Roden Cutler Lodge · GORDON NSW 2072 Approved provider: Anglican Retirement Villages Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation

Roden Cutler Lodge

RACS ID 0418 10 Edward Street

GORDON NSW 2072

Approved provider: Anglican Retirement Villages

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 18 December 2017.

We made our decision on 07 November 2014.

The audit was conducted on 07 October 2014 to 09 October 2014. The assessment team’s report is attached.

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

Home name: Roden Cutler Lodge RACS ID: 0418 2 Dates of audit: 07 October 2014 to 09 October 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Roden Cutler Lodge 0418


Introduction

This is the report of a re-accreditation audit from 07 October 2014 to 09 October 2014 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 07 October 2014 to 09 October 2014.

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

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

Assessment team

Team leader: Judith Roach

Team member/s: Ingrid Fairlie

Rodney Offner

Approved provider details


Details of home

Name of home: Roden Cutler Lodge

RACS ID: 0418

Total number of allocated places:

165

Number of care recipients during audit:

160

Number of care recipients receiving high care during audit:

139

Special needs catered for: N/A

Street/PO Box: 10 Edward Street

City/Town: GORDON

State: NSW

Postcode: 2072

Phone number: 02 9499 1333

Facsimile: 02 9498 6765

E-mail address: Nil


Audit trail

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

Interviews

Category Number

General manager 1

Manager 1

Clinical leader 1

Quality and compliance manager - group 1

Quality and development leader - site 1

Operations manager 1

Registered nurses 8

Care supervisors 3

Care staff 8

Workplace trainer 1

Physiotherapy leader and physiotherapy aides 3

Admissions officer and administration staff 4

Care recipients 25

Representatives 8

Lifestyle manager - group 1

Lifestyle leader - site 1

Recreational activities officers 2

Assistant chaplain 1

Volunteer coordinator and volunteers 4

Servery staff supervisor and servery staff 4

Area manager contract cleaning services and cleaning staff 5

Laundry staff/continence care 1

Maintenance/fire officer 1


Sampled documents

Category Number

Care recipients’ files including advance care directives, progress notes, medical officer notes and referrals, hospital discharge notes, pathology and radiology reports

16

Care plans - initial and extended formats including health and personal care and care recipient lifestyle

16

Medication charts including doctors’ authorised charts and staff signing sheets

25

Care recipient accident and incident register 1

Other documents reviewed

The team also reviewed:

Audit schedule and completed audits

Care recipient’s individual clinical care assessments including behaviours, continence, mobility, nutrition and hydration, medications, mobility, pain, palliative care, oral and dental, sensory, skin, sleep, specialised nursing care

Care recipient’s individual clinical care observations, monitoring and treatment charts including behaviours, blood glucose levels (BGLs), food and fluid intake, enteral nutrition program, urinary catheter care, weights, wounds

Care recipient’s individual lifestyle assessments and evaluations including choice and decision making, cultural and spiritual preferences, emotional support, independence, leisure and lifestyle activities, pastoral care, privacy and dignity

Care recipients’ individual incident reports including behaviours, falls, infections, medication errors, skin tears, wounds

Care staff’s daily care records including care recipient bowel monitoring, personal hygiene, weekly and monthly weights

Cleaning manual, schedules, cleaning quality inspection reports, work instructions and work completed sign off log sheets

Clothing label register, belt and sling laundry log book and unlabeled clothing register

Communication records including doctors’ books, staff communication books, staff memorandum and handover sheets, notices and diaries, staff newsletters

Consent forms showing authorisation and consent for use of bed rails, consent for care recipient outings

Documented follow up on care recipients’ needs with medical and other related health personnel by registered nurses


Education: policies and procedures, internal education calendar, organisation’s education calendar, mandatory training register, education attendance register, learning and development training history, learning plan

Feedback folder including comments, complaints suggestions and responses, electronic feedback register

Fire safety and emergencies documentation: inspection records, annual fire safety statement, emergency procedures, crises and emergency management plan, lock up procedures, evacuation details of care recipients and emergency evacuation signage

Food servery manual, food safety monitoring records, care recipient meal preferences, diet requirements and menu; folders with care recipients’ dietary forms and notifications for changes

Hair dressing manual including hair dresser license and beauty therapist certificate, business insurance and infection control processes

Hazard register

Human resource documentation: recruitment processes, employment criteria, position descriptions and processes, staff agreement and handbook, performance management register and processes, consent forms, staff separation processes, staff confidentiality agreements, staff handbook and agreement, staff orientation packs, staff survey results, student visa register, roster, processes for managing roster changes, casual staff register, leave forms and check list

Infection control: policies and procedures, spills kits, outbreak kits and resource cupboard, personal protective equipment throughout, hand sanitiser units, sharps containers, contaminated waste bins and legionella species report

Information systems including electronic updates, alerts, email communication updates and payroll systems

Maintenance records: preventative maintenance schedule, maintenance reports, warm water temperature check record, air conditioning reports and pest control reports

Medication management records including controlled drug registers, monitoring records for clinical refrigerator temperatures, pharmacy re-ordering records, information on safe altering of medications including crushing, medication audits

