Chamberlain Gardens Aged Care - Aged Care Quality · Chamberlain Gardens Aged Care RACS ID 0723 53 - 67 Chamberlain Road WYOMING NSW 2250 Approved provider: Christadelphian Homes

Chamberlain Gardens Aged Care

RACS ID 0723 53 - 67 Chamberlain Road

WYOMING NSW 2250

Approved provider: Christadelphian Homes Limited

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 14 January 2020.

We made our decision on 28 November 2016.

The audit was conducted on 18 October 2016 to 20 October 2016. The assessment team’s report is attached.

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

Home name: Chamberlain Gardens Aged Care RACS ID: 0723 2 Dates of audit: 18 October 2016 to 20 October 2016

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

Chamberlain Gardens Aged Care 0723


Introduction

This is the report of a re-accreditation audit from 18 October 2016 to 20 October 2016 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 18 October 2016 to 20 October 2016.

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: Sandra Heathcote

Team member/s: Helen Ledwidge

Approved provider details


Details of home

Name of home: Chamberlain Gardens Aged Care

RACS ID: 0723

Total number of allocated places:

148

Number of care recipients during audit:

145

Number of care recipients receiving high care during audit:

145

Special needs catered for: Dementia specific unit 53 beds

Street/PO Box: 53 - 67 Chamberlain Road

City/Town: WYOMING

State: NSW

Postcode: 2250

Phone number: 02 4329 8000

Facsimile: 02 4329 8009

E-mail address: Nil

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


Audit trail

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

Interviews

Category Number

Chief operations officer 1

Facility manager 1

Care manager 1

Senior manager operations 1

Quality manager 1

Clinical nurse educator 1

Registered nurses 4

Care staff 25

Physiotherapy aides 2

Care and compliance team leader and staff 2

Care recipients 16

Representatives 4

Leisure and lifestyle coordinator and recreational activity officers 3

Regional pastoral care coordinator and volunteer/ pastoral care coordinator

2

Resident service officer 1

Head chef and catering staff 2

Property manager and maintenance staff 2

Laundry staff 2

Cleaning contractor (state manager) and staff 3

Administration and reception staff 2

Sampled documents

Category Number

Care recipients’ files 15

Personnel files 9

Medication charts 25


Other documents reviewed

The team also reviewed:

Activity programs, assessments and care plans, activity attendance records; risk assessments, evaluation records

Advance care plans

Allied health assessments, care directives, treatment records

Care recipients’ admission packages, handbook and residential agreements

Care recipients’ dietary requirements and preferences documentation and menu

Cleaning documentation including audit results and follow up action taken

Clinical care assessment, care planning documentation, progress notes, medical notes, medical specialists reports, pathology results, family conference records, restraint authorisation records

Clinical monitoring charts including weights, temperature, pulse, blood pressure, blood glucose levels, pain, wound, bowel, enteral feeding charts, catheter line management charts, restraint monitoring chart

Education records including education calendar, education attendance records, mandatory training records, competency assessments

Fire safety and emergencies documentation including inspection records, annual fire safety certificate, evacuation details of care recipients, sign in and out registers for visitors and contractors

Food safety program, catering documentation and food safety monitoring records

Human resource management: selection policies, consent and confidentiality agreements, position descriptions, duty statements, employee information pack, new employee checklist, appraisals and performance management, orientation program and checklist, employee handbook, volunteer information pack and staff rosters

Incident and accident report forms

Infection control documentation including audit reports, staff immunisation data and legionella species reports, outbreak management plan, infection control manual and resources

Maintenance documentation including maintenance schedules, computerised maintenance logs, warm water temperature check records, pest control reports, contractor and supplier documentation and agreements

Medication records including medication identification charts, nurse initiated medications lists authorised by medical practitioner, registers of schedule eight and four medications, medication incident forms; self-medication assessment documentation, medication fridge temperature monitoring charts

Minutes of meetings


Policy and procedure manual

Quality management system: audit schedule, audit results and follow up, comment, complaint and compliment logs, continuous improvement documentation, staff and care recipient/representatives survey data, organisational mission, values and inspirational statements; self-assessment documentation for re-accreditation

Regulatory compliance: mandatory and consolidated reporting register, police check records, NSW Food Authority Licence, professional registration records, consent forms for the collection and handling of private information

Work health and safety system including environmental audit results and actions taken, incident and hazard information, electrical tagging records and safety data sheets

