Published_decision_(SA_and_RA) - aacqa.gov.au Web viewFood safety program ... Registered nurses administer medications via a blister packaging ... The care recipient and representatives’

Estia Health Mona ValeRACS ID: 2831

Approved provider: Estia Investments Pty Ltd

Home address: 50 Golf Avenue MONA VALE NSW 2103

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 27 October 2020.

We made our decision on 28 September 2017.

The audit was conducted on 22 August 2017 to 23 August 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep MetHome name: Estia Health Mona Vale Date/s of audit: 22 August 2017 to 23 August 2017RACS ID: 2831 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

Home name: Estia Health Mona Vale Date/s of audit: 22 August 2017 to 23 August 2017RACS ID: 2831 3

Audit ReportName of home: Estia Health Mona Vale

RACS ID: 2831

Approved provider: Estia Investments Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 22 August 2017 to 23 August 2017 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 22 August 2017 to 23 August 2017.

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.

Details of homeTotal number of allocated places: 54

Number of care recipients during audit: 50

Number of care recipients receiving high care during audit: 50

Special needs catered for: N/A


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

Interviews

Position title Number

Care recipients 13

Representatives 8

Locum executive director 1

Executive director 1

Acting care director 1

Quality manager NSW 1

Registered nurses 3

Care staff 8

Lifestyle staff 2

Administration assistant 1

General practitioner 1

Physiotherapist 1

Occupational therapist 1

Property manager 1

Maintenance officer 1

Cleaners 2

Chef and catering staff 2

Laundry staff 2

Sampled documents

Document type Number

Care recipients’ files (assessments, progress notes, care and lifestyle plans and associated documentation)

8

Medication charts 8

Personnel files 6


Document type Number

Residency agreements 6

Other documents reviewedThe team also reviewed:

Accident and incident reports

Behaviour management: behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, bed rail restraint risk assessments and authorisations

Cleaning schedules and workbooks

Clinical monitoring records: anticoagulant therapy, blood glucose levels, blood pressure, neurological observations, sight charts, pain, hygiene and pressure relief turning charts, case conference records, care plan review schedule

Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care

Education documentation: calendars, education training attendance records, educational resource information, staff mandatory training requirements, staff competency assessment information, education and training reports

Equipment registers and lists

External service: providers’ contracts and service agreements, certificates of currency (insurances), contract list and service records

Fire and emergency documentation: annual fire safety statement, evacuation plans, fire equipment audits and testing records, emergency evacuation signage, emergency procedures guide flipchart

Food safety program: food safety monitoring records, care recipients’ dietary requirements and food preference information and menu; dietetic review of menu report, NSW Food Authority licence and audit report

Human resources documentation including policies and procedures, staff handbook, staff orientation program, job descriptions, duty statements, staff rosters, performance management documentation, privacy and confidentiality statements, orientation program, staff information register

Infection control: fluvax register care recipients and staff, outbreak management resource folder, infection control guidelines, Public Health Unit line listing reports, training records, pest management service records

Information system documentation including policies and procedures, flowcharts, meeting minutes, memoranda, handover record, handbooks and information packages, communication diaries, memorandum folders, notices, survey results, contact lists, organisational information

Lifestyle management: lifestyle past history “About Me”, leisure and spiritual assessments, activity plans, attendance records, activity evaluations, consent forms

Maintenance documentation including preventative maintenance schedules, maintenance and approved supplier register, maintenance service reports and warm


water temperature check records, external service agreement documentation, contractor site induction and orientation checklists

Medication management: medication administration plans, signing sheets, PRN medication (whenever necessary) evaluations, clinical refrigerator temperature monitoring records, medication incident reports, nurse initiated medication forms, Drugs of addiction registers, complex health care directives diabetic management, professional signatures register

Mobility: mobility assessments, physiotherapy care plans, individual exercise, massage and heat pack therapy attendance records