Minutes of meetings - various

Mission, vision and values

Other health and related services referrals, reports, assessments, plans of care including behaviour management specialist, dentists, dietician, physiotherapy, podiatry, specialist physicians and surgeons, wound care

Palliative care ‘Butterfly’ program: individual folders with personalised palliative care information for respective care recipients

Policies and procedures - various


Privacy agreements showing consultation and agreement on use of care recipients’ information including photographs and use of names

Quality management system: policies and procedures, continuous improvement plans, audit schedule, audit results and report, organisation’s vision, mission and values, care recipient information package, organisational management alerts, feedback survey results, external contractor/supplier agreements and the home’s self-assessment documentation for re-accreditation and quality indicator scorecard

Records of care conferences and/or discussions and meetings between management, registered nurses and/or doctors and care recipients and representatives

Regulatory compliance: compulsory reporting register with consolidated records, police certificate records and renewal register, NSW Food Authority Licence, professional registration records

Resident information folder, pre-admission pack and checklist, care recipient (resident) agreement

The monthly ‘Grapevine’ newsletter for care recipients

Work health and safety: policies and procedures, “My safety” handbook, WHS Committee minutes, return to work plan, risk assessments, workplace incident register, hazard register and workplace inspections

Work Health and Safety system: electrical tagging records, safety manual for servery staff, material safety data sheets and certification of plant item registrations.

Observations

The team observed the following:

Annual fire safety statement, fire safety plans, equipment and emergency evacuation kits

Archive room and archiving trays

Care recipient lifestyle resources and equipment - various

Care recipients and/or representatives interacting with staff, visitors and each other

Care recipients participating in lifestyle and leisure activities

Care recipients’ general appearance

Charter of Residents’ rights and responsibilities displayed

Complaints information including internal and external mechanisms displayed around home, provision of confidential complaints mechanism, suggestion box

Daily handover between registered nurses and care staff

Dining rooms 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, care recipients being assisted with meals in their rooms


Equipment and supply storage rooms including clinical, linen stock in sufficient quantities and equipment available and in use for manual handling such as lifting machines, hand rails, ramps and walking frames

Infection control resources including hand washing stations, personal protective clothing, and supplies; spills kits, sharps containers and contaminated waste disposal

Information on noticeboards for care recipients, visitors and staff including care recipient activity calendar, Quality Care Agency re-accreditation notices, activity programs, education calendars and menus, meeting minutes, refurbishment information board

Laundry collection and distribution, care recipient laundries, dirty linen rooms

Living environment and outdoor areas including chapel, café, palliative care room, refurbished care recipient room

Medication system and processes - administration and storage including controlled drugs, re-ordering program, disposal system, supplies including emergency stock

NSW Food Authority Licence displayed

Nurse call system in operation including care recipient access

Organisation chart

Registered nurses supervising and directing staff

Secure document storage including care recipient and staff files, secure access to computer system

Short group observation in dining room

Short message service (SMS) - text messaging alert system notifying staff of shift availability

Staff ‘s courteous interactions between care recipients, each other, visitors

Staff accessing information including care plans, progress notes

Staff interacting with medical and other related health services personnel including medical officers

Staff work areas including care stations, clinical and other utility rooms, staff room, reception and offices, information in staff room

‘Step back’ posters guiding staff on management of challenging behaviours

Visitor sign and out book, volunteer sign and out book, care recipients’ sign in and out books and contractor register

Work health and safety notice boards.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The home utilises a continuous improvement system which includes a quality management system and performance review mechanisms. Improvements are identified through a number of avenues including care recipient and representative meetings, staff meetings, audits, benchmarking and review of clinical data. Also the home utilises surveys, case conferences, comments, complaints and suggestions, incidents and staff performance appraisals. Part of this system also includes ensuring compliance with the Accreditation Standards through the audit program. The home uses these indicators along with other input from stakeholders to identify opportunities for improvement and to develop improvement plans. Care recipients and representatives and staff report they have opportunities and are encouraged to participate in the home’s continuous improvement activities.

Examples of recent improvements in relation to Accreditation Standard One include:

Management identified the need for staff to be kept fully informed regarding changes occurring within in the home especially in matters relating to planned and current building works. As such a weekly leadership team meeting was established which management report is a very effective means of keeping team leaders and staff informed of recent and planned changes.

The organisation identified the need to implement a comprehensive human resource register whereby monitoring of police certificates, staff registrations and employment visas could occur in a more effective manner. Consequently a computer based information system was introduced for the monitoring of such information.

Management identified the need to ensure new staff are more aware of their responsibilities regarding the collection and handling of linen and of caring for care recipients’ personal clothing. As such a topic area on laundry services was incorporated into the orientation program thereby assisting to ensure staff practices relating to laundry services are effective and efficient.

Management identified benefits could be gained by educating new and current staff on how to best deliver quality care in accordance with the organisation’s vision, mission and values. This has resulted in a focussed education topic related to quality care being introduced on weekly basis. The workplace trainer undertakes education sessions,


observes work practises and asks staff questions regarding selected weekly topics. Management said the initiative is very effective in assisting to ensure quality care is delivered to care recipients.