Observations

The team observed the following:

Activities in progress and activity program displayed

Annual fire safety statement, fire safety plans, equipment and evacuation pack

Archive storage

Australian Aged Care Quality Agency re-accreditation audit notices displayed

Brochures and posters - external complaints and advocacy services, various others

Care recipient call bell system

Charter of care recipients’ rights and responsibilities displayed

Chemical storage areas, safety data sheets

Cleaning equipment and cleaning in progress

Clinical, linen and continence products and storage

Dining service with staff assisting care recipients as required, menu displayed daily

Emergency procedures flip charts located throughout the home

Equipment and supply storage areas

Feedback forms, suggestion boxes

Fire safety equipment and evacuation plans displayed

Hairdressing salon in operation

Infection control resources including personal protective equipment, infectious outbreak resources and supplies, spills kits, sharps containers, hand sanitiser dispensers, contaminated waste disposal

Information notice boards for staff, care recipients and visitors


Interactions between staff and care recipients

Laundry in operation

Living environment

Medication administration; drugs of addiction cupboard; storage of medications including refrigeration

Mission, values and inspiration statements displayed

NSW Food Authority Licence

Nurse call system in operation

Secure storage of care recipient and staff information

Small group observation – Garden Suite

Staff work areas and practices

Visitor and contractor sign in and out registers


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The home has a continuous improvement system to identify and implement improvements across the four Accreditation Standards. Care recipients/representatives and staff use formal and informal mechanisms to provide feedback on all aspects of care and service delivery.

Mechanisms include: audits, monitoring of clinical data, critical analysis of incidents, surveys, verbal and written comments and complaints and meetings. Continuous improvement matters are captured in a continuous improvement plan and actions logged on the plan are followed up in a timely manner. Continuous improvement matters are discussed and reported at various meetings. Meetings are held to progress initiatives. Staff are familiar with continuous improvement mechanisms and are aware of recent improvements. Care recipients/representatives are encouraged to make suggestions and to put forward ideas for improvement using the various feedback mechanisms. Examples of improvements in relation to Accreditation Standard One, Management systems, staffing and organisational development, include:

In August 2016 management identified the need to have a robust system and schedule to ensure the appropriate and timely review of policies. Management team staff reviewed processes and established a policy review schedule and strategy for implementation. The implementation strategy incorporates maximising expertise from members of the management team. The modified review process commenced in September 2016 and the management team report the process is operating effectively and is resulting in improved and timely policy review.

In November 2015 the organisation introduced care conferencing involving multidisciplinary teams for all care recipients every four months. The process involves a systematic evaluation of care provided for care recipients, compliance against policy and ensures documentation of care is accurate and matches care recipient needs. Staff feedback has been positive and management report the process has provided a structure for comprehensive review of care and has resulted in improved quality of care and improved documentation.

In July 2016 management identified the need to increase registered nurse staffing hours to meet the increasing acuity needs of care recipients. Registered nurses have been recruited to staff the home on weekends and an additional registered nurse has been


added to the evening shift seven days a week. Management and staff report improved supervision and leadership of staff has been achieved. Medication administration and management and nursing care delivery have also improved.

1.2 Regulatory compliance

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

Team’s findings


The home has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. New and updated legislation policy directives and guidelines are regularly accessed from sources which include the Department of Health, head office communications and membership of industry peak bodies. Head office staff ensure currency of policies, procedures and forms. Staff demonstrated awareness of current legislation. Relevant information is provided to care recipients/ representatives at meetings, and through information on display in the home. Staff are informed through notices, memoranda, meetings and education. Audits, surveys, quality improvement activities and staff supervision ensure that work practices are consistent and compliant with legislative requirements and professional standards. Examples of regulatory compliance relating to Accreditation Standard One include:

Systems and processes are in place to ensure all staff and volunteers have current police certification.

The provision of information to care recipients and stakeholders about internal and external complaint mechanisms.

1.3 Education and staff development

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

Team’s findings


The home has an education program that ensures management and staff have the appropriate knowledge and skills to perform their roles effectively. Staff education includes: orientation, annual mandatory training and a range of internal and external training programs. The organisation also subscribes to an education provider and this includes a range of online learning packages. Management maintains education records and relevant staff receive training and education across the four Accreditation Standards. Staff training needs are identified through legislative requirements, changes in care recipient needs, observation of staff practices, consultation with staff and stakeholders, staff performance appraisals, surveys and a range of clinical and audit data. The effectiveness of training and education is assessed. Staff are satisfied with the education programs and opportunities provided. Care recipient/representative interviews demonstrated they are satisfied staff are skilled and knowledgeable in their delivery of care and services to the care recipients.