Nutrition and hydration: nutritional preferences assessments, weight monitoring records, dietitian reviews/management plans, speech pathologist reviews/reports, menu, nutrition and hydration, supplements list, catering documents and notices regarding preferred diets and food allergies

Pain management and palliative care: pain assessments, pain management plans, advanced care plan directives, palliative specialised nursing care plans

Quality management system: Mission, Vision and Values statements, organisational chart, audit schedules, audit results and reports, clinical indicator reports, plans for continuous improvement, compliments and complaints

Regulatory compliance documentation: incident management reporting system includes reportable incidents, staff criminal records checks, professional registration records, visa records, electrical equipment inspection register and consent forms for the collection and handling of private information

Self-assessment report for re-accreditation and associated documentation

Skin integrity: wound assessments and management plans, photographic wound monitoring records, pressure care directives , podiatry assessments and reports

Work health and safety system documentation: incident and hazard reports, work health and safety documentation, safety data sheets, risk assessment documentation, workplace health and safety inspection checklists

ObservationsThe team observed the following:

Activities in progress

Complaints documentation, advocacy service brochures, information pamphlets on display

Dining environment during midday meal service and morning and afternoon teas including staff serving meals, supervision and assisting care recipients

Electronic and hardcopy record keeping systems - clinical and administration

Equipment and supplies in use and in storage such as lifting equipment, manual handling aids, mobility equipment, motion sensor lights, bed sensor mats and pressure relieving aids in use and in storage; clinical stores and continence aids

Fire safety systems and equipment, evacuation kit, security systems, signing in/out sheets

Infection control including: outbreak supplies, spill kits, sharps disposal containers, hand-washing facilities, waste disposal, hand sanitiser dispensers around the home, general and contaminated waste disposal systems, cytotoxic waste disposal system, colour coded cleaning equipment and personal protective equipment

Interactions between staff ,care recipients and representatives


Living environment

Mobility equipment in use including mechanical lifters, wheel chairs, shower chairs, low-low beds and hand rails in corridors

Information noticeboards

Nurse call system in operation

Re-accreditation audit notice on display.

Secure storage of care recipients' clinical files and confidential staff handover

Secure storage of medications and oxygen; medication administration

Short group observation in red lounge

Sign in/out registers, entry/exit key pad access

Staff work practices and work areas including administrative, clinical, lifestyle, catering, cleaning, laundry and maintenance

Vision, Mission and Philosophy statements and Charter of Care Recipients' Rights and Responsibilities displayed

Wound dressing trolley and wound management supplies


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

Standard 1 – Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The home has a systematic approach for actively pursuing continuous improvement. The continuous improvement system is supported by an overall quality structure that has both local and organisational dimensions. The home utilises a continuous improvement system including performance review mechanisms. Improvements are identified through a number of avenues including care recipient and representative meetings, staff meetings, audits, surveys, and review of clinical data. The home also utilises surveys, benchmarking, suggestions, incidents and staff performance appraisals. Part of this system includes ensuring compliance with the Accreditation Standards through the audit program. These mechanisms provide for input and feedback by stakeholders.

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

In order to promote a more robust education system the home introduced tool box talks. These tool box talks are short, information packed sessions, relevant to the topic of the day that changes dependant on the care recipient population. Review of education evaluation tools and interview with staff shows the tool box talks have been informative. These sessions will continue indefinitely.

The organisation has had a restructure at the corporate level during late 2016. The restructure has provided the home with a more regional/local approach to the policies and procedures. For example, the corporate office collects data on changing policies and guidelines nationally. These are disseminated across the relevant state and territory, and the home has a legislative update folder to collect and collate such information. The home’s online access to policies and procedures is updated centrally with such information. Management said the new regional/local approach has been effective in providing two-way communication at the local level.

Through the corporate restructure a chief nursing officer position has been developed. The home reported this position has been instrumental in updating policies and procedures consistent with state and local legislative and regulatory requirements. For example, the home has recently updated the insulin administration and diabetic management guidelines policies and procedures.


