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Fairlea Aged Care@Harris ParkRACS ID: 0579

Approved provider: Trinity Aged Care Pty Ltd

Home address: 7-11 Crown Street HARRIS PARK NSW 2150

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 13 February 2021.

We made our decision on 30 November 2017.

The audit was conducted on 17 October 2017 to 18 October 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: Fairlea Aged Care@Harris Park Date/s of audit: 17 October 2017 to 18 October 2017RACS ID: 0579 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: Fairlea Aged Care@Harris Park Date/s of audit: 17 October 2017 to 18 October 2017RACS ID: 0579 3

Audit ReportName of home: Fairlea Aged Care@Harris Park

RACS ID: 0579

Approved provider: Trinity Aged Care Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 17 October 2017 to 18 October 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 17 October 2017 to 18 October 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: 50

Number of care recipients during audit: 50

Number of care recipients receiving high care during audit: 47

Special needs catered for: Those living with dementia – 12 places


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

Interviews

Position title Number

Facility director 1

Care manager 2

Registered nurse 2

Care staff 7

Physiotherapist 1

Chaplain 1

Administration officer 1

Catering staff 2

Care recipients and/or representatives 13

Fire safety officer 1

Area manager and supervisor contracted cleaning service

2

Cleaning staff 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files 6

Summary and/or quick reference care plans 6

Medication charts 6

Personnel files 4

Residents agreements 4

Other documents reviewedThe team also reviewed:

Activities programs including newsletters, weekly calendars, activity records and valuations, attendance forms


Annual education calendar, attendance records and evaluations, competency assessments

Care recipient meal preferences, diet requirements and menu

Care recipients’ information package and handbook

Clinical and care assessment documentation including assessments for initial and ongoing care recipient care needs and preferences needs and preferences such as care recipient dietary and observation charts including weighs , blood glucose levels, continence, behaviour, sleep skin integrity, pain, mobility, fall risk, toileting, wound assessment and authorization for restraint forms and case conference forms. Recruitment policies and procedures

Communication folders and diaries, end of shift handover sheets

Continuous improvement documentation including plan for continuous improvement, comments/complaints register, feedback forms, audit schedule, audit and survey results, clinical indicator records

Falls prevention program records

Human resource documentation including recruitment policies and procedures, orientation documentation, position descriptions and duty statements, confidentiality agreements, criminal record checks, professional staff registration records

Infection surveillance data audit reports

Influenza vaccination records staff and care recipients

Leisure and lifestyle assessment

Mandatory reporting register and reportable assault flowchart

Medication management policy and procedures

Meeting minutes

NSW Food authority audit report, food safety manual, cleaning, temperature and sanitising records consistent with hazard analysis critical control point (HACCP) requirements

Physiotherapy assessments and records

Policies and procedures

Preventative maintenance schedule, maintenance logs, legionella testing and pest control records

Roster, shift availability form

Speech pathology reports

Staff handbook

Work health and safety manual, incident management procedure, incident response process

ObservationsThe team observed the following:

Activities in progress and activity program on display

Archive room

Care recipient call system

Cleaning cupboards and cleaning in progress


Dining environment during lunch and beverage services with staff assistance, morning and afternoon tea, including care recipient seating, staff serving/supervising, use of assistive devices for meals.

Equipment and supply storage areas and equipment in use

Equipment and supply storage rooms including clinical, medication, oxygen and linen stock in sufficient quantities and equipment available and in use for manual handling such as hand rails, ramps lifters and mobile walkers

Hand washing station

Infection control resources including hand washing facilities and hand sanitisers, spills kits, sharps containers, contaminated waste disposal, chemical storage, personal protective and colour coded equipment, outbreak kit

Information noticeboards and notices displayed including Care Recipients Rights and Responsibilities and Complaints information in English and Chinese

Interactions between staff, care recipients and representatives

Laundry collection and distribution

Lifting equipment and manual handling aids

Living environment internal and external

Medication administration and safely stored medications

Mobile X ray in attendance

Secure storage of care recipients’ information

Short group observation in Joy wing

Staff practices and interactions with visitors and allied health

Staff work areas including nurses’ station and utility rooms

Suggestion forms and suggestion boxes


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

Fairlie Aged Care@Harris Park has a quality improvement system that supports the organisation’s Vision and Values and promotes continuous quality improvement. Information is obtained through comments and complaints, results of audits and surveys, incident reports, meetings, observation and informal feedback from staff, care recipients and representatives. A continuous improvement plan is developed with corrective action plans to address identified issues, and ongoing monitoring occurs. Feedback to key stakeholders including management, staff, care recipients and family members is through meeting minutes, memoranda, noticeboards and newsletters.