Education topics recently provided by the home relating to Accreditation Standard One include: mission and values; accreditation (standards and outcomes); orientation for new staff


and volunteers; documentation; bullying and harassment; equal employment opportunity; identifying poor performance; managing the discipline process; aged care funding instrument (ACFI) and electronic clinical record system training.

1.4 Comments and complaints

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

Team’s findings


The home has internal and external feedback and complaint mechanisms available to all care recipients/representatives. On entry all new care recipients are made aware of feedback mechanisms and advocacy services in the care recipient agreement and via brochures.

Internal feedback forms and brochures for accessing external complaints and advocacy services are also on display and the home has locked suggestion boxes. The manager has an open door policy. Satisfaction surveys are conducted and care recipient meetings provide forums for feedback and updates on action taken. Complaints are handled confidentially and are registered and analysed. Issues are incorporated into the continuous improvement program. Care recipient/representative and staff interviews demonstrated they are aware of the home’s complaints and feedback processes and they reported management are approachable to discuss any concerns.

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 organisation’s mission, values and inspiration statements are documented in staff and care recipient handbooks and are displayed in the home. The home’s operations are supported by head office staff and resources. Documentation and interviews with management and staff confirm a commitment to quality care and services within 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


The home has systems to ensure there are sufficient appropriately skilled and qualified staff to deliver care and services in accordance with the Accreditation Standards, the home’s philosophy and objectives and the needs of the home’s care recipients. The home is supported by head office human resources staff and police record certification is obtained prior to employment and is monitored for renewal. All new staff complete an orientation program


and position descriptions, handbook, and policies inform staff of care and service delivery requirements. Staff sign to acknowledge confidentiality requirements. Staff practices are monitored through observation, skill assessments, performance appraisals, feedback and audit results. Registered nurses are rostered on every shift and there is flexibility in rostering to ensure the staffing allocation addresses care recipient needs. Staff absences are replaced using the home’s casual and part time staff and supplemented by agency staff when necessary. Care recipients/representatives expressed satisfaction with care provided by staff and care recipients said they are generally assisted when necessary in a timely manner.

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 an equipment management system to ensure appropriate stocks of goods and equipment are maintained to provide quality service delivery. The home has systems to register, replace and purchase equipment. Equipment is well maintained and there is a comprehensive system to manage corrective and preventive maintenance in the home. Staff and care recipients/representatives confirmed the operation of this system is effective and maintenance requests are actioned in a timely manner. Electrical items are tested and tagged. Staff are familiar with ordering and maintenance systems and have sufficient goods and equipment on an ongoing basis. Care recipient/representative interviews demonstrated they are satisfied that goods and equipment required for use by care recipients are well maintained and readily available.

1.8 Information systems

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

Team’s findings


The organisation has an effective information management system which includes policies and procedures to support care practices and the delivery of services. Various regular staff and care recipient/representative meetings are held. The home manages information review through a broad range of audits and information gathered is analysed, reported on and actioned where required. Care recipients/representatives, staff and other stakeholders have access to information through mechanisms such as handbooks, orientation and training sessions, meeting minutes and noticeboards, staff handover discussions and verbal communication. Staff have access to electronic and hard copy policies and procedures. Care recipient and staff information was observed to be kept secured and staff are aware of their responsibility to keep care recipient information confidential. The organisation backs up electronic files regularly and there is a system for archiving and destruction of confidential care recipient information. Care recipient/representative and staff interviews demonstrated they can access information and are kept informed about relevant matters.


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


The home demonstrated it has systems to monitor the quality of work being undertaken by externally sourced services to ensure services are provided in a way that meets the home’s needs and service quality goals. Preferred external suppliers are managed by the organisation and the home through service agreements or contracts. Service agreements/ contracts include specifications of service delivery, qualifications, insurance, police record certification and registration details as appropriate. Suppliers and contractors are regularly assessed against their service agreement and unsatisfactory service/breach of contract are addressed. Staff said they are satisfied with the quality of the services currently being provided by external providers.