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


The home has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home is advised of any changes in regulatory requirements and professional standards by the corporate office. The corporate office monitor the regulatory environment through updates from government and industry bodies, industry conferences, internet access and various other mechanisms. Staff are advised of regulatory requirements and any relevant changes to them through various means including memos, updates to policies, meetings and education. Compliance with regulatory requirements and other standards is monitored through a comprehensive audit program as well as day-to-day supervisory arrangements. We sighted relevant legislation and/or legal documentation displayed in various locations in the home.

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

Ensuring care recipients and representatives were informed of the re-accreditation audit in keeping with legislative requirements

Ensuring care recipients and other stakeholders have access to complaints mechanisms

Ensuring police certificate checks and relevant visa requirements are undertaken for staff, volunteers and relevant contractors

Monitoring external service providers for applicable insurances, registrations, licences and other necessary regulatory requirements.

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


It was evident from our observations, document review and interviews that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has an education program which is based on educational needs identified through a wide range of mechanisms. These include feedback from various meetings, quality improvement systems and individual input from staff, care recipients and representatives. The education program encompasses all four Accreditation Standards, including Standard 1 Management systems, staffing and organisational development. The program is reinforced by competency assessments and online interactive education questionnaires in relevant areas. Staff also have access to external educational opportunities and, where appropriate are supported to obtain formal qualifications.

Examples of recent education sessions related to Standard 1 include:

Accessing policies and procedures

Clinical documentation

Appropriate workplace behaviour – bullying, harassment and discrimination

Compulsory reporting in residential care


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


The home has policies, procedures and processes to ensure each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Care recipients and representatives and staff are made aware of internal and external complaints mechanisms through the care recipients’ handbook, the residency agreements, newsletters, complaints forms and care recipients’ meetings. There is a procedure to ensure any complaints raised are recorded for review, action, follow up and feedback in a timely manner. Care recipients and representatives advised they feel comfortable approaching management about any concerns or suggestions they may have.

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


The home is a part of the Estia organisation and, as such, comes under its overall vision, values, philosophy, objectives and commitment to quality. These are encapsulated in its vision and values statements that have been documented and communicated to all stakeholders in the home. These statements are published in key documentation including resident and staff handbooks. In addition, staff are made aware of these statements through the home’s staff recruitment, orientation and education processes, staff meetings and other communication.

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


The home has a system of human resource policies and procedures. This system ensures appropriate staffing and skills levels for quality service provision, in accordance with the Accreditation Standards and the home’s philosophy and objectives. The system includes appropriate recruitment and selection processes, induction, education, and performance management. There are also processes to ensure that staffing levels are sufficient to cater for the mix of care recipients, their changing needs and the demands of the home’s daily routine. We noted that many care and other staff have obtained qualifications and/or attended specific education relevant to their job roles.

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



There are policies and procedures for ensuring there are stocks of appropriate goods and equipment available for quality service delivery. The home has an overall purchasing system of preferred suppliers designed to ensure desired standards are met. A stock control and ordering system is in operation, with particular staff roles having specific responsibility for particular areas of inventory monitoring and ordering. The home also has clear procedures for purchasing necessary equipment for use in various functional areas and in response to care recipients’ needs. We observed storerooms, staff areas, clinical areas, the kitchen, laundry and other work areas to be well equipped, well stocked and well maintained. Staff advised there were adequate supplies of inventory and equipment for them to perform their job roles effectively. A routine and preventive maintenance program is in operation which, among other things, ensures equipment is maintained and ready for use.

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


The home has an information management system that provides relevant information to stakeholders. The home’s communication system includes meetings, handbooks for staff, information pack for care recipients, policies and procedures, noticeboards, staff handovers and a clinical documentation system. The home utilises these communication channels alongside management’s open-door policy to disseminate information and to collect feedback. The information management system governs the collection, processing, accessing, reporting, storage, archiving and destruction of information and records. The home has policies covering relevant regulatory requirements for management of information and records including confidentiality and privacy matters. Access to confidential information and records is controlled and limited to authorised staff. Observations demonstrated that care recipient and staff files are stored securely. Staff confirmed they receive and have access to relevant information that allows them to perform their roles effectively. Care recipients and representatives stated they are well informed regarding care recipients’ needs and all other matters appropriate to them.