Continuous improvement activities undertaken in relation to Accreditation Standard One – Management Systems, Staffing and Organisational Development include:

Review of the levels of care recipient need demonstrated more care hours were required to meet these needs. Additional hours were provided for the dementia unit and two other wings. Feedback from families has been very positive including “we are very pleased to see more staff”

Duty statements were reviewed in consultation with the staff to accommodate the extra hours. Feedback from staff has been positive as they are now able to work in pairs to support the increased needs of care recipients.

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”.


There are systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Information is obtained through peak industry bodies, circulars and bulletins from government and non-government departments and professional organisations. Regulatory issues and updates are communicated to staff through memoranda, meetings and education sessions. Staff state they are made aware of regulatory issues and that they have access to information regarding legislative and regulatory requirements.


Examples of the monitoring and compliance with regulatory requirements relevant to Accreditation Standard One are:

A system to ensure all criminal record checks and professional qualifications remain current.

Notification to care recipients and representatives of reaccreditation site audits

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


The home's processes support the recruitment of staff with the required knowledge and skills to perform their roles. New staff participate in the orientation program that provides them with information about the organisation, key policies, and procedures and equips them with mandatory skills for their role. Staff are scheduled to attend regular mandatory training and attendance is monitored. The effectiveness of the education program is monitored through attendance records and observation of staff practice. Care recipients and representatives interviewed are satisfied staff have the knowledge and skills to perform their roles and staff are satisfied with the education and training provided. Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include:

Elder abuse and mandatory reporting

Workplace bullying and harassment

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".


There are systems to ensure that care recipients, their representatives and other interested parties have access to internal and external complaints mechanisms. Internal mechanisms include meetings, feedback forms, and discussions with management. Care recipients and family members are encouraged to address any concerns directly with the home’s management. Information on external complaints mechanisms is available and detailed in the care recipient handbook and care recipient agreement. Care recipients and representatives interviewed are aware of complaints mechanisms

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 Vision, Values and Philosophy of Fairlie Aged Care was developed in consultation with staff and is documented and displayed in the facility. The home’s continuous improvement plan demonstrates its ongoing commitment to quality care and service. Management and staff are aware of and understand the philosophy of the organisation and their commitment can be observed in the practices and attitudes and interactions between management, staff and care recipients/ representatives.


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 systems and processes to ensure there are sufficiently skilled and qualified staff to deliver services at the home. Recruitment, selection and orientation processes ensure staff have the required knowledge and skills to deliver services. Staffing levels and skill mix are reviewed in response to changes in care recipients' needs. The home's monitoring, human resource and feedback processes identify opportunities for improvement in relation to staff development. Staff are satisfied they have sufficient time to complete their work and meet care recipients' needs. Care recipients and representatives interviewed are generally satisfied with the availability of skilled and qualified staff and however two care recipients commented that some staff required more training.

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


The home has processes to monitor stock levels, order goods and maintain equipment to ensure delivery of quality services. Goods and equipment are securely stored and, where appropriate, stock rotation occurs. Preventative maintenance and cleaning schedules ensure equipment is monitored for operation and safety. The home purchases equipment to meet care recipients' needs and maintains appropriate stocks of required supplies. Staff receive training in the safe use and storage of goods and equipment. Observation, management and staff interviews demonstrate there are appropriate levels of stock and equipment including medical supplies, food, chemicals, furniture and linen, to provide quality care and services to care recipients.