Standard 2 – Health and personal care

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system. Examples of improvements undertaken by the home relevant to Accreditation Standard Two, Health and personal care include:

In April 2016 feedback from a care recipient’s representative identified the need to improve the management of complex wounds. In response to this identified need the care manager has a closer monitoring role and registered nurses are exclusively managing wound care. All staff have been provided with compulsory education concerning wound care and a wound resource folder is available in each area of the home. Documentation of wound progress includes a weekly photograph of the wound. Regular reporting regarding new wounds as well as the healing progress of existing care recipient wounds is now included in daily handover reports and discussed at registered nurse/team leader meetings. Management report wound care and healing rates have improved as a result of the improved strategies.

Management identified medication incidents and documentation errors could be reduced by minimising interruptions when staff are administering medications to care recipients. Medication round identification aprons were introduced in July 2016 to alert staff and care recipients that the wearer of the apron is undertaking a medication round and should not be interrupted. The use of the aprons has been discussed with staff who administer medications. The aprons have been well received by staff and have been effective in reducing the incidence of interruptions during medication administration rounds. Management will continue to monitor the effectiveness of this strategy in reducing medication incidents and documentation errors.

In August 2016 the care manager identified the advantages of each care recipient with a diagnosis of diabetes having their own blood glucose monitoring equipment. The home liaised with the pharmacy and arranged for new machines to be provided for each relevant care recipient. As a result the risk of infection to care recipients is minimised and diabetic management processes operate more efficiently.



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 regarding the system to ensure that the home complies with legislation and regulations relevant to care recipients’ health and personal care. Examples of regulatory compliance related to Accreditation Standard Two:

Staff who require professional registration hold current registration certificates.

Medications are stored and managed in line with NSW state legislation requirements.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles.

Education topics recently provided by the home relating to Accreditation Standard Two include: personal care; nutrition, hydration and weight monitoring; pain management; palliative care; skin care and wound management; continence management; falls management; medication management; behaviour management workshop; specialised nursing care including management of care recipients with diabetes.

Clinical care

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

Team’s findings


Care recipients receive clinical care that is appropriate to their individual needs and preferences. The home has systems to assess, identify, monitor and evaluate care recipients’ care needs on entry to the home and on an ongoing basis. Information obtained from care recipients and representatives when care recipients move into the home, together with a range of assessments are used to prepare individualised care plans. Care plans are reviewed on a regular basis and as required. Medical practitioners conduct regular reviews and in emergencies after hours medical services are contacted or care recipients are transferred to hospital. Care recipients and their representatives expressed satisfaction with the care provided to care recipients.


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


Specialised nursing care needs are identified and appropriate qualified staff deliver care to meet care recipients’ needs and preferences. The registered nurses assess care recipients for specialised nursing care and undertake or oversee any specialised nursing treatments. Care recipients are referred to a range of allied health professionals and other specialists to assist the home’s staff to manage care recipients’ complex and specialised needs. Care plans include appropriate management of care recipients’ specific specialised care needs such as diabetes management, catheter care and wound management. Care recipients and representatives said they are satisfied the home’s staff are able to provide specialised nursing care to the care recipient.

2.6 Other health and related services

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

Team’s findings


The home ensures care recipients are referred to appropriate health specialists in accordance with care recipients’ needs and preferences. Care recipients requiring referral to other health services are identified through assessments which are completed during entry processes and also during ongoing observation, monitoring and reviewing of care recipients’ needs. A physiotherapist is contracted to review care recipients’ mobility and pain management and to provide treatment. A podiatrist regularly visits the home to assess and provide treatment for care recipients. Annual visits are organised for assessment and treatment from the optometrist. The services of other health professionals such as a dietician, audiologist and speech pathologist are arranged for consultation on site. In addition the home can access services from the area health service for palliative care advice, mental health and emergency review. Information and recommendations made by health professionals are referred to the medical practitioner and actioned where necessary. A hairdresser is also available in the home for care recipients. Care recipients are assisted to access external services through transport provided by the care recipients’ representatives or as arranged by the home. Care recipients confirm they are referred to specialists as the need arises.

2.7 Medication management

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

Team’s findings


The home has systems to ensure that care recipients’ medication is managed safely and correctly; including the ordering, storage, disposal, administration, recording and review of


medications. The home uses a sachet packed medication system and liaison with the supplying pharmacist ensures that new or changed medications are supplied promptly.