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


The home’s externally sourced services are arranged primarily by way of specified contract agreements. A range of contractors and external service providers operate within these agreements covering care recipient and care related services, fire systems and various building maintenance and services. Service agreements encompass the home’s requirements/expectations for quality service provision, relevant insurances and police checks where appropriate. The home’s management and staff monitor the performance of external service providers and take appropriate action in order to ensure that services are provided at the desired level of quality. The home also relies on feedback from care recipients and representatives to assess the quality of service providers such as physiotherapy, podiatry, hairdressing and other similar care recipient-related services. It was reported there are good working relationships with the range of external service providers and services are being provided at desired levels.


Standard 2 – Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



The home's well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 2 Health and personal care.

Examples of specific improvements relating to Standard 2 include:

A new dietary preference system was introduced in August 2017. The electronic management system collects data on dietary changes such as consistency of food and fluids. The changes are overseen and reviewed by allied health professionals. Changes made on the electronic management system then communicate changes to the registered nurses in the home. Registered nurses then print up new labels for the kitchen. We observed the coloured labels in the kitchen depicting different dietary and consistency of food requirements.

Through feedback, usage and development of the quality system, the home has recently commenced detailed analysis of clinical indicator data. Detailed analysis involves the use of drilling down in the data to extrapolate times and places where incidents occur, to better identify the causative factors. Management report the new clinical indicator data is very useful in identifying and resolving causes.

As a result of the call bell audit July 2017, repairs were made to the call bell system. In addition, the home is in the process of purchasing a number of portable electronic call bells. The portable bells will be used by care recipients as they move around the home. The improvements to the call bell system have ensured care recipients can suitably alert staff to their need.

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


The home's systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard 2 Health and personal care.

Examples of regulatory requirements in relation to Accreditation Standard 2 include:

Having appropriate arrangements in operation to ensure the correct management and administration of medications

Monitoring relevant registrations of nursing and allied health professionals


Having policies and procedures in operation to ensure the Department of Health is notified if care recipients are reported missing without explanation and the police are notified.



The home's comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 2 Health and personal care.


Documentation and assessments

Medication management

Oral and dental health

Diabetes management

Continence aids and management

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


There are systems and processes to ensure care recipients receive appropriate clinical care and policies and procedures to guide staff practice. The care director oversees clinical care at the home. Twenty four hour registered nursing care is provided and a comprehensive program of assessments is completed on entry. Individualised care plans are formulated, regularly reviewed and monitored by registered nurses. Care is planned in consultation with the care recipient and/or their representative, the care recipient’s medical practitioner and allied health professionals. Staff have a sound understanding of the clinical care process. The home has appropriate supplies of equipment and resources maintained in good working order to meet the ongoing and changing needs of care recipients. Care recipients and representatives state they are satisfied with the clinical care provided and representatives say they are informed of changes in the care recipient’s condition and care needs.

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


There are systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Documentation and discussions with staff show care recipients’ specialised nursing care needs are identified when they move into the home and are addressed in the care planning process. Registered nurses coordinate assessments on the care recipients’ specialised care needs. The home liaises with external health professionals including the Local Area Health Service to ensure care recipients’ specialised nursing care needs are met. Staff access internal and external education programs and there are appropriate resources and well maintained equipment to provide specialised nursing


care. Care recipients and representatives are satisfied with the specialised nursing care provided.

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


Documentation shows the home refers care recipients to external health professionals and any changes to care following specialist visits are implemented in a timely manner. An occupational therapist is on site five days a week and several allied health professionals visit the home on a regular basis including pathology services, the podiatrist, the dietitian, speech pathologist, nurse practitioner and the Area Health Service Mental Health team. Representatives report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care are implemented.

