrupted sleep.


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 and results of continuous improvement specifically relating to Accreditation Standard Three include:

It was identified that care recipients sometimes get lost trying to locate their rooms. It was suggested to introduce a room identifier to assist with this. Each care recipient was asked to nominate a picture or symbol which reflected them or their likes. This has resulted in care recipient having ownership of their room and their personalised symbol. It has helped with care recipients who may wander around the home and improves the ability of the care recipient to identify their room. Staff also note that there has been a lot of care recipient feedback that they like to talk about the picture and what it means to them.

A representative’s group identified that they do not know what is on the activities program for their care recipient. As the monthly newsletter was now being emailed out the activity program has been added as an attachment. Care recipients and representatives have expressed their thanks.

A review of care recipients’ documentation identified that new care recipients are not always receiving the care recipient handbook at entry to the home. A welcome pack was developed which includes basic toiletries, and a handbook. Verbal feedback has been received thanking the management and staff.



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



Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Three include:

The Charter of Care Recipients’ Rights and Responsibilities is on display in the home, and included in the care recipient and relatives handbook which is given to care recipients on entry to the home. The care recipient and relatives handbook given in conjunction with the care recipient agreement also provides information in keeping with current legislation.

The organisation has a system to report and record alleged and suspected assaults. Staff and management are aware of their obligations in regard to reporting assaults.



Team’s findings



Examples of recent examples of education and training relevant to Accreditation Standard Three include:

Care recipients rights

Reportable assault

Privacy policy

Consent and capacity


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


Care recipients and their representatives told us they were extremely satisfied with the way they were welcomed to life in the home and are assisted on a regular basis. A number gave examples of the emotional support given by the chaplain, registered nurses and care staff. Staff and documentation demonstrate the home has a system to ensure care recipients receive support in adjusting to life in the home and on an ongoing basis. A welcome pack has been created and is given to all new care recipients. Care recipient files confirmed their emotional needs are documented and monitored and staff provide support to care recipients who require it. Any special needs a care recipient may have are ascertained through the initial assessment and ongoing process. Observations of staff interactions with care recipients showed warmth, respect, empathy and understanding.

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


The home has an environment that encourages care recipients to maintain independence and friendships and participate in the life of the community within and outside the home. Care recipients’ independence is also fostered through having personal items and photographs in their rooms, provision of mobility aids and utensils to assist with eating and drinking, a varied activity program and the ability and assistance provided to vote in government elections. Care recipient files showed they are actively encouraged to maintain independence in areas such as decision-making, personal hygiene and attendance at activities. Care recipients and their representatives told us they are encouraged by the home to maintain their independence and friendships.

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 a comprehensive system that ensures each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Observation of staff practices and their interactions with care recipients demonstrate staff treat care recipients respectfully and with dignity. The home has a system to gain consent from care recipients or their representative in relation to privacy, for example to display or publish photographs. We observed care recipients electronic and paper files to be stored securely and no information of a private nature was on


display in areas where unauthorised persons could access. Care recipients and their representatives confirm staff treat them in a dignified manner and with respect.

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


There are systems in place that demonstrate care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them. On entry to the home, care recipients and their representatives are consulted in relation to their past and current leisure interests and activities which assist in the development of their social history and care plan. Recreational activity staff develop a monthly program of group and individual activities which are evaluated regularly. The program is modified in response to attendance and ongoing care recipient feedback via mechanisms including surveys and care recipient meetings. Celebratory themes are held throughout the year and include Melbourne Cup, ANZAC day, Mother’s Day, Father’s Day, Christmas and Easter. The visits by pet therapists are very popular. The activities program is provided to care recipients and their representatives and displayed around the home. Care recipients are satisfied participation is encouraged and supported and the activities offered by the home are of interest to them.

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’ cultural and spiritual needs are valued and fostered at Wesley Heights Nursing Home. The home has systems to recognise care recipients’ individual interests, customs, religions and ethnic backgrounds. Provision is made for the celebration of special cultural and religious days, for example; Christmas, Easter, Mother’s day, Father’s day, Anzac Day, Remembrance Day and Australia Day. Religious services are conducted regularly and all denominations are welcome. The chaplain recently conducted a memorial service using Buddhist traditions. Staff have attended the lesbian, gay, bisexual, transgender and intersex (LGBTI) diversity in aged care workshop. Various ministers of religion visit the home to meet the individual needs of care recipients. Care recipients and their representatives stated they are satisfied with the care the home provides to support their cultural and spiritual lives. They commented on the support given to them by the chaplain, some acknowledging they did not have Christian beliefs but enjoyed the conversations.


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


There are systems to ensure each care recipient and their representative are able to exercise choice and control over care recipients’ lifestyles. Examples of this are; care recipients being given the choice of their own medical practitioner, being able to participate in decisions about care and services provided through consultation processes, having diet preferences documented and communicated to the catering staff and what activities they participate in. Care recipients’ meetings are held where care recipients and their representatives are encouraged to express views about care and service provision. All care recipients are provided with a handbook that details their rights and responsibilities. The home provides opportunities and support for care recipients wishing to vote at government elections. Care recipients and their representatives confirm they are provided with choice and are able to make decisions about their lifestyle.