Medications are stored securely and we observed safe and correct medication administration by staff. Regular medication reviews are undertaken by the medical practitioner and an external consultant pharmacist. The home uses internal audits and incident reporting to monitor the medication system. Care recipients and representatives expressed satisfaction with the way care recipients’ medication is managed.

2.8 Pain management

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

Team’s findings


To ensure that care recipients are as free from pain as possible all care recipients are assessed for pain on entry to the home and ongoing pain assessments are conducted to monitor care recipients’ pain. Consultation with the care recipient, physiotherapist and their medical practitioner is conducted by the home with the specific management strategies devised recorded on care recipients’ care plans. The physiotherapist and physiotherapy aides provide treatment such as heat therapy, exercise and massage. The effectiveness of pain management is monitored through feedback from care recipients and the use of a pain chart. Care recipients said they are satisfied with how the home manages their pain.

2.9 Palliative care

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

Team’s findings


The home has systems in place to ensure the comfort and dignity of care recipients requiring palliative care is maintained. Advance care directives are discussed with the care recipients and or their representatives and the medical practitioner. Care recipients’ pain management, religious, spiritual and cultural requirements and preferences regarding end of life are recorded to direct staff care. Care recipients are supported to remain in the home for palliative care if this is their preference. Family members are able to stay with care recipients and meals and refreshments are available. Members of the clergy are available for spiritual care and additional emotional support if that is the wish of care recipients. Pastoral carers are also involved in providing emotional support for the care recipient and their representatives. Staff have access to advice regarding palliative care from services available locally. A review of compliments received and feedback from a representative identified representatives as being satisfied with the care and support provided for their loved ones during the palliative care process.


2.10 Nutrition and hydration

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

Team’s findings


The home has systems to provide care recipients with adequate nutrition and hydration through initial and ongoing assessment of care recipients’ dietary preferences and requirements. Care recipients food allergies are clearly identified in documentation; as are care recipient likes and dislikes. Care recipients identified as having changes in swallowing are assessed, monitored closely and referred to relevant health professionals as needed. Special dietary requirements or alterations to diets are specified in care recipients’ care plans and communicated to the catering department. Care recipients are weighed monthly to monitor changes and significant weight loss is investigated and appropriate action taken.

Care recipients said they are satisfied with the home’s approach to meeting the care recipient’s nutrition and hydration needs.

2.11 Skin care

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

Team’s findings


The home has an effective system to ensure that care recipients’ skin integrity is consistent with their general health. Assessments are conducted to identify skin care needs and management strategies are incorporated into the care recipient’s care plan. Repositioning of care recipients when required and the application of emollients aids in maintaining care recipients’ skin integrity. In addition the home also uses devices such as pressure relieving mattresses, bed rail protectors and limb protectors. Care recipients’ wounds are managed appropriately, sufficient supplies are available and referrals are made as required. The home monitors accidents and incidents including wound infections and skin tears. Care recipients and representatives report satisfaction with the way the home manages care recipients’ skin care needs.

2.12 Continence management

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

Team’s findings


The home has systems to ensure that care recipients’ continence is managed effectively. On entry to the home care recipients are assessed for their continence needs and then on an ongoing basis. Continence management care plans are formulated and monitoring is by daily recording by care staff with appropriate procedures in place if any issues are identified. Care staff are knowledgeable about care recipients’ care needs and preferences for toileting and the use of continence aids. Aids to manage and support care recipients with continence care include a range of continence pads, exercise programs, dietary supplements and medications.


Staff said the home has an adequate supply of continence aids and linen. Care recipients and representatives stated they are satisfied with the continence care provided to the care recipients.

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 assess and manage care recipients with challenging behaviours. This includes using initial and ongoing assessment tools and monitoring charts to develop appropriate care plans and interventions. Medical practitioners are consulted and referral to a geriatrician or the local behavioural management specialist team is arranged if needed.

Recommendations are followed up and incorporated into the care recipients’ care plans. Staff demonstrate an understanding of care recipients’ behaviours and care recipient specific interventions they use to minimise the incidence of the behaviour. Physical restraint is only used in the home after consultation with the care recipient/representative and medical practitioner. Restraint use is monitored by care staff to ensure the safety of care recipients.

Care recipients and representatives said they are satisfied with the way in which the home’s staff manages care recipients’ challenging behaviours.