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


The home has systems to provide all stakeholders with access to current and accurate information. Management and staff have access to information that assists them in providing care and services. Information is stored securely, electronic information is password protected and hard copy records are securely stored. Processes are in place for backup, archiving and destruction of records according to legislative requirements. Key information is collected, analysed, revised and updated on an ongoing basis. Data obtained through information management systems is used to identify opportunities for improvement. Staff interviewed stated they are satisfied they have access to current and accurate information. Care recipients and representatives interviewed are satisfied that information provided is appropriate to their needs, and supports them in decision-making

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".



There are mechanisms to identify external service needs. The home's expectations in relation to service and quality is specified and communicated to external providers. The home has agreements with external service providers which outline minimum performance and regulatory requirements. There is a process to review the quality of external service providers and where appropriate, action is taken to ensure the needs of care recipients and the home are met. Staff are able to provide feedback on external service providers. Care recipients, representatives and staff are satisfied with the quality of externally sourced services.


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.



For details of the continuous improvement system refer to expected outcome 1.1 Continuous improvement in this report. Examples of continuous improvement activities relevant to Accreditation Standard Two include:

Information regarding clinical indicators is normally discussed at staff meetings. Following external education the Facility Director has decided that data on for example: falls and medication incidents, be provided at care recipient/representative meetings, so that families are aware of issues and improvements made.

Purchase of new equipment including a lifter, additional slings and shower chairs to more easily support the needs of care recipients.

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”.


Refer also in this report to expected outcome 1.2 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to Accreditation Standard Two include:

A system to ensure the currency of professional staff registrations

A system to ensure medications are managed safely and correctly



Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to Accreditation Standard Two include:

Pain management

Continence management

Behaviour management


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


The home provides residents with appropriate clinical care through the provision of doctors’ reviews, initial and ongoing assessment of care recipients’ care needs, care planning and evaluation processes. A multi-disciplinary approach to the care recipient’s care is offered with case conferencing with care recipients and their representatives occurring yearly or when changes occur. Medical officers contact details are readily available or staff and there are arrangements for contacting medical officers after hours. We observed clinical care delivered is consistent with the care plans and is delivered in consultation with the medical officer and/or other allied health professionals where appropriate. Information in relation to the care recipient care needs is communicated between staff through progress notes, communication book, registered nurse handover report and the mini care plan in each of the care recipient files. Clinical care is monitored through daily observation, and review of clinical data is overseen by the care manager. Care recipients and representatives interviewed said they were informed about the clinical care required and are very satisfied with the care provided.

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”.


The need for specialist nursing care is identified on entry to the home and on an ongoing basis. Care plans are developed which suit the individual needs of the care recipient and identify their specialist care needs. Registered nurses in the home monitor the care recipients’ health status to detect changes, and if necessary appropriate referrals are made to a number of community support services including wound care and behaviour management. Staff are provided with education and appropriate equipment for specialised nursing care. Clinical records reviewed describe care required for individual care recipients, including diabetes management, stoma management and oxygen therapy. Referrals to health specialists and follow up of treatment prescribed were also reviewed. Care recipients said their specialised nursing care needs are appropriately met and representatives said they were kept informed at all times of any changes in the care recipients’ care needs and requirements.

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”.


The care recipients are able to access appropriate health specialists through requests, recommendations and referrals from their doctor. A number of health care specialists visit the home on a regular basis and as required; including a physiotherapist, podiatrist, nutritionist, dietician and speech pathologist. Other specialist health services, such as a wound consultant, palliative care nurse practitioner and the mental health team are accessed through local hospitals and the local area health service. There is a mechanism to monitor and follow up results for care services provided by external providers to ensure continuity of


care and relevant advice from theses specialists is included in the care recipients ‘care plans. Staff advised care recipients receive mainstream or alternate care provided by health specialists and related service professionals as needed. Care recipients and representatives said they are very satisfied with the access care recipients have to appropriate health specialists.

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


There are systems and processes to manage care recipients’ medication. This includes the prescription, dispensing, storage and administration of medications. Medications are administered by registered nurses and one certificate four trained care worker with a medication competency, using a unit dose packaging system. Observation of a medication administration round demonstrates staff carry out appropriate checking procedures in accordance with medication management policy. Staff are aware of, and respond to individual need such as time to ingest or breaking/crushing of medications. Medications are stored within a secure environment and checking procedures are in place. Medication incidents and errors are reviewed and discussed at appropriate meetings. There is regular review of medications by general medical practitioners and pharmacy services. Care recipients/representatives interviewed expressed satisfaction with the management of care recipients’ medications.

