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West Coast District Hospital - Lyell House

RACS ID 8046 60-64 Orr Street

QUEENSTOWN TAS 7467

Approved provider: Tasmanian Health Organisation - North West

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 15 November 2018.

We made our decision on 30 September 2015.

The audit was conducted on 25 August 2015 to 26 August 2015. The assessment team’s report is attached.

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

Home name: West Coast District Hospital - Lyell House RACS ID: 8046 2 Dates of audit: 25 August 2015 to 26 August 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 care recipients, 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:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care 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 Care recipient security of tenure and responsibilities

Met

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.





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

West Coast District Hospital - Lyell House 8046


Introduction

This is the report of a re-accreditation audit from 25 August 2015 to 26 August 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 25 August 2015 to 26 August 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: Adrian Clementz

Team member: Margaret Giffard

Approved provider details


Details of home

Name of home: West Coast District Hospital - Lyell House

RACS ID: 8046

Total number of allocated places:

16

Number of care recipients during audit:

14

Number of care recipients receiving high care during audit:

Not applicable

Special needs catered for: Not applicable

Street: 60-64 Orr Street

City: Queenstown

State: Tasmania

Postcode: 7467

Phone number: 03 6472 2300

Facsimile: 03 6471 1457

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Management, quality and administrative staff 6

Clinical, care and lifestyle staff 6

Care recipients and representatives 8

Catering, cleaning, laundry and maintenance staff 8

Sampled documents

Category Number

Care recipients’ clinical files 5

Care recipients lifestyle files 4

Medication charts 6

Other documents reviewed

The team also reviewed:

Audit schedule, audits and reports

Care recipient residential agreement and handbook

Cleaning instructions, duty lists and temperature logs

Clinical incident data and analysis

Comments and complaints process documentation

Communication books

Education calendar, attendances and evaluations

Emergency management plan and procedures

Essential services equipment service records

External contractor documentation

Feedback forms and care recipient satisfaction surveys

Food safety plan, external third party audit and local council certification

Handover documentation


Lifestyle calendar and related records

Material safety data sheets

Medication register, nursing staff signature specimen sheet

Meetings schedule and minutes

Menu, dietary details forms, changes to diet forms, catering folder

Newsletters

Occupational health and safety documentation

Outbreak guidelines

Performance appraisals

Plan for continuous improvement

Policies and procedures

Preventative maintenance schedules, testing records and monitoring processes

Quality improvement register

Reactive maintenance records

Regulatory compliance monitoring tools and related documentation

Care recipient of the day checklist

Risk assessments and charting

Rosters

Self-assessment

Specialised nursing care management plans

Staff handbook and orientation information

Statements of duties

Statutory declaration records

Volunteer pack.

Observations

The team observed the following:

Activity resources and activities in progress

Administration and storage of medications


Charter of care recipients’ rights and responsibilities

Chemical storage

Clinical, general supplies and linen storage

Emergency egress routes and assembly areas

Emergency evacuation pack

Equipment and supply storage areas

External complaints mechanisms and advocacy information

Fire and emergency equipment

Interactions between staff and care recipients

Internal and external living environment

Internal feedback processes and lodgement boxes

Laundry and cleaning in progress

Mission, vision and values displayed

Noticeboards and information displays

Notification to stakeholders of re-accreditation audit

Occupational health and safety information

Outbreak equipment

Safety and security mechanisms

Secure archiving area

Short group observation in lounge/dining area

Test and tagging processes

Videoconferencing equipment and training room

Washing machine and dryer for personal use by care recipients

Whiteboard in kitchen listing care recipients’ dietary preferences.


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

There is a system at the home to pursue continuous improvement across the Accreditation Standards. The system draws on a quality framework that includes scheduled audits, surveys and analysis of key quality indicators. Management identify other opportunities for continuous improvement activities through feedback mechanisms and meeting structures. The home’s processes encourage input from staff, care recipients, representatives and visitors. Improvements are monitored through the quality improvement register and the plan for continuous improvement. There are processes to prioritise and track the progress of new initiatives and to evaluate the outcome of improvements generated through the system.