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


Management demonstrates care recipients’ medication is managed safely and correctly. Registered nurses administer medications via a blister packaging system. A current pharmacy contract and locked storage of medication promotes safe and correct management of medication to care recipients. The medication system includes photographic identification of each care recipient with their date of birth and clearly defined allergies. Pharmacy and medical practitioner protocols have been established in the home and staff practices are consistent with policy and procedures as evidenced through audits and training. The medical advisory committee review legislation changes, medication and pharmacy issues. Regular medication reviews are completed by a consultant pharmacist. Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned by the care director. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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


There are systems to ensure all care recipients are as free as possible from pain. Initial assessments identify any pain a care recipient may have and individual pain management plans are developed. Staff are trained in pain prevention and management and use verbal and non-verbal pain assessment tools to identify, monitor and evaluate the effectiveness of pain management strategies. Documentation shows strategies to prevent and manage care recipients’ pain include attendance to clinical and emotional needs, medication and alternative approaches including heat, massage and pressure relieving devices. Pain management measures are followed up for effectiveness and referral to the care recipient’s medical practitioner and other services is organised as needed. Staff regularly liaise with medical practitioners and allied health personnel to ensure effective holistic care planning.


Care recipients and representatives report care recipients are as free as possible from pain and staff respond in a timely manner to their requests for pain control.

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


There are systems to ensure the comfort and dignity of terminally ill care recipients and support for their families and those involved in their care. Documentation and staff discussions show the spiritual, cultural, psychological and emotional needs of care recipients are considered in care planning and ongoing pastoral care and emotional support is provided. Representatives are informed of the palliation process and the home is in regular communication with representatives, medical practitioners and specialists throughout the palliative care process.

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


Documentation demonstrates care recipients’ nutrition and hydration status is assessed on entry to the home and individual needs including swallowing difficulties, sensory loss, special diets and individual preferences are identified and included in care planning. Appropriate referrals to the speech pathologist, dietitian and dentist are made in consultation with the care recipient/representative and others involved in their care. The seasonal menu is reviewed by a dietitian and provides care recipients with an alternative for the midday and evening meal. Care recipients are weighed monthly or more often if indicated and weight loss/gain monitored with referral to medical practitioners or allied health for investigation and treatment as necessary. Nutritional supplements and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements including thickened fluids, pureed and soft food. Care recipients and representatives are satisfied with the frequency and variety of food and drinks supplied.

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


Care recipients’ skin integrity is assessed through the initial assessment process. Staff monitor care recipients’ skin care as part of daily care and report any changes in skin integrity to the registered nurse for assessment, review and referral to their medical practitioner as needed. Staff have access to sufficient supplies of appropriate equipment and resources to meet the needs of care recipients. Staff receive ongoing training and supervision in skin care and the use of specialist equipment such as lifting devices used to maintain care recipients’ skin integrity. The home has a wound committee, the reporting system for accidents and incidents includes skin integrity and is monitored monthly and included in the quality clinical indicators. Care recipients have access to the occupational therapist and other external health professionals. Care recipients and representatives report


staff pay careful attention to care recipients’ individual needs and preferences for skin care. Observation confirms the use of pressure relieving and limb protecting equipment.

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


There are systems to ensure care recipients’ continence is managed effectively. The continence link nurse and the care director oversee continence management at the home. Clinical documentation and discussions with staff show continence management strategies are developed for each care recipient following initial assessment. Care staff report they assist care recipients with their continence programs regularly and monitor care recipients’ skin integrity. Staff are trained in continence management including scheduled toileting, the use of continence aids and the assessment and management of urinary tract infections. Bowel management strategies include daily monitoring. Staff ensure care recipients have access to regular fluids, appropriate diet and medications as ordered to assist continence. There are appropriate supplies of continence aids to meet the individual care recipient’s needs. Care recipients and representatives state they are satisfied with the continence care provided to the care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behavioural management needs are identified by initial assessments and behaviour care plans formulated. Behaviour management strategies include one-on-one and group activities which are regularly reviewed in consultation with the care recipient and/or representatives and other specialist services. Staff confirm they have received education in managing challenging behaviours and work as a team to provide care. The home has access to other health professionals including the Area Health Service Mental Health Team. Staff were observed to use a variety of management strategies and resources to effectively manage care recipients with challenging behaviours and to ensure the care recipients’ dignity and individual needs were respected at all times. Care recipients and representatives are satisfied with how challenging behaviours are managed at the home.