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


The care recipients have a pain assessment and initial pain history when they come into the home and on an ongoing basis. For all care recipients identified as experiencing pain a comprehensive pain assessment is conducted using appropriate tools. Consultations with the care recipient/representatives as well as doctor are utilised in developing a pain management plan. We noted that staff administered pain medication as prescribed and recorded. Observations of behaviour and nonverbal signs are used to asses care recipients’ with communication and/or cognitive deficits. The home provides a range of non- pharmacological interventions such as heat packs, massage, air mattress and one to one re-assurance and divisional therapy. Care recipients and representatives advised that the care recipients are as free of pain as possible and the treatment for the care recipient’s pain is provided regularly with pain relief can be accessed as required.

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


When care recipients enter the home information about advanced care directives is provided to them and their family for consideration. From this a care plan is developed in consultation with their nominated doctor. The home provides palliative care as needed and has protocols for palliative care which can easily be accessed by staff. Staff ensure the care recipients and family members are supported and the care recipient‘s advanced care directive is respected.


Staff have received training in palliative care and appropriate pain relief administration Emotional support is provided by the chaplain, visiting catholic group or the recreational activities officer. Care recipients and representatives said they were satisfied that the care and dignity of the care recipients would be maintained

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


Care recipients are assessed on entering the home for dietary needs and preferences, these are documented on the care recipients’ nutrition and hydration care plan that is reviewed every three months or more often as required. Care recipients are offered a varied, culturally specific healthy and well balanced diet. Special diets and dietary supplements are available to meet the care recipients’ individual needs. We observed staff assisting care recipients with their meals and assistive feeding devices were also provided when necessary. Care recipients receive appropriate fluids with drinks at all meals, morning and afternoon teas, diner and supper. Care recipients are weighed monthly or more often as directed by the doctor. The home refers to a dietician or speech pathologist as required. Care recipients/ representatives said they were satisfied with meals provided and that their dietary needs are being met.

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


On entry to the home care recipients’ skin integrity is assessed together with a pressure injury risk assessment. Skin care needs are identified and incorporated into their care plan which is evaluated every three months or as necessary. Incident reports are attended for skin tears and appropriate action taken. Wound care is carried out by a registered nurse and treatment and progress is documented in wound care charts. Pressure area care is provided for care recipients as needed and equipment is available to assist with pressure area care. A podiatrist visits the home on a regular basis to provide foot care. Skin care in the home is monitored on through daily observation by care staff and review of clinical data by registered nurses. Care recipients and representatives said care recipients are satisfied with the care provided.

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


All care recipients have a continence assessment on entry to the home and an individual management program based on data and input from care recipients/representatives. This is developed and documented in the care plan. The effectiveness of the prescribed care is regularly evaluated. Staff were observed to be responsive to the needs of the care recipients for toileting and this was achieved with maintaining respect and dignity. Staff monitor and document the continence of care recipients’ daily charts and progress notes. We observed there are adequate supplies of disposable continence aids of varying sizes available for care recipients and staff receive training in the use of these products. Care recipients are


monitored for the onset of urinary tract infections or other complications such as constipation. The effectiveness of these strategies to manage continence is monitored by the registered nurse and care team. Care recipients and representatives said care recipients are satisfied with the care provided and the dignified way staff manage their continence requirements

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


The home demonstrates that the needs of the care recipients with challenging behaviours are managed effectively. Initial and ongoing screening assessments are carried out on entry to the home. For care recipients who present with challenging behaviours, assessments are conducted and data collected from family members to establish past coping strategies, triggers and strategies to minimise distress. Behaviour monitoring forms are used to establish any underlying causes for the behaviour and are reviewed to determine what need the behaviour is expressing. The developed care plan reflects preventative strategies previously identified as effective. The home has access to specialist behavioural and mental health consultants who are sought on an as needs basis. We observed staff interacting appropriately with care recipients with behaviour problems and reviewed progress notes reports from specialists. Staff talked about the various strategies provided with education in behavioural management .Care recipients and representatives are satisfied that staff effectively interact and provide care for care recipients including those with challenging behaviours.