Management discuss improvement initiatives with staff, care recipients and representatives through the weekly newsletter and meetings.

Examples of recent improvements undertaken or in progress that relate to Standard 1 Management systems, staffing and organisational development include the following:

Management initiated a review of clinical documentation. This resulted in the introduction of a suite of new assessments and an expanded care plan. Policies and procedures referenced by staff were reviewed and aligned to the new clinical documentation and made more specific to the home. Management and staff said the new documentation is simpler and more relevant to contemporary practice.

Management identified clinical data on the handover sheet was inconsistent with the information maintained on the reference white board in the nurses’ station. During the review of the process used to populate these reference tools, a decision was made to limit the amount of information contained on the handover sheet to key care recipient clinical indicators. At the same time, additional categories were identified to broaden the quality of information held on the white board, thereby installing it as the primary reference point. Management and staff said both tools are now relevant and accurate.


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


There is an effective system at the home to identify, respond to and meet relevant legislation, regulatory requirements, professional standards and guidelines across the Accreditation Standards. Management interpret information received from sources that include peak bodies, legislative update services, industry newsletters and government departments.

Policies and procedures are developed or amended in response to information received. Staff are advised of regulatory compliance matters and policy updates through meetings, the weekly newsletter and education. Staff demonstrate knowledge of regulatory requirements relevant to their role. There are formal processes to monitor the home’s compliance with relevant legislation and regulatory requirements.

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

Management notified stakeholders of the re-accreditation audit as required and within regulated timeframes.

Management has a system to undertake self-assessment.

Management maintain processes to ensure the currency of police certificates for staff, volunteers and contractors.

There is an effective process to manage relevant statutory declarations.

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


Management and staff have appropriate knowledge and skills to perform their roles effectively. Identification of the appropriate knowledge and skills required commences with the recruitment process and staff appointed participate in an orientation program and annual mandatory education relevant to their role. The home implements additional education across the Accreditation Standards, identified through training needs analysis, changing needs of care recipients, regulatory compliance changes, professional development agreements, verbal and written feedback, meetings, audits, incidents and observation of practice. Staff receive education with internal and external facilitators, through videoconferencing, taped sessions and online learning. Management document attendance, review training evaluations and monitor the effectiveness of education through observation, feedback and audits. Staff said they are provided with appropriate and sufficient education at orientation and on a regular


basis to support them in their roles. Care recipients and representatives are satisfied staff have appropriate knowledge and skills.

Recent education relating to Standard 1 Management systems, staffing and organisational development includes:

auditing

clinical portfolios

goals of care planning

legal and ethical issues

scope of practice.

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


There are formal and informal comments and complaints processes accessible to each care recipient, their representatives and other interested parties. Information handbooks, posters and brochures convey information about complaint handling processes and external complaints resolution services. Care recipients and representatives are encouraged to raise comments or concerns via the feedback form or verbally with staff or management in the home. Comments and concerns are also captured through surveys and care recipient meetings. Locked lodgement boxes located within the home promotes confidentiality. Staff are made aware of complaint handling procedures and feel comfortable to advocate for care recipients. Care recipients and representatives are satisfied with the response of management to concerns raised.

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 mission, vision and values and reinforces its commitment to quality through a range of communication and documentation processes. Information is available in care recipient and staff information handbooks and is displayed throughout the home.


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


Management ensure there are appropriately skilled and qualified staffs sufficient to meet the needs of those living in the home and the philosophy of care. Registered and enrolled nurses are rostered on each shift across the week. Resources to enable staff to perform their roles include mentoring, statements of duties, policies and procedures and the weekly newsletter. Audits, feedback from stakeholders, management observations, staff appraisals, analysis of incidents and competency assessments assist management in monitoring staff skills and practices. There are processes to replace staff for planned and unplanned leave. Staff are satisfied they have sufficient time to provide care and services in a timely manner. Care recipients and representatives said staff are attentive and attend promptly to the needs of 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


Management has an effective system to ensure stocks of appropriate goods and equipment are available for quality service delivery. Approved suppliers deliver consumables in accordance with a regular order cycle and there are processes to maintain adequate stock holding levels. Management identifies equipment needs through audits, feedback, meetings and the input of visiting professional services. Management ensure staff are provided with education in the safe and effective use of equipment. The home has a structured preventative maintenance program and there is a system for reporting breakdown of equipment. Storage areas are sufficient, organised and secure. Staff, care recipients and representatives are satisfied with the amount and quality of equipment and inventory supplies at the home.