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


Optimum levels of mobility and dexterity are achieved for all care recipients. The registered nurses and physiotherapist assess care recipients’ mobility and dexterity needs and develop an individualised care plan. Exercise classes are available for care recipients to attend and some care recipients also have individual exercise programs. A range of assistive devices are provided including walking frames, walking belts, wheelchairs, lifters and slide sheets. The environment is kept safe to decrease the risk of falls. Handrails are throughout the home, corridors’ are free of clutter, staff supervise and assist care recipients to mobilise and care recipients are encouraged to use their mobility aids. Modified crockery and cutlery is provided to care recipients with reduced dexterity. All staff in the home attend training on manual handling. Care recipients and representatives expressed satisfaction with the assistance care recipients receive in relation to 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


Initial and ongoing assessment is undertaken and care plans are developed to ensure that oral and dental health is maintained. Care recipients access dentists of their choice in the community. Oral health care is monitored daily by care staff during teeth and denture cleaning. The day-to-day oral care is attended as per care recipients’ care plans with care recipients being encouraged to brush their own teeth or dentures to maintain their independence. Aids to maintain dental hygiene include toothbrushes, toothpastes and mouth swabs. Care recipients are satisfied with the oral and dental health assistance provided to care recipients.

2.16 Sensory loss

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

Team’s findings


The home has systems to identify and address the sensory loss of individual care recipients. Sensory loss is identified on entry to the home and an assessment is completed to identify care recipients’ specific needs. Care recipients have access to specialist services including speech therapy, audiology and optometry. The physical environment is set up to assist care recipients with sensory impairment and includes safe walking areas, clear corridors, hand rails along the corridor and grab rails in the bathrooms. Activities such as hand massage, relaxing music, gardening, tactile books, large print resources and painting provide sensory stimulation. Care recipients and representatives said they are satisfied with the support provided to assist care recipients manage sensory loss.

2.17 Sleep

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

Team’s findings


The home ensures care recipients are able to achieve natural sleep pattern. The home conducts a sleep assessment to identify the care recipients’ normal sleep patterns or sleeping difficulties. The sleep assessment is evaluated and strategies are developed to enhance sleep patterns. The home also uses strategies such as dimming the lights, answering buzzers promptly and ensuring noise is at a minimum. Care recipients said they are able to sleep and if not are given individual attention to make them comfortable.


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


Refer to expected outcome 1.1 Continuous improvement for information regarding the home’s continuous improvement system. Examples of improvements undertaken by the home relevant to Accreditation Standard Three, Care recipient lifestyle include:

In August 2016 the Facility manager identified the advantages of subscribing to the Golden Carers website. Subscription to the website has been arranged and management have discussed using the resource with the home’s leisure and lifestyle staff and encouraged them to use the website to inform and enrich the home’s activities program. Management receive a monthly report from the leisure and lifestyle staff regarding their use of the website. Management and staff spoke positively about the usefulness of subscribing to the website and provided examples of ideas they have introduced to the home’s program.

In June 2016 the Facility manager and pastoral carers decided to arrange for farewell bags to be made available to families and friends of recently deceased care recipients. The bags were designed in consultation with marketing and pastoral care staff and a suitable size and shape chosen. Families and friends of care recipients have given positive feedback regarding the dignity these bags present for their loved ones and their belongings.

In August 2016 care recipient families and leisure and lifestyle staff identified the advantages to be gained by putting together individual care recipient Brag Albums for care recipients with a diagnosis of dementia. The albums encourage staff to individualise care to those care recipients as they showcase images and letters from the care recipient and their loved ones from their life past and present. The Brag Album also showcases the care recipient’s pictures and creations since residing at the home. The albums encourage a sense of pride within the care recipients and also serve as a conversation starter with care staff and visitors.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information regarding the system to ensure that the home complies with legislation and regulations relevant to care recipients’ health and personal care. Examples of regulatory compliance related to Accreditation Standard Three:

Mandatory reporting guidelines and training have been implemented by the home in accordance with regulatory requirements.

Care recipients/representatives are provided with a resident agreement. Agreements include information about security of tenure and include the Charter of care recipients’ rights and responsibilities.



Team’s findings



Education topics recently provided by the home relating to Accreditation Standard Three include: grief and loss; privacy and dignity; confidentiality; mandatory reporting and elder abuse.