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


The mobility and dexterity of care recipients is assessed on entry to the home and strategies to achieve optimum levels of mobility and dexterity are recorded in the care recipients care plan. The manual handling of the care recipients are also assessed to identify the need for equipment and assistance by staff. A physiotherapist visits the home four days a week to conduct assessments, review incidents, provide individual treatments and conduct a pain management clinic. Morning exercise classes are conducted by the recreational activity officers Monday to Friday with a tai chi class held each week. There is access to a falls prevention class conducted by an exercise physiologist through private arrangement. Mobility aids and independent living aids are available to all care recipients and are consistent with individual care plans and identified care recipient needs. Care recipients and representatives are satisfied with the way the home staff support care recipients to achieve maximum levels of mobility and dexterity.

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


Care recipients oral and dental care is maintained through initial assessment, care planning and evaluation processes. Care recipients ongoing oral and dental care needs are monitored through staff observations and care recipient/representative feedback. Care recipients can


access the dentist of their choice outside the home and a dentist locally visits to attend assessments. Referrals are made to the local hospital when necessary. Care staff advised that care recipients are provided with oral care such as cleaning teeth, mouth swabs and denture care. Care recipients are also supplied with tooth brushes and cleaning agents and these are reviewed on a three monthly basis. Care recipients and representatives are satisfied with the way staff support and assist care recipients with their oral and dental care.

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


The home provides effective management of care recipients vision, hearing loss and deficits relating to taste, touch and smell through initial and ongoing assessment, care planning and evaluation processes. Eye testing by an optometrist and audiology services are available to all care recipients. Staff assist care recipients with the application and maintenance of hearing aids. Staffs are aware of strategies used to assist care recipients with vision impairment such as explaining processes, the use of large printed materials, reading newspapers during the recreational program. Additional sensory support is provided to care recipients through art, craft and music.

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


The home ensures care recipients achieve natural sleep patterns through assessment of their sleep pattern, care planning and staff support at night. A range of strategies are available to support care recipients to sleep. These include warm drinks, and snacks, comfortable positioning, toileting, continence care, and night sedation as per doctor’s orders and an environment conducive to sleep. Care recipients have access to call bells for their use if required. Care recipients reported the living environment is quiet at night and they generally sleep well.


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.



For details of the continuous improvement system, refer to expected outcome 1.1 Continuous improvement. Examples of continuous improvement activities relevant to Accreditation Standard Three include:

Following recognition that care recipients living with dementia required more specific activities a program of smaller group activities was introduced. There has been a good response to these activities with care recipients more relaxed and involved in activities such as craft and cooking

It was identified that care recipients find it difficult to conceptualise items on the menu from the written word. To encourage care recipients to make choices regarding their nutritional intake, pictures of meals included in the Spring/Summer menu will be introduced.

Reintroduction of dog therapy has received a good response from care recipients.

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”.


Refer also in this report to expected outcome 1.2 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to Accreditation Standard Three include:

Care recipients/representatives are provided with information on prudential arrangements and sign agreements on or before entry to the home.

The care recipient handbook and agreement detail security of tenure arrangements and charter of care recipient rights and responsibilities, which is also displayed.



Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to Accreditation Standard Three include:


Privacy and Dignity

Loss and grief - responding to grieving people

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".


The home demonstrates that care recipients are supported in adjusting to life in the new environment and that their emotional status and needs are identified and met on an ongoing basis. Comprehensive information is provided for care recipients and their family members pre entry to ensure any needs are identified. On entry care recipients are welcomed into the home, introduced to staff and other care recipients, advised of activities they may enjoy and of the opportunities to maintain their links with the community. The lifestyle program offers opportunities through one to one interaction with staff, for care recipients’ emotional needs to be identified and addressed. Observation and interviews demonstrate that staff are empathetic with, and supportive of care recipients’ emotional needs.

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".