1.2 Regulatory compliance

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

Team’s findings


The home has systems that identify and ensure compliance with changes in relevant legislation, professional standards and guidelines. The organisation accesses relevant information through subscription to legislative update services, from government departments, attendance at professional meetings and seminars and accessing the internet and other sources. Management communicate changes to staff by documentation, staff meetings and staff education sessions. Compliance with regulatory requirements is monitored through audits, competency assessments, staff appraisals and observations by management.

Examples of regulatory compliance relating to Accreditation Standard One include:

The organisation conducts reviews of all policy and procedure manuals on a regular basis to ensure all relevant legislation, regulatory requirements, professional standards and guidelines are appropriately documented.

Procedures for police certificates for staff and volunteers are in place. Interviews and documentation confirmed that these have been completed.

The home has a system whereby external contractors’ registrations and insurances are checked to ensure they are current.

Information brochures on the Aged Care Complaint Scheme are available throughout the home.

1.3 Education and staff development

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

Team’s findings


The home has an education and training program to ensure management and staff have the appropriate knowledge to perform their roles effectively. Processes include an orientation program, “on-the-job” training supported by learning plans and competency assessment, planned training and access to the organisation’s professional development programs. New staff are supported in their roles with a “buddy” mentor. The workplace trainer maintains a register for mandatory training and regular training sessions. Information from audits, incident and competency checks, continuous improvement, care supervisors, the clinical leader and requests from staff is used to develop individual learning plans and group based training activities. Staff have access to digital video discs from an aged care education broadcast channel. An annual performance appraisal process identifies professional development


opportunities or performance related training needs. Results show training is monitored and there are processes to identify staff on leave and follow-up for attendance. Audits and competency assessment evaluate the effectiveness of training programs. The education program includes areas relevant to the four Accreditation Standards. Staff interviewed said they are supported to achieve the necessary skills to perform competently in their roles and they have access to learning and development opportunities.

Examples of recent or planned education and training for staff relevant to Accreditation Standard One:

Leadership development

Performance planning and review

Orientation program.

1.4 Comments and complaints

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

Team’s findings


Care recipients and their representatives have access to internal and external comments and complaints mechanisms. Management and staff encourage and support all stakeholders to provide feedback. Care recipients and their representatives are informed of the complaints management process on entry into the home and on an ongoing basis and access to care recipient and resident meetings. Feedback forms are available throughout the home.

Processes include reviewing each comment or complaint, maintaining a confidential register of comments, allocation to a management representative for action and follow-up and response to the stakeholder. Feedback is monitored for timely response and effectiveness of actions. Results show comments and complaints are managed consistently to policies and procedures and are responsive to care recipient and representative requests. Care recipients and representatives interviewed are aware of how to raise a complaint and commented management and staff are approachable and responsive to requests.

1.5 Planning and leadership

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

Team’s findings


The home’s vision, mission and values are provided to all stakeholders in published handbooks and welcome packs. They are on display in the home. Staff are aware of the organisation’s philosophy and objectives from the home’s orientation program and education material. Results demonstrate management and staff reflect the organisation’s commitment to quality through all areas of service delivery.


1.6 Human resource management

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

Team’s findings


The home ensures there is sufficient and appropriately skilled and qualified staff to deliver services in accordance with the Standards. Recruitment processes include selection criteria to meet the home’s philosophy and objectives, required skills or qualifications relevant to each position. Human resources undertake reference checking, medical checks and police certificate clearances. Personnel files are maintained at head office with the home managing day to day staff related information. All shifts include registered nursing staff and care supervisors. Results show staffing is monitored by a documented roster system including replacing staff during planned and unplanned absences. Staffing levels are linked to assessed care recipient needs, clinical and service indicators and feedback. Staff performance is monitored through planned annual performance review. Staff confirmed they are able to complete their duties during their shift. Care recipients and representatives interviewed are generally satisfied about the sufficiency of staff and skills to deliver the care and services.

1.7 Inventory and equipment

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

Team’s findings


The home has stocks of goods and equipment that support quality service delivery. Specific staff are designated for maintaining adequate stock levels and ensuring such stock meets the required quality standards. The home has systems to guarantee the integrity of the stock, and stock is rotated as required. Equipment needs are identified through staff requests, audits, asset replacements and acquisition programs. The home has preventative and reactive maintenance programs. Maintenance request reports are maintained and action is taken in an efficient and effective manner to deal with any requests or preventative maintenance tasks. The home maintains equipment registers. Emergency maintenance requirements are dealt with in a timely manner. Staff are satisfied with the amount of supplies and quality of the equipment available to ensure the provision of quality care and services.

1.8 Information systems

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

Team’s findings


The home utilises various information systems for delivery of care and services. The home ensures all stakeholders are informed and there are various methods for communication and seeking feedback. Organisation processes include managing care and lifestyle, human resource management and managing safety. Care recipients and representatives are informed of the care and services they receive within their agreements and information packs. The


home ensures information is stored securely and confidentiality and privacy is maintained. Both electronic and hard copy information is archived and as scheduled, securely destroyed. Results show the home monitors their information systems for effectiveness. All stakeholders interviewed said they have access to information they need, are consulted and kept informed of areas that are important to them.