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


There are systems to ensure optimum levels of mobility and dexterity are achieved for each care recipient. Systems include comprehensive assessments, the development of mobility and dexterity plans and mobility programs. There is an occupational therapist on site five days a week. Individual programs are designed to promote optimum levels of mobility and dexterity for all care recipients. Falls incidents are analysed and are monitored in the quality clinical indicators. Care recipients and representatives report appropriate referrals to the occupational therapist are made in a timely manner. The home has a fall prevention


committee; staff are trained in falls prevention, manual handling and the use of specialist equipment. Assistive devices such as mobile frames, walk belts, mechanical lifters and wheelchairs are available.

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


There are systems to ensure care recipients’ oral and dental health is maintained. Oral and dental health is assessed on entry to the home and documented on care plans. Staff state they receive education in oral and dental care and assist care recipients to maintain daily dental and oral health. Swallowing difficulties and pain are referred to the medical practitioner or allied health services for assessment and review. Care recipients and representatives state care recipients are provided with appropriate diets, fluids, referral and equipment to ensure their oral and dental health is maintained.

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


Sensory loss is assessed on entry to the home and appropriate referrals are made to ensure care recipients’ care needs are managed effectively. Specialist equipment is maintained in good working order and staff are trained in sensory loss. Staff have implemented programs to assist care recipients with sensory stimulation including of taste, touch and smell. Care recipients and representatives report staff are supportive of care recipients with sensory loss and promote independence and choice as part of daily care.

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


Care recipients’ sleep patterns including a history of night sedation are assessed on entry and sleep care plans are formulated. Lighting and noise is subdued at night. Care recipients’ ongoing sleep patterns are reviewed and sleep disturbances monitored and appropriate interventions put in place to assist care recipients to achieve natural sleep. Staff report care recipients who experience sleep disturbances are assisted with toileting, repositioning, snacks and fluids as requested and assessed as needed. Care recipients and representatives are satisfied with the way care recipients’ sleep is managed.


Standard 3 – Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



The home's well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 3 Care recipient lifestyle.

Examples of improvements relating to Standard 3 include:

The organisation has introduced a 24-hour manned 1800 number for advice and reporting. There is an email also available for advice on any policy, procedure, outbreak or mandatory reporting matter. Emails sent are raised with three senior managers in the group whom respond promptly. The 24-hour manned phone line provides staff advice on and reporting for any outbreak, mandatory reporting matter, or other relevant operational concerns. Interview with management and staff show the 24-hour manned phone line has been most helpful.

The home uses an electronic care platform. Lifestyle staff also document their assessment and delivery of lifestyle needs to care recipients on the electronic platform. In July 2017, the home introduced an About Me assessment tool. The assessment tool collects more personal data on care recipients’ preferences and previous life experiences including significant events. This data is then incorporated into the care recipient’s plan of care. Lifestyle staff say the new tool has added more valuable personal information increasing their capacity to provide more individualised activities.

Alongside the About Me assessment tool, as above, the home introduced the Brighter Life Program, in July 2017. The Brighter Life Program has been developed along the lines of the Montessori principles. These principles provide for a more individual focus on capability and involvement for the satisfaction of the individual. Interview with care recipients/representatives shows involvement in lifestyle activities has improved.

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


The home's systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard 3 Care recipient lifestyle.