3.4 Emotional support

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

Team’s findings


The entry process includes a tour of the home for new care recipients and their representatives and the gathering of information from care recipients and their representatives to identify the care recipients’ care needs and social histories. Information about care recipients’ assessed emotional support needs is included in their care plan. Staff spend one-to-one time with care recipients during their settling in period and thereafter according to need. The pastoral care coordinator meets the new care recipients and provides support during the settling in period and ongoing as needed. Care recipients are welcome to personalise their


rooms with familiar objects. Care recipients said they are provided with appropriate emotional support and feel staff are supportive in helping them to adjust to their new life within the home.

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 systems to ensure that care recipients are assisted to maximise their independence, maintain friendships and participate in the life of the community within and outside the residential care service. Care recipients are encouraged to be as independent as possible with their activities of daily living, and receive support to maintain and improve their mobility and dexterity. Physiotherapists assess care recipient mobility and arrange suitable equipment or programs to assist the care recipient to maintain their independence. Some care recipients go out with family and friends and others have the opportunity to go into the community on bus outings. The activity program incorporates visiting community groups and care recipients who are able go out to the local shopping centre and community events. Care recipients said they are satisfied with the opportunities available to them to participate in the life of the community.

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


Care recipients reported that their privacy, dignity and confidentiality are respected at all times. The organisation has confidentiality and privacy statements which are provided to staff, care recipients/representatives. The home has single rooms with en-suite bathrooms for privacy and shared rooms with a privacy screen which may be drawn to provide the care recipients with privacy. There are sitting rooms and outdoors areas throughout the home where care recipients may entertain family and friends. Staff provided examples of the ways they show respect for care recipients’ privacy and dignity. Care recipients said they are addressed by their name of choice and staff treat them with respect and consideration.

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


Care recipients expressed satisfaction with the activity program offered by the home. The home has systems to ensure care recipients are encouraged and supported to participate in their interests and activities. When entering the home, information about a care recipient’s lifestyle interest is collected and used to develop individual care plans. Care recipient activity


interests are included in the monthly activity plan which is displayed in communal areas of the home and a copy is given to care recipients. The monthly activity programs which include special events, take into account care recipients’ preferred activities and significant cultural days. Activities are modified as necessary to optimise care recipients’ enjoyment and participation. Care recipients said they are satisfied with the activities on offer and can choose whether or not to participate.

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 reported they are satisfied with the support provided for their cultural and spiritual needs. The individual requirements of care recipients to continue their beliefs and customs are identified in the assessment process on entry. Specific cultural days such as Australia Day, Anzac Day, Christmas and Easter are commemorated with appropriate festivities. A number of religious clergy hold services at the home and care recipients are invited to attend these if they wish to do so. The pastoral care coordinator holds bible study groups and meets care recipients individually as needed. Memorial services are held twice a year in the home with staff, care recipients and representatives invited to attend. Care recipients said they are satisfied with the way the home supports their cultural and spiritual needs.

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


Care recipients reported satisfaction with the choices available to them at the home. They said they are able to have control over matters that affect them by putting their views forward during discussions about care, at family conferences, through the complaints process and at meetings. Care recipients/representatives are offered the opportunity to discuss and plan end of life choices, but any decision not to do so is respected. Participation in group activities is the choice of the care recipient and they are asked to choose how they wish to spend individual time with activity staff. Care recipients have personalised their rooms with memorabilia and items of their choosing.


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


The home has processes to ensure care recipients have secure tenure within the residential care service and understand their rights and responsibilities. On entry care recipients/ representatives receive a residential agreement and handbook. The Charter of care recipients’ rights and responsibilities is displayed in the home, as well being in the care recipient’s information pack. The resident service officer discusses the information in the agreement and handbook with each care recipient/representative. Care recipients/ representatives indicated awareness of care recipients’ rights and responsibilities and security of tenure at the home.


Standard 4 – Physical environment and safe systems

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system. Examples of improvements undertaken by the home relevant to Accreditation Standard Four, Physical environment and safe systems, include:

In September 2016 feedback from the care manager and staff identified the need to modify the lounge/dining area used within the Garden Suite of the home where care recipients diagnosed with dementia reside. As the Garden Suite houses 52 care recipients it was decided to create a more intimate and calmer mealtime atmosphere by having three dining rooms instead of one and by creating smaller communal sitting and activities areas where visitors can engage more privately with their care recipient. Staff and visitors have provided very positive feedback about the success of these changes in enhancing the living environment, creating better quality home life and less distraction at mealtimes for care recipients.