1.9 External services

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

Team’s findings


The home’s externally sourced services are arranged primarily by way of specified contract agreements. There is a designated process whereby specific criteria must be met in relation to services to be supplied and references, insurance and police checks are made. All major contracts are reviewed regularly through feedback by the home. Contractor non-performance is recorded and actioned immediately if urgent or at the time of reviewing the contract. To enable staff to contact an appropriate contractor/supplier lists are maintained at the home and updated as required. Staff are informed of appropriate matters relating to the provision of externally sourced services.


Standard 2 – Health and personal care

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement system.

Examples of specific improvements relating to Accreditation Standard Two include:

Management identified the need to ensure when the home is delivering palliative care services the relevant care recipients and family and/or representatives are provided with appropriate services and support. As such a program titled the ‘Butterfly Program’ was introduced. This program supports and assists staff to ask appropriate questions regarding delivery of appropriate care and support and provides instruction on clinical practices. Management report the program has been very effective.

Management identified there was an inconsistent approach to behaviour management by staff as well as inadequate documentation of behaviour assessments. Consequently the home sought expert advice regarding development of a system for behaviour management assessments and appropriate interventions. Education sessions were held for staff on appropriate interventions, documentation and use of incident forms. Management report as a result the needs of care recipients with challenging behaviours are now managed more effectively.

As a result of audits being undertaken it was identified that the number of incidents relating to falls and skin tears was above the expected average. Consequently a number of preventative strategies were implemented including de-cluttering care recipients’ rooms, placing non-slip mats on chairs and use of limb protectors when care recipients are being transferred. The result of these actions resulted in a decrease in the number of incidents occurring relating to falls and skin tears.

Management identified there was an increase in medication errors and consequently sent letters to staff members requesting a discussion on why such errors occur. Also education sessions were held for staff on safe medication administration including consequences of medication errors. Management report there has been as a result of these actions a decrease in the number of medication errors.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, and professional standards and guidelines.

Examples of regulatory compliance relating to Accreditation Standard Two include:

The home monitors nurse registrations as well as registrations of visiting health professionals to ensure they are current.

The home has an accredited medication system in accordance with relevant laws and guidelines governing medication management practices.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes.

In relation to Standard 2 Health and personal care, mandatory training is attended and monitored through a register. Management and staff interviewed said they receive positive support in their training and education needs and are aware of mandatory training requirements.

Examples of recent training or planned events in relation to Standard 2 Health and personal care include:

Use of limb protectors

Colostomy care

Palliative care modules

Medication management

“Step back” – behavioural management strategies.


2.4 Clinical care

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

Team’s findings


Care recipients receive clinical care that is appropriate to their individual needs and preferences. Our review of care recipients’ files shows a comprehensive assessment program is undertaken on initial entry to the home including input from the care recipient, and/or their representative. The results along with information from relevant health personnel inform the development of plans of care reflecting individual care recipients’ clinical needs and the process is ongoing. The clinical leader and registered nurses oversee clinical care delivery and we observed their consultation with care recipients, representatives and/or health professionals about changes occurring in care recipients’ needs. Care recipients’ clinical care outcomes are monitored through internal auditing processes including document review and results show clinical and care staff provide care consistent with documented care plans. Care recipients and representatives are satisfied with the clinical care provided to care recipients.

2.5 Specialised nursing care needs

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

Team’s findings


Care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Care recipients’ specialised nursing care needs are directed and supervised by the clinical leader and registered nurses in consultation with relevant health professionals. Established treatment regimes address care recipients’ specialised nursing care needs including complex pain and enteral nutrition programs. Registered nurses demonstrated their knowledge of care recipients’ specialised nursing care needs including stoma care and urinary catheter management. Our observations and staff interviews confirmed adequate supplies of equipment and resources are available to meet care recipients’ specialised nursing care needs. Relevant care recipients and representatives are satisfied with the standard of specialised nursing care provided to care recipients.

2.6 Other health and related services

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

Team’s findings


The home has systems to facilitate the referral of care recipients to other health and related services personnel. Other health and related referral services available to care recipients include behaviour management, dietitian, physiotherapy, podiatry, wound care and referrals to specialist physicians and surgeons. Care recipients are referred as required by their doctors to trained and qualified audiology, dental and optometry services personnel. We observed matters being identified by doctors in liaison with registered nurses for referral and follow-up by other health and related services personnel. In general, care recipients and representatives


are well informed and said they are satisfied with the referrals made for care recipients to other health and related services personnel.