1.8 Information systems

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

Team’s findings


Effective information management systems are in place. Management communicates with care recipients and their representatives through care recipients’ agreements, meetings, comments and complaints system, newsletters, quality forms, care consultations, electronic mail, letters, telephone calls and noticeboards. Staff are informed through statements of duties, meetings, handovers, communication books, electronic mail, newsletters, the health service’s intranet, policies, procedures and memoranda. Confidential information is stored and archived securely, placed in confidential waste bins or shredded. Information technology


support regularly back up electronic information. Management monitor the effectiveness of information systems through audits, surveys, verbal and written feedback and meetings.

Care recipients and staff are satisfied they have access to information appropriate to their needs.

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


There is a system to ensure external providers deliver services in a way that meets the home’s needs and quality goals. The parent health service maintains service agreements with a wide range of external service providers. Management has processes to ensure external service providers meet their contracted obligations as scheduled. There are processes to monitor and review the quality of services provided by contractors. Care recipients and staff are satisfied with the services provided by external contractors.


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


There is a system that demonstrates improvements in health and personal care. For a description of the system refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvements undertaken or in progress that relate to Standard 2 Health and personal care include the following:

In response to a medication incident where an external pain medicating patch was not changed per schedule, management reviewed the home’s processes for administering external medications. A new process was introduced whereby all care recipients requiring these types of medication are now re-administered at the same time each week. Management said the process is user friendly for staff and no further medication incidents of a similar nature have since occurred.

Analysis of clinical data identified that care recipients in general were gaining weight, and a significant weight gain in respect to one care recipient was posing challenges. In consultation with care recipients and the dietitian, management conducted a review of the home’s menu which identified areas of unnecessary excess. This resulted in the scaling back of the full three-course meal served in the evening following on from the three- course meal served at lunch. Fruit was introduced as an alternative to cake or scones during tea times, which management said has resulted in improved bowel habits. Strategies were introduced to discreetly cut down meal sizes of specific care recipients. Management said the changes have moderated the weight gain of care recipients. All care recipients interviewed during the visit provided very positive feedback about the quality and quantity of meals provided by the home.



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


There is a system to identify and meet regulatory compliance obligations in relation to health and personal care. For a description of the system refer to expected outcome 1.2 Regulatory compliance.

Examples of responsiveness to regulatory compliance relating to Standard 2 Health and personal care include:

Appropriately qualified staff manage clinical care and carry out specialised nursing care.

Management monitor the professional registrations of staff.

There are policies and procedures for the safe management and administration of medications.

There are processes to manage and report the unexplained absence of a care recipient.



Team’s findings


Management ensure staff have the knowledge and skills to effectively perform their roles in relation to care recipients’ health and personal care. For details regarding the system, refer to expected outcome 1.3 Education and staff development.

Education and training scheduled and attended in relation to Standard 2 Care recipient health and personal care include:

falls prevention

medication

pain management

palliative care

Parkinson’s disease

swallowing difficulties

wound management.


2.4 Clinical care

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

Team’s findings


There is a system to ensure care recipients receive appropriate clinical care. Care recipients are assessed when moving into the home and interim care plans are developed to guide initial care. Staff complete comprehensive care plans which are reviewed regularly and when care recipients’ needs change. Handover, communication books and boards, charting, progress notes and care plans inform staff of care recipients’ needs. Appropriately qualified staff provide and oversee care to care recipients and management and staff ensure correct management of clinical incidents. Medical practitioners, other health professionals and representatives are notified of changes in care recipients’ conditions. Staff ensure current information accompanies the care recipient in the event of hospitalisation and discharge information is then communicated to staff. Staff said they have enough time to attend to care recipients. Care recipients and representatives are satisfied with the clinical care provided.