Examples in relation to regulatory requirements for Standard 3 include:

Having various arrangements in operation to meet obligations regarding staff and care recipients' confidentiality and privacy provisions


Ensuring care recipients' security of tenure and informing care recipients of their rights and responsibilities

Having mechanisms to ensure the appropriate reporting of suspected or alleged incidents of elder abuse.



The home's comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 3 Care recipient lifestyle.


Compulsory reporting in residential care

Quality of life program

Meaningful activities and engagement for someone with dementia

Specific education related to leisure and lifestyle staff.

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the leisure and lifestyle officers, care recipient/representatives’ meetings and involvement of family in the activity program. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors including pets are encouraged. Care recipients and representatives are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive.

3.5 IndependenceThis expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Community visitors, volunteers and entertainers are encouraged and arranged. The environment encourages care recipients, their representatives and their friends to participate in activities. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.


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


There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs, including the care recipient’s preferred name. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Care recipients’ rooms are managed so that privacy is not compromised; lockable storage is available to all care recipients. Staff handovers and confidential information is discussed in private and care recipients’ files securely stored. Staff practices respect privacy and dignity and care recipients and representatives are satisfied with how privacy and dignity is managed at the home.

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


The lifestyle program offers an extensive range of activities five days a week. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. Lifestyle programs include concerts, bus outings, entertainers, bingo, word games, monthly theme days, weekly happy hour, daily exercise classes and armchair travel. Care recipients are given the choice of whether or not to take part in activities. The results of interviews, document review and observations confirm care recipients and representatives are highly satisfied with the activities provided to the care recipients.

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


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients/representatives are asked about end of life wishes and this information is documented in their file. Pastoral visitors of various denominations regularly visit and religious services are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met.

3.9 Choice and decision-makingThis expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to


exercise choice and control over his or her lifestyle while not infringing on the rights of other people".


Management demonstrates each care recipient participates in decisions about the services the home provides and is able to exercise choice and control over their lifestyle through consultation around their individual needs and preferences. Management has an open door policy and this promotes continuous and timely interactions between the management team, care recipients and/or representatives. Observation of staff practices and staff interviews show care recipients have choices available to them including waking and sleeping times, shower times, meals and activities. Care recipients/representatives meetings and surveys occur regularly to enable care recipients and representatives to discuss and provide feedback about the services provided. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


Care recipients and representatives reported they are satisfied with the information the home provides to care recipients on entry regarding care recipients’ entitlements, details of tenure as well as the fees and charges. Designated staff members explain the care recipient accommodation agreement to care recipients and representatives prior to care recipients coming to live at the home. Care recipients and representatives are advised to seek independent legal and financial advice. The care recipient and representatives’ handbook which is provided to care recipients on entry contains information about the services available, privacy and confidentiality, processes for making complaints and care recipients’ rights and responsibilities. Management explained the process for room changes within the home and advised that agreement is always reached prior to any room changes occurring.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



The home's well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 4 Physical environment and safe systems.

Examples of improvements relating to Standard 4 include:

Commencing in February 2017 the home has commenced using the organisational electronic food ordering system. The electronic ordering system is centrally managed through the organisation’s head office. The home now orders all foods online and the order is passed through head office before being sent to the supplier. The use of this system has ensured food purchased is consistent with the menu provided. Management report this system has assisted with the provision of additional foods for care recipient special event days.

Commencing November 2016, the home has been refurbished. The look, feel and comfort of the home has been greatly improved. The main corridors have new flooring and new lighting. The corridors were observably bright. There is also a new hairdressing salon in the middle of the home. The salon was observed to have modern décor. Staff and care recipient’s and representative’s interviews show the new hairdressing salon has received great reviews.

The kitchen has been refitted with a new combi oven. The combi oven was observed to be in self-clean mode during the site visit. Catering staff report food is reheated more effectively with the new combi oven. Interview with care recipients and representatives show some improvement in the temperature of food since the combi oven was installed.

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


The home's systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards, including Standard 4 Physical environment and safe systems.