2.7 Medication management

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

Team’s findings


The home has systems and processes to ensure care recipients’ medication is managed safely and correctly. We observed qualified and trained staff using an accredited pre-packed medication system to administer prescribed medications to care recipients. Relevant staff interviewed explained practices and protocols they use to ensure care recipients receive their medications safely and correctly. Document review confirmed evaluation and review of care recipients’ prescribed medication is regularly undertaken by their doctors and an accredited pharmacist carries out additional auditing and review. The medication management system is monitored through the home’s regular auditing program and the medication advisory committee. All medication incidents are documented and reported to management and the home is responsive in taking remedial action, as required. Care recipients and representatives are satisfied with the way staff manage care recipients’ medication needs.

2.8 Pain management

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

Team’s findings


Care recipients are assessed for acute and chronic pain on their entry to the home and then regularly and as indicated. Assessment and review of individual care recipients’ pain is carried out by their doctors and a registered nurse in consultation with care recipients and/or their representatives. Staff described their role in identifying and reporting care recipients’ pain and demonstrated the use of an assessment tool they use for care recipients unable to verbalise their pain. Care recipients are provided with a holistic approach to pain relief including prescribed analgesia and physical therapies such as massage, repositioning, and gentle exercise programs. Emotional support is provided by care and lifestyle staff and by the home’s pastoral support program as desired. Care recipients and representatives are satisfied that care recipients are as free as possible from pain and that staff respond in a timely manner to care recipients’ requests for pain relief.

2.9 Palliative care

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

Team’s findings


The home has a system to ensure the comfort and dignity of terminally ill care recipients is maintained through a palliative care approach. Care recipients’ terminal care wishes may be documented on their entry to the home or later including the level of clinical intervention


preferred. Liaison with doctors and palliative care specialists occurs through consultation with the registered nurses and care recipients and representatives as required. Staff described a range of interventions they would employ when caring for a terminally ill care recipient to ensure their pain would be managed and their comfort and dignity maintained. Non-medicinal care and resources that can be provided to care recipients include a program of gentle massage, aromatherapy, and emotional support provided by care and lifestyle staff. Pastoral care and support is available for the care recipient and their representative/s as desired including through the home’s chaplaincy program.

2.10 Nutrition and hydration

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

Team’s findings


The home provides care recipients with adequate nourishment and hydration. Care recipients’ initial and ongoing dietary requirements are assessed by registered nurses who advise the catering staff about identified needs and preferences. Assessments are undertaken to identify any oral or dental needs, swallowing difficulties, or the need for special diets and a dietitian is available as needed. All care recipients are regularly weighed and significant weight variations are followed up by their doctors. Document review and interviews with care recipients and representatives show food satisfaction is monitored through surveys, during care recipient and representative meetings and through case conferences. Our observations and feedback from care recipients and representatives show care recipients are encouraged to maintain hydration. Care recipients and representatives are satisfied with the quantity, quality and choice of care recipients’ meals.

2.11 Skin care

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

Team’s findings


The home is ensuring that care recipients’ skin integrity is consistent with their general health. The home recognises a close link between care recipients’ skin integrity and their nutrition and hydration, mobility status and clinical incidents occurring including falls and skin tears. Registered nurses initially and then regularly assess, action, and evaluate care recipients’ skin care needs as required. Staff demonstrated their knowledge for identifying and reporting changes in care recipients’ skin integrity. Registered nurses regularly assess and evaluate wounds and provide all wound care in liaison with the care recipients’ doctors. Care recipients are referred by their doctors to wound specialists for assessment and review of wounds and treatment regimes as required. Care recipients and representatives are satisfied with the skin care provided to care recipients.


2.12 Continence management

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

Team’s findings


The home has a system and processes to ensure care recipients’ continence is effectively managed. Registered nurses oversee the continence program in liaison with a staff member trained in continence care and liaison with care staff on issues associated with care recipients’ continence needs. Where required, individual toileting programs are scheduled for care recipients to assist in managing their needs and preferences. Staff said adequate continence care supplies are available. Care recipients are monitored for the presence of urinary tract infections which may impact their level of continence and preventive strategies implemented as needed. Bowel management programs used include daily monitoring, appropriate diets and provision of aperients and other interventions as required. Care recipients and representatives are satisfied that care recipients’ continence is effectively managed.

2.13 Behavioural management

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

Team’s findings


The home has a system and processes to ensure the needs of care recipients with challenging behaviours can be managed effectively. Results of relevant care recipients’ initial assessments are used to develop and evaluate behavioural management care plans which are reviewed and updated as required. Behaviour incidents are recorded, addressed and reviewed in a timely manner. Contributing medical causes are identified, treated and in general, factors known to intensify challenging behaviours are managed, regularly reviewed and followed up by appropriate health professionals as needed. Review of a care recipient’s need for review by a specialist mental health professional/s occurs in consultation with their representative through referral by their doctor or the clinical leader. Care recipients and representatives expressed their satisfaction for the way in which care staff meet the needs of care recipients living with challenging behaviours. Feedback from care recipients and representatives interviewed shows they are satisfied that overall, care recipients’ lives are not impacted by other care recipients living at the home.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings


The home has a mobility program tailored to individual care recipients’ needs and preferences. A program of initial and ongoing assessment, review and evaluation of their mobility needs is undertaken. Liaison occurs between the physiotherapist, the care recipient and/or their representative, their doctor, registered nurses and the physiotherapy staff. Staff interviews


show the use of mobility aids and individual falls minimisation strategies are consistent with the care recipients’ identified needs as documented in their plans of care.