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


Management has a system to ensure appropriately qualified nursing staff identify and meet care recipients’ specialised nursing care needs. Care recipients who require specialised care have documented instructions, reportable ranges and treatment strategies in specific management plans. Staff use a referral process to ensure care recipients have access to health professionals if required. Management facilitate the education for staff in relevant complex care to ensure currency of knowledge. Monitoring of specialised nursing care occurs through regular reviews, audits and feedback from care recipients and representatives. Staff have sufficient time and resources available to provide specialised care. Care recipients and representatives are satisfied with the specialised care provided.

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


There is a system to ensure care recipients are referred to appropriate health specialists in accordance with care recipients’ needs and preferences. Physiotherapists assess care recipients when they move into the home, and then regularly and as required. Services care recipients have access to include medical practitioners and specialists, speech pathologist, dietitian, podiatrist, wound management, palliative care, vision, hearing, behaviour management and dental services. Any treatments or interventions recommended by any service are incorporated into the care recipients’ care plans and these changes are communicated to staff. Monitoring of effectiveness of other health and related services is


through reviews, audits and feedback. Care recipients and representatives are satisfied referrals to other health and related services occur according to care recipients’ needs and wishes.

2.7 Medication management

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

Team’s findings


There is a system to ensure the safe and correct management of care recipients’ medication. The health service has medication policies and procedures and these are available to staff. Medication is stored securely as per legislative requirements. There is a process for monitoring opened creams and drops and staff refrigerate medication as required.

Management has a system to ensure there are supplies of regular medication as well as those required after hours. Staff follow a process to ensure care recipients who choose to self-medicate can do so safely. A pharmacist reviews care recipients’ medications and forwards the report to the general practitioner and nursing staff for consideration.

Management monitor medication administration through audits, incident analysis, completion of staff medication competencies and feedback from care recipients and representatives.

Care recipients and representatives are satisfied with medication management provided.

2.8 Pain management

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

Team’s findings


Management ensure all care recipients are as free as possible from pain. Staff complete pain charts and assessments to identify individual pain experiences and strategies used to assist with pain relief. Care plans include information on interventions offered such as encouragement to mobilise, massage, heat packs, positional changes and diversional therapy. Staff review care recipients’ pain management regularly and if new pain is reported. Staff consult with the medical practitioner and the physiotherapist if further review is required. The effectiveness of pain treatments is monitored through care plan reviews, care consultations, re-assessments, audits and feedback. Care recipients and representatives are satisfied pain is managed effectively.


2.9 Palliative care

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

Team’s findings


Management and staff ensure the comfort and dignity of terminally ill care recipients is maintained. Staff provide opportunities for care recipients and their representatives to discuss and complete advanced care plans and terminal care wishes. Consultation with the medical practitioner and an external palliative care service also occurs for recommendations and advice. Staff develop and review care plans as care recipients’ health care needs alter. Staff use appropriate equipment and resources for minimising pain and increasing comfort and are further supported in providing optimal palliative care through monthly videoconferencing sessions with an external palliative care provider. A social worker and local clergy are available to provide emotional and spiritual comfort during the palliative phase. The effectiveness of palliative care is monitored through reviews, audits and feedback. Representatives are satisfied the provision of palliative care is managed sensitively and effectively.

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 nourishment and hydration. Staff complete an assessment to identify menu choices, personal preferences, allergies and specific requirements. This information is communicated to the kitchen as soon as possible after entry to the home. Care plans reflect details regarding texture modified food and fluids, assistive devices and any support from staff that is required and these are reviewed regularly. Staff monitor care recipients’ weights and changes in eating and drinking habits and refer to the medical practitioner, speech pathologist or dietitian in the event of significant or ongoing weight loss or other changes. Any resulting changes in interventions are added to the care plans and staff informed. Dietary preferences are checked through the monthly ‘Resident of the day’ process to ensure all listed likes and dislikes are current. Meals, snacks and refreshments are available and offered throughout the day. Care recipients and representatives are satisfied with the meal and refreshment services provided.