Care recipients are assisted to achieve maximum independence, maintain existing relationships and form new ones. On entry to the home assessment of the care recipients abilities are attended and strategies are identified in order to maintain their independence. The home also creates a resident profile utilising recreational and cultural assessments. The home encourages relatives and community groups to visit. For example relatives and community groups are invited to special events celebrated in the home such as Chinese New Year and Christmas. Care recipient independence is also fostered through having personal items in their rooms. The home encourages the care recipient’s ongoing decision making an example of this is the availability of a mobile polling station during elections. The provision of mobility aids fosters physical independence and access to newspapers and Chinese pay TV in the lounge areas encourages engagement with the outside community. The recreational activities program includes bus outings to local parks and clubs for lunches. Care recipients and their representatives are satisfied with the way in which care recipients are assisted to achieve maximum independence.

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


The home privacy policy statement clearly outlines the staff responsibilities in maintaining privacy and confidentiality in relationship to the care provided to the care recipient. Staff are required to abide by this, as well as uphold the dignity of the care recipient at all times. Our observations of interactions between staff and care recipients showed staff respect the privacy and dignity of care recipients, waiting for permission before entering a care recipient’s room and referring to the care recipient in a dignified manner. Personal


information is collated and stored securely with access by authorised staff only. Written consent is obtained from the care recipient or representative for collection of personal information. Staff interviewed were able to give examples of the ways they show respect for care recipients’ privacy and maintain their dignity and confidentiality. Care recipients said they were satisfied with the way staff respect their privacy and maintained their dignity and confidentiality.

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 home’s staff encourage and supports the care recipients to participate in leisure activities through assessment and care planning processes, providing recreational activity programs, bus outings, one to one support and the celebration of special events. Recreational activity officers are employed to provide recreational activity programs. The recreational activity program covers a wide range of activities including musical activities, pet therapy, bingo mah-jong, gardening, reminiscing tai chi and exercise classes. The home encourages families to participate. Activities cater for care recipients various levels of physical and cognitive abilities. Care recipients and representatives are verbally informed in English and Chinese of the recreational activities and the monthly program is on display. Care recipients and representatives are satisfied with the activities provided for the residents at the home.

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


The home has systems to value and foster care recipients’ cultural and spiritual needs through identification and documentation of care recipients’ individual interests, customs, religious and cultural backgrounds. The home employs Chinese speaking staff and provides translation cards to non-Chinese staff to facilitate effective communication. The home celebrates special cultural and religious events for example ANZAC day, Mother’s and Father’s day, Melbourne Cup Day, Christmas, Easter, Chinese New Year and Mid-Autumn Day. Care recipients birthdays are acknowledge and celebrated. The home has a chaplain who supports care recipients of any religious affiliation. Communion is celebrated each month and a catholic group is held monthly. Care recipients have access to Chinese television which is available in communal areas. Care recipients and representatives said the 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".


The home has processes in place to ensure care recipients participate in decisions about the services provided and are enabled to exercise choice and control in relation to their lifestyle.


Care recipients/representatives are provided with information to assist them in making informed choices when they come into the home and on an ongoing basis. Care recipients indicate their likes and preferences when they move into the home and these are documented on the care recipient’s assessments and care plan. We observed staff consulting with care recipients about their wishes and preferences and the choices of the care recipients are respected in all care activities, leisure interests, lifestyle and beliefs. Care recipients and representatives said that care recipients are able to exercise choice in regards to their care and lifestyle and have opportunities for input about the home’s service delivery.

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".


Fairlie Aged Care@Harris Park is able to demonstrate that care recipients have secure tenure within the home and understand their rights and responsibilities. A Care Recipient Agreement and Care Recipient Handbook is provided. The agreement outlines information on security of tenure, Charter of care recipients’ rights and responsibilities, privacy matters and specified care and services. Noticeboards and brochures provide information for care recipients/representatives including on internal and external complaints mechanisms. Care recipients/representatives interviewed state they are satisfied with the information that was provided pre entry and on entry to the home and on an ongoing basis.


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.



Refer also in this report to expected outcome 1.1 Continuous improvement. The home’s continuous improvement activities include systems to check the home provides a safe and comfortable environment consistent with residents’ care needs. Examples of continuous improvement activities include:

Garden areas were observed to be overgrown and untidy. Quotes were obtained for a professional upgrade which was completed in June 2017. A gardener will now visit regularly to ensure the garden is kept in good condition. Care recipients were noted to be utilising the garden and courtyard areas.