Mobility incidents including falls are responded to, reported on, and followed up in a timely manner. Feedback is provided to doctors, care staff, care recipients and to representatives by the physiotherapy staff and registered nurses. The home has a falls minimisation and regular exercise program conducted by the physiotherapy staff and overseen by the physiotherapist in liaison with care recipients’ doctors. Care recipients’ and representatives are satisfied that care recipients are achieving and maintaining levels of mobility and dexterity suited to their individual capabilities.

2.15 Oral and dental care

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

Team’s findings


Care recipients’ oral and dental health is maintained. The home’s approach to the maintenance of care recipients’ oral and dental health includes initial and ongoing assessment and review of their oral and dental care needs. Assessments are carried out by clinical staff and referrals to dentists or dental specialists are arranged by doctors according to the care recipients’ individual needs and preferences. Staff said and interviews with care recipients show that care recipients have their daily oral care needs encouraged, supervised and/or attended by care staff. Care recipients and representatives said care recipients have access to a dentist of their choice in the local area, and are assisted to make and attend appointments as required.

2.16 Sensory loss

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

Team’s findings


The home has a system to ensure that care recipients’ sensory losses are identified and effectively managed. The identification of sensory impairment is included in clinical and lifestyle assessments covering communication, sight and hearing, and the senses of touch, smell and taste. Incorporated clinical and lifestyle features that focus on sensory stimulation include gentle exercise programs, massage, cooking, gardening and various craft activities. Plans of care that incorporate the care recipients’ sensory needs are initially developed and regularly reviewed. Medical and other health personnel are involved as required. Interviews with staff, care recipients and representatives demonstrate that staff assist care recipients with cleaning and fitting their communication aids. Care recipients and representatives are satisfied that care recipients sensory losses are identified and effectively managed.


2.17 Sleep

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

Team’s findings


Care recipients are encouraged to achieve natural sleeping patterns. The home has a system of initial and ongoing identification and review of night care requirements that encourage natural sleeping patterns for care recipients. Sleep strategies implemented include flexible retiring times, offering a warm drink, gentle massage, one-to-one time, night sedation and/or pain relief medication if prescribed by a doctor. Care recipients and representatives are satisfied that care recipients generally sleep well at night and that staff help them if they experience difficulty in sleeping.


Standard 3 – Care recipient lifestyle

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for the details of the home’s continuous improvement system.

Examples of continuous improvement relating to Accreditation Standard Three include:

Management and staff identified the need to have a suitable leisure area and activities for care recipients of Chinese background. Consequently an oriental area was established incorporating oriental furniture and fittings as well as Chinese language books and papers. Management report a high level of satisfaction by care recipients of Chinese backgrounds with these changes.

Following a complaint by a family member that a care recipient was not always ready for a pre-arranged outing management investigated ways in which improvements could be made. Consequently a new form was introduced detailing information about care recipient outings undertaken by family members and staff received education on how to use the new form appropriately. Management report care recipients going on family outings are now dressed and ready for their outings.

Management and staff identified that there needed to be an improved support structure for care recipients when they are admitted to hospital or wishing to attend funeral services. As a result the home’s assistant chaplain now makes arrangements to visit care recipients who may have been transferred to hospital and accompanies them to funerals as desired.

The organisation identified the need to improve care recipients’ rights to privacy and dignity when accommodated in areas of the home dedicated to providing high acuity care. As such these areas of the home are being re-furbished and bedroom sizes being reduced from four to two bed rooms with dividing privacy partitions between beds. The result of these improvements is increased privacy for care recipients.



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

Team’s findings



Examples of regulatory compliance relating to Accreditation Standard Three include:

The Charter of residents’ rights and responsibilities is displayed in the home.

The residency agreement outlines security of tenure and is based on applicable legislation.

The home has a system for compulsory reporting according to the requirements of applicable legislation.



Team’s findings



In relation to care recipient lifestyle, the workplace trainer is supported by the organisation to plan, develop, deliver and source lifestyle related training programs.

Examples of recent training or planned events in relation to Standard 3 Care recipient lifestyle include:

Rhythm of life – dignity and care

Mandatory reporting

Palliative care module – includes areas related to Standard 3.


3.4 Emotional support

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

Team’s findings


The home provides initial and ongoing support to each care recipient in adjusting to their new life in the home. An initial assessment process identifies their need for emotional support with results used to develop a personalised plan of care that is regularly reviewed, evaluated and updated. Other support services available include newsletters, meetings for care recipients and representatives, a volunteer visiting program, and if desired, visits from the home’s chaplaincy staff and/or local clergy. We observed lifestyle, care and chaplaincy staff providing support to care recipients for participating in life at the home whilst respecting their right to refuse. Care recipients and representatives are satisfied with the emotional support offered when a care recipient first enters the home and said the support is ongoing.