2.11 Skin care

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

Team’s findings


Care recipients’ skin integrity is consistent with their general health. Staff complete an assessment using a risk management approach to identify past and current factors affecting care recipients’ skin integrity. The care plan incorporates details on resources, equipment and


assistance required from staff to maintain care recipients’ skin integrity, such as the use of soap substitutes and moisturising creams. Care plans are reviewed regularly and staff monitor skin integrity during personal care interventions. Staff complete wound charts, documenting the management of wounds and progress of healing. Consultation occurs with the medical practitioner and wound consultant for further management if indicated. Staff are aware of the process for completing incident forms and other documentation for any skin trauma, such as pressure areas and wounds. Management monitor, analyse and evaluate data monthly with regular audits occurring. Care recipients and representatives are satisfied with the assistance received regarding skin care.

2.12 Continence management

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

Team’s findings


Management demonstrates there are systems to ensure care recipients’ continence is managed effectively. Assessments identify care recipients’ continence history, current condition and individual toileting needs. Care plans reflect the assistance and aids required. Care recipients have access to their ensuite when in their rooms and there are clearly marked toilets for easy access near communal areas. Staff seek continence advice for care recipients who require further support or management of continence issues. Staff report urinary tract infections with monitoring of treatments and monthly analysis of data to identify trends. A proactive approach to bowel management includes offering adequate fibre and promoting mobility and fluid intake. Continence is monitored through charting, care plan reviews and audits. Care recipients and representatives are satisfied staff respond to continence management needs in a timely manner.

2.13 Behavioural management

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

Team’s findings


Management and staff ensure the needs of care recipients with challenging behaviours are managed effectively. Staff collect information regarding prior history and current status, complete charts and other assessments to identify each care recipient’s behaviours of concern. Care plans detail information regarding identified triggers for behaviours and the individualised strategies used by staff in care and lifestyle settings. Staff document behaviour related incidents as they occur and there is regular monitoring and analysis of these incidents Consultation occurs with the medical practitioner, staff, dementia advisory service specialists and representatives, if available, to determine the most appropriate management. Staff demonstrate knowledge regarding their approach to caring for care recipients with challenging behaviours. Care recipients and representatives are satisfied with the management of behavioural issues.


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


Management demonstrates optimum levels of mobility and dexterity are achieved for all care recipients. Staff and a physiotherapist assess and identify mobility and transfer needs, rate the care recipient’s falls risk and identify the individual functional ability of each care recipient when the care recipient moves into the home. The physiotherapist conducts further reviews regularly, after falls and as required. Care plans provide information on a range of strategies, equipment and aids used to maximise independence. Walking, exercise, heat application, massage, adaptive crockery and cutlery, availability of grab rails and safe, well-lit walking areas help to maintain and promote independence. Staff monitor the effectiveness of mobility and dexterity through review and analysis of falls incidents, review of care plans, audits, feedback and observation. Care recipients and representatives are satisfied with the support received in order to maintain 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


Management and staff demonstrate care recipients’ oral and dental health is maintained. Staff document each care recipient’s prior history, current condition and complete an oral and dental assessment which assists with identifying gum, teeth and mouth problems. Texture of foods can be modified for care recipients who have difficulty managing a normal diet due to oral or dental difficulties. Staff consult the medical practitioner and care recipients’ choice of dentist or technician for any treatments necessary and appointments are attended with support from family or staff, as required. Care plans contain details on the frequency of oral care, what resources are used and any staff assistance required. Mouth care products are provided and replaced as needed. Monitoring of effective oral and dental care is through care plan reviews, feedback, observations and audits. Care recipients and representatives are satisfied with the assistance they receive with oral care.

2.16 Sensory loss

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

Team’s findings


Care recipients’ sensory losses are identified and managed effectively. Staff use a range of assessments to assess and identify care recipients’ reduced sensory capacities in all five senses. Staff complete care plans which detail the assistance and aids required to support care recipients with sensory loss. An optometrist and audiologist provide services with relevant information forwarded to the medical practitioner as necessary. The lifestyle program incorporates activities that seek to engage and enhance the experience for care recipients with


sensory loss. The home is well-lit and enables care recipients to mobilise safely. Staff review care recipients’ sensory losses through specialist appointments, regular care plan reviews, reassessments, audits, feedback and observations. Care recipients and representatives are satisfied with the assistance received in meeting sensory needs.

2.17 Sleep

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

Team’s findings


Management and staff assist care recipients to achieve natural sleep patterns. Staff document each care recipient’s settling and sleep history and complete charts and an assessment to develop interventions to support care recipients achieve restful sleep. Care plans contain details on rising and retiring preferences, room temperature, lighting and other comfort measures. Staff support care recipients with their pre-sleep rituals which may include sedation or non-pharmacological measures such as hot drinks, late supper, reading, watching television and listening to music. Staff review care plans regularly, seek feedback and conduct audits to ensure current interventions are still effective. Care recipients said the environment is quiet at night and they sleep well.


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


There is a system that demonstrates improvements in the area of care recipient lifestyle. For a description of the system refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvements undertaken or in progress that relate to Standard 3 Care recipient lifestyle include the following:

Staff extended an invitation to a local bagpiper to play in the home’s courtyard. The session was so well received by care recipients that the musician now plays the bagpipes each week in the courtyard. While care recipients in general look forward to each occasion, staff specifically highlighted the positive impact on individual care recipients, including one care recipient who very seldom leaves their room except to watch the piper in action.

A local trained in the art of tai chi offered to volunteer his services to the home for a weekly tai chi activity, having noted how this regular exercise benefitted his own ageing mother. Half of the home’s care recipients have regularly attended the weekly session since inception in March 2015. Management said incidents of falls have decreased during this period and demonstrated how the exercise regime has positively impacted a previously frequent faller. Care recipients said they really enjoy the structured exercise.



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


There is a generally effective system to identify and meet regulatory compliance obligations in relation to care recipient lifestyle. Staff generally demonstrate knowledge of regulatory requirements relevant to their role. For a description of the system refer to expected outcome 1.2 Regulatory compliance.

Examples of responsiveness to regulatory compliance relating to Standard 3 Care recipient lifestyle include:

Care recipients, representatives and staff are made aware of and respect care recipients’ rights to privacy and confidentiality.

There are procedures and guidelines in relation to elder abuse and compulsory reporting.

The Charter of care recipients’ rights and responsibilities is displayed.

At entry, a residential agreement is offered to each care recipient or their nominated representative.



Team’s findings


Management ensure staff have the knowledge and skills to effectively perform their roles in relation to care recipient lifestyle. For details regarding the system, refer to expected outcome 1.3 Education and staff development.

Education and training scheduled and attended in relation to Standard 3 Care recipient lifestyle include:

mindfulness

open disclosure

person-centred care

privacy and dignity.


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


There is a system to ensure staff and management support care recipients adjust to life at the home and to provide emotional support on an ongoing basis. Strategies to assist a new care recipient to settle into their environment include the promotion of friendships and social engagement and encouragement to attend activities. Staff complete formal assessments that take into account the level of emotional support required by each care recipient. The review of care plans occurs on a regular basis and in response to changing needs of care recipients. Staff ensure there is ongoing interaction with all care recipients and provide ongoing emotional support, especially during times of grief or sickness. The health service’s social worker provides additional support to care recipients and guidance to families where the need is identified. Families and friends are made to feel welcome to visit and are encouraged to participate in events and life at the home. Care recipients and representatives are satisfied with the emotional support provided by staff.

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


There is a system to assist and encourage each care recipient to achieve maximum independence and maintain community ties and friendships. Assessment of care recipient independence includes physical, cognitive, emotional and social aspects. Staff run a range of programs that promote care recipient independence and encourage community involvement in the home. Specific individual activities are arranged to enable care recipients to continue hobbies and interests they enjoy. Staff and volunteers assist care recipients to attend activities and events in the local community. Visitors are encouraged and there are areas where the care recipient and family can spend exclusive time together. Care recipients and representatives are satisfied staff encourage, support and assist care recipients to optimise independence and wellbeing.