In July 2016 many of the home’s care recipients were affected by the gastroenteritis outbreak. As a result of managing the outbreak management identified improvements and developed an outbreak management plan in consultation with the senior management team. Additional education was also provided to staff and additional equipment and resources purchased to minimise cross infection. Staff provided very positive feedback about the improved documentation, extra education and the availability of supplies and equipment to respond to infectious outbreaks and to minimise the risk of infection.



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


The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance, for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Four include:

A current annual fire safety statement is displayed.

A current NSW Food Authority licence is held and displayed.



Team’s findings



Education topics recently provided by the home relating to Accreditation Standard Four include: food safety training; chemical safety; risk management; incident reporting; first aid; handwashing competency; fire equipment, safety and evacuation training; infection prevention and control; manual handling; office ergonomics; injury management; work health and safety and grievance policy.

4.4 Living environment

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

Team’s findings


The home demonstrated it provides care recipients with a safe and comfortable environment consistent with their needs. The majority of care recipients are accommodated in single rooms with an ensuite and the home also has four double rooms with ensuites. Care recipients may personalise their rooms. Sitting and lounge areas are available for use by family and friends. Preventative maintenance schedules ensure the safety of the internal and external environment and equipment and maintenance requests are actioned promptly. The safety and comfort of the home is monitored through regular environmental audits, analysis of accident and incidents and hazard reporting. All care recipients have access to nurse call bells. Care


recipients/representatives stated they are satisfied with the home’s maintenance and comfort of the environment provided to care recipients.

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


The home actively works to provide a safe working environment that meets regulatory requirements. Information regarding work health and safety (WHS) is included in the home’s education programs, posted on notice boards, and work health and safety is a standing agenda item for staff meetings. Audits and environmental inspections are used to monitor workplace safety and the safety of the environment including an accident/incident/hazard reporting system which highlights areas for improvement. Safety data sheets are available for chemicals at point of use. Staff are provided with training and instructions on each care recipient’s manual handling needs and equipment is provided to support safe work practices. Staff are satisfied with the safety of their working environment.

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 ensure an environment and safe systems of work that minimise fire, security and emergency risks to care recipients and staff. These include regular checks of equipment by staff and external providers. Fire-fighting equipment inspection and testing is current and an annual fire safety statement is held. Fire/emergency/evacuation information is accessible to staff and evacuation packs contain current care recipient information.

Compulsory fire training is provided annually for staff to manage emergency situations and staff are aware of the evacuation process should it be necessary. The home is equipped with fire warning and fire-fighting equipment, extinguishers, fire blankets and evacuation plans.

Emergency exits are clearly marked and free from obstruction.

4.7 Infection control

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

Team’s findings


The home has an effective infection control program that includes infection control policies, practices and guidelines. The facility manager and the management team ensure the operation and effectiveness of the infection control program through clear policies and procedures, education and an infection surveillance program. The program is monitored through reporting of infections, trend analysis, audits and managerial review. The home has


mandatory annual training in infection control and hand washing. Hand washing facilities, personal protective equipment and other equipment is available to enable staff to carry out infection control procedures. The infection control program also includes an outbreak management policy and plan, a food safety program, a vaccination program for care recipients and staff, pest control and waste management. Staff demonstrated they have a sound knowledge and understanding of infection control and were observed implementing the program.

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 procedures, policies, and duty lists for hospitality services and staff demonstrated practices are conducted in accordance with infection control and WHS guidelines. Meals are freshly cooked on site following a dietician reviewed rotational menu. Identified food preferences, allergies and special dietary needs are communicated to catering staff. Care recipients are consulted about menus and their preferred daily choices. There is a food safety program and the home holds a NSW Food Authority licence. Contract cleaning staff are in attendance seven days a week and follow schedules for care recipients’ rooms and communal areas. All areas were observed to be clean.

Personal items are laundered on site by the home’s staff on site. Some care recipients do their personal laundry in accordance with their preferences. Staff deliver personal items to care recipients and provide a labelling service.

Feedback about services is given by care recipients through surveys, meetings and verbally. Most care recipients/representatives stated they are satisfied with hospitality services available for care recipients.

Documents

Chamberlain Gardens Aged Care - Aged Care Quality · Chamberlain Gardens Aged Care RACS ID 0723 53 - 67 Chamberlain Road WYOMING NSW 2250 Approved provider: Christadelphian Homes