Examples of regulatory requirements in relation to Standard 4 include:

Displaying relevant regulatory information concerning work health and safety legislation

The installation of fire safety systems including sprinklers, displaying the annual fire safety statement in accordance with legislative requirements, and staff undertaking mandatory fire safety training


Various arrangements to ensure the home meets food safety requirements such as those encompassed in the NSW Food Authority's vulnerable person's food safety scheme and its licensing and audit requirements.



The home's comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 4 Physical environment and safe systems.


Fire safety and evacuation

Manual handling (including use of lifters and other equipment)

Infection control (including hand washing)

Work health and safety

Outbreak management

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


The home implements ongoing mechanisms that demonstrate they are continuing to improve the safety and comfort of care recipients in their living environment. These mechanisms include regular environmental safety inspections, cleaning, maintenance and other safety related checks, and incident and accident reporting. There are also care recipient feedback mechanisms, such as care recipient and representatives’ meetings and direct discussions with management, in relation to the comfort and safety of the living environment. Care recipients and representatives stated the home is safe and comfortable. This view was also supported by various safety monitoring and reporting data we reviewed.

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


There are effective mechanisms in operation to ensure management is actively working to provide a safe working environment that meets regulatory requirements. The system includes regular staff training, regular safety related audits and inspections, hazard reporting, accident and incident reporting and risk assessments. A preventative and routine maintenance program is in operation in the home, which helps ensure the overall safety of the environment and equipment. Chemicals are appropriately stored and safety data sheets and personal protective equipment is available at point of use. Staff demonstrated knowledge and understanding of workplace safety issues and responsibilities and we observed safe practices in operation.


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


The home has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire evacuation plans, emergency procedure documentation and exit signs are located throughout the home. Monitoring and maintenance of all fire and alarm equipment is undertaken by contractors and reports provided. Fire equipment is located throughout the home. Appropriately responding to emergency training is included in the orientation program and there are mandatory annual updates. Staff are aware of procedures to be followed in the event of an emergency. Emergency evacuation documentation is readily available which includes information detailing care recipients’ care needs and relevant contact information. Staff stated they are aware of and understand their responsibilities in the case of fire and other emergencies.

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


The home has an infection control program in place. This includes audits, ongoing monitoring of infection rates, staff education and policy and procedure relating to infection control. Infection data is collected and analysed internally as well as through the benchmarking program across the homes within the organisation. Infection control procedures such as colour coded equipment; personal protective equipment and monitoring of temperatures were observed. There are processes for the removal of contaminated waste and spills kits and sharps containers are available. Staff interviewed could describe the use of infection control precautions in their work such as the use of personal protective equipment and colour coded equipment.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Care recipients and representatives expressed satisfaction with the hospitality services provided at the home.

Care recipients’ dietary needs and choices are assessed and documented on entry to the home and details provided to catering staff. All food is cooked on site. There is a food safety program and the home has a current NSW Food Authority licence. The home has a seasonal menu with input from a dietitian. We observed food preparation and service and staff practices are according to the appropriate food safety guidelines, including infection control requirements. Appropriate staff have undertaken training in relation to appropriate food handling and infection control. Care recipients said they are satisfied with catering services provided.

The home presents as clean, fresh and well maintained. Cleaning staff perform their duties guided by documented schedules, work instructions and results of inspections. Cleaning equipment is colour coded and chemicals are securely stored. Staff are trained in the use of equipment, infection control, outbreak management procedures and work, health and safety.


Staff demonstrated a good knowledge of infection control, manual handling requirements and safe handling of chemicals.

Laundry services are provided on site. Dirty laundry is collected in appropriate coloured linen bags and transported to the laundry area. There are procedures and work instructions for the collection and handling of linen. Staff described the processes for the collection and transportation of dirty clothes and linen and distribution of clean linen and clothes to care recipients. Staff confirmed they receive training in infection control and safe work practices.


Documents

Published_decision_(SA_and_RA) - aacqa.gov.au Web viewFood safety program ... Registered nurses administer medications via a blister packaging ... The care recipient and representatives’