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


Management and staff ensure that each care recipient’s right to privacy and dignity is recognised and respected. Each care recipient’s specific needs and preferences are identified through the suite of assessments initiated when a care recipient moves into the home and this is documented on care plans. Care recipients receive information about how the home protects


and respects their privacy, confidentiality and dignity. Policies and procedures guide staff practice and this is supplemented by specific information received through handover and meetings. Access to confidential documents is limited to authorised staff and visiting health professionals. There are areas within the living environment for care recipients to receive visitors or spend quiet time. Care recipients and representatives are satisfied with the way staff at the home respect and maintain the privacy and dignity of care recipients.

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


Management and staff encourage and support care recipients to participate in a range of interests and activities of relevance to them. In consultation with the care recipient and their representatives, lifestyle staff complete assessments that capture information about previous and current social and lifestyle choices and preferences. This information forms the basis of the individual care plan which is reviewed on a regular basis. With the support of volunteers, lifestyle staff conduct a full and varied activity program throughout the week in both group and individual settings. Staff consider the specific needs of care recipients when providing or arranging activities. There are processes to communicate to care recipients the program of activities offered each week. Lifestyle staff redesign leisure activities and programs in response to levels of participation, feedback, surveys, discussion at meetings and changing needs. Care recipients and representatives are satisfied the home provides a program of activities that meet the needs of care recipients.

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’ individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. Assessments and care plans outline care recipients’ customs and cultural and spiritual choices. A church service is held in the home once a month. The local priest visits the Catholic care recipients weekly for communion and an Anglican minister attends the home regularly. Staff ensures celebrations occur for a range of popular cultural days and events of significance to care recipients. Staff and management monitor and evaluate the effectiveness of processes through observations, feedback and surveys. Care recipients and representatives are satisfied the cultural and spiritual needs of care recipients are met.


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


Each care recipient participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over their lifestyle while not infringing on the rights of others. Care recipients and representatives are encouraged to express their wishes during the assessment process, at meetings, during individual consultations, in surveys, through feedback processes and in direct communication with management. Staff document this information in care plans and regularly review each care recipient’s preferences for care and support. An authorised representative is identified to provide decision-making support to care recipients who have a reduced decision-making capacity. Care recipients and representatives are satisfied they have input into the care and services received including personal care, meals and level of participation in activities.

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 and there are processes to ensure they understand their rights and responsibilities. Management ensures information such as care recipients’ rights and responsibilities, security of tenure, advocacy services, complaints resolution and specified care and services is communicated to and understood by care recipients and their representatives. This information is provided both before and during entry and a formal residential agreement and information guide is provided to care recipients. Staff are informed during orientation of their responsibilities regarding care recipients’ rights. Care recipients and representatives said security of tenure is respected.


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


There is a system that shows ongoing improvements in the area of physical environment and safe systems. For a description of the system refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvements undertaken or in progress that relate to Standard 4 Physical environment and safe systems include the following:

The floor tiles on the internal courtyard started to lift, posing a risk to users of the area. Management explored ways to replace the tiles with a low risk surface and one better able to cope with the extremes of the local weather. As a result, non-slip flooring, resembling a grass surface, has recently been installed across the courtyard. Management said an immediate benefit of the choice of colour has been a reduction in the level of reflective glare in the courtyard. Management are currently consulting with care recipients to further develop the courtyard with raised garden beds and outside furniture.

The home has a laundry room that some care recipients choose to use to wash their own clothing. Management recognised the importance for care recipients to continue to exercise choice and independence while evaluating the risk to infection control and the handling of detergents. To balance these conflicting needs an automatic detergent dispenser was installed to the washing machine to ensure the correct quantity of detergent is dispensed for each wash without the need for handling by care recipients.



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


There is a system to identify and meet regulatory compliance obligations in relation to the physical environment and safe systems. For a description of the system refer to expected outcome 1.2 Regulatory compliance.