It was identified at a care recipient meeting that those who were washing their personal items were utilising inappropriate areas for drying their clothes. A new area was identified and a washing line erected. This has been well received by care recipients and representatives.

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”.


Refer also in this report to expected outcome 1.2 Regulatory compliance. There are systems to ensure compliance with regulations relevant to residents’ quality of life and provision of a safe environment. Examples of regulatory compliance relevant to Accreditation Standard Four include:

A system to ensure compliance with food safety requirements including a food safety program and NSW Food Authority license

A system to ensure compliance with fire safety and work health and safety requirements



Refer also in this report to expected outcome 1.3 Education and staff development. The home demonstrates that staff have the knowledge and skills required for effective performance in relation to physical environment and safe systems. Examples of education and training programs relevant to Accreditation Standard Four include:


Fire safety

Manual handling

Infection control

Work Health and Safety

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".


Fairlie Aged Care@Harris Park is a single level home with care recipient accommodated in three wings in single and double rooms with adjacent bathrooms. Care recipients are encouraged to personalise their rooms and colourful posters identify individual room doors. There are areas for activities, sitting and dining areas. There is key pad access for entry and exit to the home and closed circuit television surveillance in common areas. Courtyard and garden areas provide pleasant places for care recipients and their family members to meet. There are preventative and reactive maintenance programs for buildings, furniture, equipment and fittings, and the living environment presents as clean and cared for.

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 systems and processes which enable the home to demonstrate there is a safe working environment that meets regulatory requirements. Education provided at orientation and on an ongoing basis includes manual handling, fire safety awareness, infection control, and hazard and accident/incident reporting. Lifting devices, personal protective and other equipment is available for the protection of both staff and care recipients. Accident/incident and infection data, and results of audits and surveys are reviewed at meetings. Preventative and reactive maintenance programs are in place and workplace inspections and environmental audits are conducted regularly. Staff interviewed are aware of their responsibilities regarding work health and safety.

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".


There are systems to ensure the provision of a safe environment that minimises fire, security and emergency risks. Fire safety and emergency response is covered at orientation and included in annual mandatory training. Fire detection and firefighting equipment is inspected regularly by a fire safety contractor. All visitors are required to sign in and out to ensure staff are aware of who is in the building in the event of an emergency. There is a disaster management plan, and contingency arrangements in place. Emergency evacuation plans are available and emergency flip charts and exit signs are in position across the home. An evacuation pack is available. Staff are able to describe the training provided and understand emergency procedures. Care recipients state they feel safe and secure within the home.


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


There is an effective infection control program at the home which includes processes to manage, prevent, monitor and minimise the risk of infection to staff and residents. Infection data are collected, evaluated and reported at meetings. Infection control and hand washing competencies are included in staff orientation and on an ongoing basis. The team observed staff practices including the use of personal protective equipment, hand washing and colour coded equipment being used in the kitchen and during general cleaning. There is a regular pest control program. An outbreak management kit is maintained, stocks of personal protective equipment are available and there is a care recipient and staff immunisation program. Staff interviewed demonstrate a good knowledge of the home’s infection control practices and outbreak management procedures.

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".


The home received an “A” rating in the NSW Food Authority audit conducted on 8 February 2017. The kitchen is well equipped and all food is cooked fresh on site. The menu has been reviewed by a dietician. There is a process for identifying care recipients’ individual requirements and preferences, such as specialised or modified diets and the need for dietary supplements, and this information and any changes is forwarded to the kitchen. Catering practices and documentation were observed to be consistent with hazard analysis critical control point (HACCP) requirements. Care recipients are satisfied with food services provided.

Cleaning staff perform their duties guided by schedules to ensure all areas are regularly maintained. Staff are aware of their responsibilities regarding infection control, including outbreak management, use of personal protective equipment and handling of chemicals. The home presents as clean and cared for. Care recipients and representatives are satisfied with the services provided.

Laundry services are provided off site by a contracted laundry. A small laundry is provided on-site for those care recipients who may wish to launder personal items. Care recipients/ representatives are satisfied with laundry services provided.


Documents

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