3.10 Resident security of tenure and responsibilities

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

Team’s findings


The home has processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Relevant information about security of tenure, fees and care recipients’ rights is discussed with care recipients and/or their representative prior to, when possible, and on entering the home. All care recipients are offered an accommodation agreement and guide which outlines the legislated government financial requirements and the complaints resolution processes. Room moves only occur with prior consultation and consent from the care recipients and/or their representative. The Charter of care recipients’ rights and responsibilities is on display in the home and included in the resident agreement. The home has an ‘open-door’ policy and ongoing communication with care recipients and their representatives is encouraged through scheduled meetings, individual meetings and notices. Care recipients and their representatives expressed satisfaction with their security of tenure at the home and an awareness of their rights and responsibilities.


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 and results of continuous improvement specifically relating to Accreditation Standard Four include:

A very lengthy blackout of the area in April 2015 identified the need to have a contingency plan for when blackouts exceed two hours. A blackout plan was developed. This will ensure the safety and wellbeing of care recipients and staff. Staff have resources to and a plan of how to manage these situations. Staff feedback indicates that they feel safer knowing this is available to them.

To improve safety with chemical usage it was determined that the safety data sheets for each chemical used at the home should be more accessible. Access to chemical alerts and safety data sheets are now available electronically on the shared drive and in hard copy also at each work station. Management confirms this has provided a safe environment.

To ensure the food service was at the appropriate standard, the contract catering decided as part of their quality improvement, to provide a feedback form in the dining room for care recipient to access. They would also provide a tasting plate for management and admin to provide feedback for each meal on food quality and presentation. This will ensure that the quality and presentation is constantly reviewed and will provide immediate feedback mechanism if it is not up to standard.



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



Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Four include:

The home meets compliance with fire safety regulations has a current annual fire safety statement, and a fire sprinkler system installed, in accordance with legislative requirements.

The home achieved a pass rate from the recent New South Wales Food Authority audit.



Team’s findings



Examples of recent education and training relevant to Accreditation Standard Four include:

Infection control

Fire and evacuation training

Food safety

Manual handling


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


Management and staff actively work to provide a safe and comfortable environment consistent with the care recipients’ care needs. Care recipients are accommodated on two levels in a combination of one, two or four-bedded rooms and shared and en-suite bathrooms facilities. Care recipients’ personal space allows for some personal belongings and mementos. There is a communal dining area and lounge room on each level. There is a system of corrective and preventative maintenance. We observed the home is clean, a comfortable temperature, and with maintained equipment and furniture. Environmental audits are used to monitor safety and comfort in the home. Care recipients and their representatives expressed satisfaction with the safety and comfort of the living environment including their rooms and communal area.

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 are actively working to provide a safe working environment. Staff are aware of issues which may affect their area of work in relation to work health and safety and what they should do if they identify an issue or hazard. Work health and safety is monitored by an active committee which has members from different work areas of the home. Methods used to maintain a safe work environment include; a variety of environmental and safety audits which are undertaken monthly, observation, discussion at meetings, informal discussion with staff and other stakeholders and incident and accident reports. All results are discussed at the health and safety committee meeting, quality improvement meetings and any other meetings relevant to the issue identified. Personal protective equipment, lifting and transferring equipment and tagging of electrical equipment were observed to be present in the home.

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. As part of the home’s safety system there are external contractual arrangements for the routine maintenance of the fire-fighting equipment and internal fire alarm system. A random check of various fire-fighting equipment around the site, confirmed they are inspected on a regular basis. Staff advised fire safety is included as part of the orientation sessions for new staff members as well as part of the routine annual education program. Staff members were able to provide a consistent


response on the procedures to be followed in the event of a fire. Key information on a range of other emergency situations such as bomb threat and natural disaster is available.

Evacuation plans in the event of the need to evacuate care recipients is located in the disaster management plan which is readily accessible to all staff members.

4.7 Infection control

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

Team’s findings


The organisation provides policies, procedures and training for management to guide them in implementing and monitoring effective infection control at the home. Vaccination to prevent influenza is offered annually to care recipients and staff. Care recipients are monitored for signs and symptoms of infection and timely follow-up action is taken to diagnose and treat infections in liaison with medical officers. Infection data is collated and discussed at the quality and staff committee meetings to assist with identifying trends and the need for improvement. Equipment and supplies are available to staff to minimise cross infection and they are provided with ongoing training on infection control and related topics. Cleaning programs are implemented for general cleaning. Sanitisation through the laundering process is achieved. A food safety program is implemented on an ongoing basis. Staff are knowledgeable about infection control principles and practices.

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


The home has a system in place to ensure hospitality services are provided in a way which enhances care recipients’ quality of life and the staff’s working environment. Management of the food services is contracted out to an external provider. Food is cooked fresh on site following a four-week rotational menu with a seasonal change. A menu has been developed and care recipients have had the opportunity to provide feedback regarding their likes and dislikes. When the seasonal change is approaching care recipients and representatives have the opportunity to have input into the review. There are options for each meal which care recipients can choose from and they also have the opportunity to say they do not want what is on the menu for a specific day and their meal is adjusted to suit at the time. Care recipients/representative feedback is via surveys and meetings. Care recipient’s likes, dislikes and allergies are recorded in the kitchen. Temperature checking is carried at each point of the meal preparation including delivery, storage, dishwasher, cooking and serving. Care recipients and their representatives say they satisfied with the food provided. Cleaning services are provided by an external provider. The living environment was observed and cleaning programs were in place. The cleaning staff interviewed demonstrated a working knowledge of the home’s cleaning schedules, practices and safe chemical use. The cleaning roster requires all rooms to be cleaned according to a set schedule. The home provides an onsite laundry service for personal clothes and all other linen is externally laundered. Care recipients and their representatives stated they are satisfied with the laundry service.