Examples of responsiveness to regulatory compliance relating to Standard 4 Physical environment and safe systems include:

Staff store chemicals safely and current material safety data sheets are available.

There is a system to ensure compliance with fire safety regulations.

There are procedures for recording, managing and reporting infectious diseases and outbreaks.

Management has a food safety program that is regularly reviewed.



Team’s findings


Management ensure staff have the knowledge and skills to effectively perform their roles in relation to physical environment and safe systems. For details regarding the system, refer to expected outcome 1.3 Education and staff development.

Education and training scheduled and attended in relation to Standard 4 Physical environment and safe systems include:

chemical training

fire and evacuation training

infection prevention and control

manual handling training

quality and safety

work health and safety practices and legislation.


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 is actively working to provide care recipients with a safe and comfortable environment consistent with the care needs of those living at the home. Care recipients enjoy single ensuite rooms and are encouraged to personalise their rooms with their own belongings. Rooms and communal areas are appropriately furnished, maintained and kept at a comfortable temperature and level of noise. Care recipients access individual and communal balconies and an internal courtyard as weather conditions allow. There are processes to ensure the maintenance of buildings and fixtures through regular servicing and maintenance programs. Workplace inspections, audits, incident and hazard reporting and feedback mechanisms are used to monitor a safe and comfortable living environment. Care recipients and representatives are satisfied management provides a comfortable, safe and well maintained 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


There is a system to support a safe working environment that meets regulatory requirements. Management inform staff about their workplace health and safety rights and responsibilities during the induction program, through information displayed in the home and in policies and procedures. The education program includes regular training for staff in manual handling, infection control and chemical safety. Health and safety representatives receive initial and ongoing accredited training. Management and maintenance staff promptly attend to deficits identified through inspections, audits, incidents, hazard reports and maintenance requests. Health and safety issues are tabled, addressed and monitored through the staff meeting and formal workplace health and safety forums in the parent health service. Staff have access to an employee assistance program. Staff are satisfied management work actively to create a safe work environment and are responsive to any issues raised.

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


Management and staff actively work to provide an environment and safe systems of work that minimise fire, security and emergency risks. There are established procedures and contingency plans to respond to a range of internal and external risks and emergencies. Qualified external contractors maintain fire safety equipment. Management ensures


emergency exits and egress routes are free from obstruction. There is a process to ensure emergency evacuation information is current. All staff are required to complete mandatory fire and emergency training and fire evacuation drills occur biannually. Arrangements for providing a secure environment include keypad access, an at-risk of wandering identification process and an evening lock up procedure. Care recipients and representatives are satisfied with the home’s processes to ensure those living in the home feel safe and secure.

4.7 Infection control

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

Team’s findings


Management has an effective infection control program. Personal protective equipment, hand washing facilities and processes for staff and care recipients who are unwell are in place to minimise the risk of infection. Review and analysis of infection data occurs and annual mandatory training includes infection control. Staff identify care recipients at risk of infection with appropriate reviews undertaken and implementation of treatment, as needed. Management ensure pest control and waste disposal processes are in place. Staff demonstrate an awareness of the practices required during a gastroenteritis or other infectious disease outbreak. Monitoring of the effectiveness of infection control includes analysis of reports, audits, feedback, online training, hand hygiene competencies and observation of practice. Care recipients and representatives are satisfied staff wear protective equipment and attend to hand hygiene.

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


Hospitality services are provided in a way that enhances care recipients’ quality of life and the working environment of staff. All food is prepared in the kitchen and served according to dietary requirements and preferences and in line with the food safety program. Care recipients’ personal clothing is laundered on site, ironing is available and general linen is provided by an external linen service. There are processes for ensuring clothing is named and to identify lost clothing. All catering, cleaning and laundry staff work to cleaning schedules and follow infection control and chemical handling guidelines. Catering, cleaning and laundry services are monitored through verbal and written feedback, internal and external audits, observation of staff practices and meetings. Care recipients and staff are satisfied with the hospitality services provided in the home.

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