3.5 Independence

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

Team’s findings


Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. A range of initial assessment results identify the care recipient’s preferences for independence and are integrated into a care plan to assist them in achieving and maintaining their independence. The home encourages the involvement of family and friends. We observed care recipients going out with family and friends and family and friends providing companionship to care recipients including enjoying time with them at the home’s café. A volunteer program including a community visitors’ scheme is available to care recipients as desired, along with visiting school programs and a range of community speakers and entertainers. Family and friends are encouraged to participate in the lives of the care recipients and we observed family and friends enjoying time with them in the home’s café. Care recipients and representatives confirmed care recipients access and participate in a wide variety of community activities inside and outside the home. Care recipients said staff support and assist them to enter exhibits in and attend local functions including the annual local show day.

3.6 Privacy and dignity

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

Team’s findings


Each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Confidential and private information is obtained with the prior consent of the care recipients and/or their representatives and is securely stored. Staff said they sign a confidentiality


agreement on commencing at the home. Staff confirmed they receive ongoing training and monitoring on supporting each care recipient’s privacy, dignity and confidentially including secure use and storage of their clinical, care and lifestyle information. Our observations of staff attending care recipients in a respectful and courteous manner show their awareness of each care recipients’ right to privacy, dignity and confidentiality. We observed and care recipients and/or their representatives said care recipients live their lives at the home with privacy and dignity.

3.7 Leisure interests and activities

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

Team’s findings


A series of leisure interest and activity assessments are conducted on a care recipient’s initial entry to the home. The results are used to develop and regularly review a lifestyle care plan that encourages and supports the care recipients’ participation in a wide range of interests and activities. A care recipient’s level of participation and their feedback assist staff in the ongoing development and review of the lifestyle care plan including group and one-on- one activities. Group activities offered include friendship groups, bus trip outings to points of local interest including coffee and shopping, indoor bowling and men’s group. Other group activities enjoyed by care recipients include birthday celebrations, bingo and other table games, cooking, happy hour, knitting, movie matinees and attending the on-site café with family and friends. One-on-one activities enjoyed by care recipients include armchair travel, art therapy, sensory boxes, garden walks, gentle massage, manicures, newspaper readings and conversations. Care recipients and representatives said care recipients participate in a wide range of activities of interest to them and confirmed their right to refuse is respected.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


Preferences and requirements for care recipients’ individual interests, customs, beliefs and cultural and ethnic backgrounds are identified, valued and fostered. An initial cultural and spiritual assessment including information provided by the care recipient and/or their family is used to develop and regularly review a plan of care. Cultural and spiritual needs are also considered when planning clinical care and end of life wishes. We observed and care recipients confirmed they are encouraged to use photographs and other visual displays of their cultural and spiritual heritage. Cultural, international, national and other celebratory days are observed at the home including Christmas day, Easter and ANZAC day. Care recipients and representatives confirmed care recipients can choose to attend cultural and spiritual support as desired including on-site bible study, devotions and prayer groups. Care recipients said they also access the on-site chaplaincy program and/or attend on-site church services as desired. Care recipients and representatives are satisfied with the range of individual interests, and cultural and spiritual support available and provided to care recipients.


3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".

Team’s findings


Each care recipient (or his or her representative) participates in decisions about the care and services a care recipient receives on their entry to the home. Care recipients and/or their representatives decide on a range of care and services available including choice of meals and participation in leisure interests and activities. Information packages and the offer of a residency agreement ensure each care recipient (or his or her representative) is aware of choices available to care recipients. We observed information regarding care recipients’ rights, complaints mechanisms and advocacy services displayed around the home and documented in entry packages, information handbooks and the residency agreement. Care recipients and representatives are aware of the need to not infringe on the rights of other care recipients. Care recipients and representatives expressed satisfaction with the encouragement and support provided in making choices and decisions about the care and services that care recipients receive.

3.10 Care recipients’ security of tenure and responsibilities

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

Team’s findings


The home has systems to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Iinformation on security of tenure and resident’s rights and responsibilities is provided and discussed with prospective care recipients and their representatives prior to and on entering the home. The care recipient’s agreement accompanied by the resident handbook outlines care and services, care recipients’ rights and feedback mechanisms. Any changes in room and/or location within the home are done in consultation with care recipients and/or their representatives. Ongoing communication with care recipients/representatives is through meetings and correspondence. Care recipients interviewed said they feel secure in their residency at the home and are aware of their rights and responsibilities.


Standard 4 – Physical environment and safe systems

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for further information relating to the home’s continuous improvement system.

Examples of recent improvements in relation to Accreditation Standard Four include:

The organisation identified there could be benefits in serving buffet breakfasts to care recipients. As such the home introduced buffet breakfasts in the dining room from approximately 7.30am to 9.30am. Care recipients interviewed expressed their satisfaction with the buffet breakfasts.

Management and staff identified care recipients’ clothes sometimes went missing and as such introduced a new labelling process for clothes. This process involves clothes requiring labelling being placed in a new bin at reception with identification details. Laundry staff place labels on the clothes. Staff report the new process is efficient and has reduced the number of clothes items missing.

A complaint from a care recipient’s family concerning the lack of cleanliness of a bathroom cabinet resulted in the home’s cleaning audit tool being amended to include bathroom cabinets. Education sessions were held for cleaning staff to assist in ensuring all bathroom cabinets are regularly and effectively cleaned. Care recipients interviewed are very satisfied with cleaning services.

Management identified there had been a case where contaminated linen had been sent to the laundry without being put in appropriate infection control bags. Consequently management implemented a number of actions to remind staff of their responsibilities. These actions included development of a poster detailing required infection control procedures, putting the poster on all laundry trolleys and educating staff on correct work practices. Management report staff are now complying with appropriate infection control procedures.



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

Team’s findings



Examples of regulatory compliance relating to Accreditation Standard Four include:

The home has a current NSW Food Authority licence and the food safety system has been audited by the NSW Food Authority.

The home has a current fire safety statement displayed.

The home provides material safety data sheets with stored chemicals.



Team’s findings



In relation to Standard 4 Physical environment and safe systems, the workplace trainer is supported by management and the organisation to plan, develop, deliver and source environmental safety and safe system related training programs. Management and staff interviewed said they receive support in their training and education needs.

Examples of recent training or planned events in relation to Standard 4 Physical environment and safe systems include:

Infection control and outbreak management

Hand washing

Fire safety, evacuation and emergency training

Manual handling

Food safety

Safe use of hot packs

Work health and safety training.


4.4 Living environment

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

Team’s findings


The home can demonstrate that it is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. The home comprises of a multi- story building containing single rooms with ensuite bathrooms together with ground level wings which have both shared bedroom accommodation and bathrooms. Many rooms have outside patios where care recipients sit and enjoy pleasant garden views. The home is generally light and bright with furnished lounges and communal rooms and there is a pleasant terrace area overlooking the pool and gardens to the north. There is a preventative and reactive maintenance program in place, including recording of warm water temperatures and regular inspection audits covering the environment are undertaken. Care recipients and representatives stated they are satisfied with care recipients’ individual and communal living environments.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


The home has systems and processes to provide a safe working environment meeting regulatory requirements. The home has regular work health and safety meetings including organisational meetings. Committee members include representatives from each work area in the home. Processes include hazard and incident registers, workplace inspections, and risk assessments. Purchasing processes ensure new equipment is risk assessed. Results show incidents are analysed and information is used to inform continuous improvement activities or training programs. There is a return to work program and staff are trained in work health and safety. Staff have access to work health and safety information and are able to report on hazards in the workplace and staff incidents. Management and staff interviewed said they regularly informed and receive training and ongoing support on working safely in the workplace.

4.6 Fire, security and other emergencies

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

Team’s findings


The home has 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 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 resource kits are readily available which includes care recipients’ detailed care needs and relevant contact information. Staff stated that they are aware of and understand their responsibilities in the case of fire and other emergencies.

4.7 Infection control

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

Team’s findings


The home has systems and processes to support an effective infection control program. The home has processes to document and monitor care recipient infections and outbreaks.

Preventative measures are evident throughout the home with access to infection control resources. Staff undergo mandatory infection control training and there is a vaccination program. Results show infection control is monitored and analysed through audits, surveys, incidents and feedback from staff and care recipients. Infection control incidents and results are communicated through meetings and notice boards. Actions are planned in response to infection results. Management and staff interviewed demonstrated awareness of infection control requirements and use of equipment relevant to their roles. Staff confirmed they receive infection control training and how to manage an outbreak.


4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Care recipients expressed satisfaction with the hospitality services provided at the home. Comments included “the food is fine”, “my room is kept beautifully clean”, “and my clothes are returned spotless by laundry staff”.

Catering

Care recipients’ dietary needs and choices are assessed and documented on entry to the home and details provided to catering staff. Food is cooked off site at the organisation’s central kitchen and delivered to the home where it is reheated and served to care recipients’ either in their rooms or in the dining rooms. There is a food safety program and the home has a current NSW Food Authority licence. The home has a four week rotating menu with input from a dietician. We observed food preparation and service and staff practices are according to the appropriate food safety guidelines, including infection control requirements. Care staff have undertaken training in relation to appropriate food handling and infection control. In general, care recipients interviewed expressed their satisfaction with the home’s catering services.

Cleaning

The home presents as clean, fresh and well maintained. Contract cleaning staff perform their duties guided by documented schedules, work instructions and results of inspections. All equipment is colour coded and chemicals 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. Care recipients interviewed expressed their satisfaction with the home’s cleaning services.

Laundry

Laundry services are provided by the organisation’s central laundry which is located off-site. Dirty laundry is collected in appropriate coloured linen bags and transported to the laundry collection area. There are laundries available for those care recipients who wish to launder their own clothes. There are procedures and work instructions for the collection and handling of linen. Staff described the processes for the collection and transportation of dirty linen and clothes and distribution of clean linen and clothes to care recipients. Staff confirmed that they receive training in infection control and safe work practices. Care recipients interviewed expressed their satisfaction with the home’s laundry services.

Documents

Roden Cutler Lodge · GORDON NSW 2072 Approved provider: Anglican Retirement Villages Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation