Villa Maria Aged Care Residence Berwick

Villa Maria Aged Care Residence Berwick RACS ID 3506

89-93 Avebury Drive BERWICK VIC 3806

Approved provider: Villa Maria Society

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 10 October 2015.

We made our decision on 28 August 2012.

The audit was conducted on 23 July 2012 to 24 July 2012. The assessment team’s report is attached.

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

Home name: Villa Maria Aged Care Residence Berwick Dates of audit: 23 July 2012 to 24 July 2012 RACS ID: 3506

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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 Accreditation 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.

Expected outcome Accreditation Agency decision




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


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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.


decision




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.


decision




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


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Audit Report

Villa Maria Aged Care Residence Berwick 3506


Introduction This is the report of a re-accreditation audit from 23 July 2012 to 24 July 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 Accreditation 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


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 23 July 2012 to 24 July 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. 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 1997. Assessment team

Team leader: Heather Pearce

Team member: Michelle Harcourt

Approved provider details


Details of home

Name of home: Villa Maria Aged Care Residence Berwick

RACS ID: 3506

Total number of allocated places:

60

Number of residents during audit:

57

Number of high care residents during audit:

49

Special needs catered for:

Dementia

Street: 89-93 Avebury Drive State: Victoria

City: Berwick Postcode: 3806

Phone number: 03 9796 2944 Facsimile: 03 9796 2164

E-mail address: [email protected]


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Audit trail The assessment team spent two days on-site and gathered information from the following: Interviews

Number Number

Executive / management 7 Residents/representatives 8

Registered nurses 7 Volunteers 7

Care staff 4 Laundry staff 1

Administration assistant 1 Cleaning staff 1

Lifestyle staff 2 Care services manager 1

Catering staff 2 Learning and development manager

1

Admissions coordinator 1

Sampled documents

Number Number

Residents' files 8 Medication charts 16

Summary/quick reference care plans

8 Personnel files 8

External contractors' service agreements / contracts

9 Residents’ finance/administrative files

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Other documents reviewed The team also reviewed:

Activity participation records

Audits folder and completed audits

Berwick education schedule and associated attendance and evaluation records

Berwick police check listing

Berwick volunteers police checks and statutory declaration list - July 2012

Building project folder

Building works commissioning plan

Bushfire - resident evacuation list

Catering - celebration days folder

Catering documentation

Complaints risk rating tool

Compulsory training tracker matrix

Consent forms

Continuous improvement plan, completed forms and other documentation

Corporate education schedule and documentation

Cultural event calendar 2012


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Dementia support strategy 2012

Education attendance database reports

Electronic maintenance register print out

Essential services schedule and documentation

Essential services statement of compliance

Evacuation and relocation plan - Berwick

External and graduate / post graduate education materials

Fire and emergency procedure manual

Food safety plan

Food safety plan audit report

Hazardous chemicals register

Health, safety and wellbeing manual

Incident, injuries and claims statistics and analysis

Infection register

Internal audit schedule and completed audits

Lifestyle assessments, care plans and documentation

Maintenance records

Mandatory report register

Mandatory training day agenda

Material safety data sheets

Meetings minutes

Memoranda

Menu selection forms

Menu survey

Missing residents register

Newsletters

New staff pack

Orientation information

Palliative care training plan 2011-2012

Policies and procedures

Position descriptions and duty statements

Recruitment and selection documentation

Resident survey - December 2012

Residential aged care services business continuity plan

Residential services audit program 2011-2012

Residential services continuous improvement forms - monthly analysis reports

Resident handbook and information package


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Roster

Safety newsletter - In good health

Staff handbook

Staff performance appraisals

Staff statutory declarations on personnel files

Strategic Plan

Summary of identified learning needs 2011-2012

Wellness guide Observations The team observed the following:

Activities in progress

Aged care channel education discs available in staff room

Archive system and storage

Blood spills kit

Catering preparation and cleaning

Charter of residents' rights and responsibilities on display

Cleaning in progress

Comments and complaints folder in each house entrance

Completed modified residents' rooms x 16

Construction work in progress

Dining room chairs with front wheels attached

Door security

Emergency exits and signage

Equipment and supply storage areas

Evacuation pack

Evacuation points

Gastroenteritis outbreak kit

Interactions between staff and residents

Laundry in progress

Living environment - internal and external

Meal and refreshment service

Menus displayed in dining rooms

Notice regarding accreditation site audit displayed on noticeboards

Resident and staff noticeboards

Sharps and infectious waste disposal bins

Staff room

Storage of medications


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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 residents, 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 uses established corporate continuous improvement systems, processes and documentation. Residents, staff and visitors advise management of suggestions for improvements, comments, compliments and complaints by submitting a continuous improvement form which administrative staff log on to a register. Issues are transferred to the continuous improvement plan as required for ongoing monitoring and closing out. Relevant department heads assist the manager to action and close out issues. Staff and management also register other issues as they arise from meetings, audits, surveys, incidents and hazards reports. Feedback on continuous improvement activities occurs at meetings and in writing or verbally with individuals. Information about the home's continuous improvement systems is contained in the resident and staff handbooks, and on noticeboards and displays around the home. Residents and staff stated they are familiar with the home's systems and are satisfied with continuous improvement activities. Recent improvements related to Standard one include:

The manager undertook a systematic review of staff training needs and processes that trigger the need for an education session, for example, the appraisal process and the auditing system. Management developed new internal audits that better identify gaps in service delivery and they actively support staff to pursue further training and qualifications through discussions held in the appraisal interviews. These changes have increased the uptake of staff undertaking formal qualifications and attendances at internally held education sessions. In addition to these measures the manager re-introduced the self learning resources of the aged care channel and staff uptake of these sessions has been high. The home has also supported 34 staff to participate in the Workplace English and Literacy program through a local Tafe college, one staff member to successfully complete the graduate nurse program and nine staff attended dementia education. Staff said they have excellent access to education and have become better at their jobs due to the support given to them by management.

In addition to the above improvements the organisation has developed a computerised database of all education sessions held. The database also records staff evaluations of sessions they attend and any additional comments they make. This information is easily available to managers to assist them to evaluate the effectiveness of education sessions held and to plan future education sessions.

The home developed risk assessment and reporting guidelines which are used to rate the risk of individual complaints on the continuous improvement register. Complaints that rate highly are immediately escalated to the executive management for oversight and involvement if required. This system ensures complaints are dealt with at appropriate levels and are closed out in acceptable time periods.


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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 meets this expected outcome The corporate organisation receives information about changes to relevant legislation, regulations and guidelines through its subscription to a legislative update service and also receives information from local, state and federal government and professional bodies. Corporate managers make appropriate changes to policies and procedures and legal services are sought as required. The general manager of residential services disseminates information about changes to the home's manager at monthly managers' meetings and changes are disseminated to staff via the internal memo system, at meetings and at handovers. Education sessions are arranged when required. Management monitor the home's compliance with legislation, regulations and guidelines by analysing data from incident reports, audits, competency testing and by observing staff practice. Staff said they are aware of their obligations in relation to regulatory compliance and confirmed management inform them when changes occur. Examples of regulatory compliance relating to Standard one include:

policies and procedures that reflect professional and regulatory guidelines are in place to guide staff practice

processes to ensure all staff, volunteers and external contractors provide police checks and statutory declarations as appropriate are in place

management displayed notices to inform stakeholders of the re-accreditation audit. 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 meets this expected outcome Management and staff have appropriate skills and knowledge to perform their roles effectively. Management develop education calendars based on staff career development reviews, analysis of monthly clinical and incident data, mandatory requirements, audit results and observation of staff practices. Education sessions include topics across the Accreditation Standards. Management monitor staff attendances at mandatory education sessions to maintain compliance and evaluate education sessions to determine their effectiveness. The organisation provides support annually to staff who elect to upgrade their qualifications. Staff said education sessions are readily available and they are encouraged to develop their skills. Residents and representatives praised staff and said they have the skills and knowledge to provide appropriate care to them. In addition to corporate education sessions, self learning digital video disc training programs and attendance at conferences, recent education relevant to Standard one includes:

orientation program

team communication skills

dealing with change


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collaborative leadership skills 1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Management have processes for recording and responding to comments and complaints. Information about internal and external complaint mechanisms is accessible via resident handbooks and resident agreements, brochures, meetings, posters and newsletters. Management has continuous improvement forms available for the use of residents, staff and other stakeholders to lodge any comments, complaints or suggestions. Verbal complaints are written on to a continuous improvement form and acted upon in the continuous improvement system. Residents, representatives and staff said they are familiar with the home's systems and management is responsive to their suggestions. A high proportion of respondents to the 2011 resident survey stated that their complaints and suggestions are always treated respectfully. 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 meets this expected outcome The home’s management display the residential aged care service’s vision, mission and values which outline the organisation's commitment to quality service delivery for its residents and the community. The vision, mission and values statements are also included in the resident and staff handbooks and underpin the organisation's strategic plan. The organisation is currently demonstrating its commitment to its vision, mission and values by adding a 16 bed wing to the home to further cater for residents with dementia. Managers and staff said they are committed to upholding the vision and values of the home in providing quality care for residents. 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 meets this expected outcome The home has appropriately skilled and qualified staff to ensure residents’ care needs and lifestyle preferences are maintained. The home uses standardised recruitment, selection and orientation systems including qualification, police and reference checking procedures. Management monitor the roster regularly to ensure the appropriate level and skill mix is maintained. The home has a very stable workforce and uses an external agency to manage their temporary staff base. All staff interviewed spoke of their commitment to the delivery of high-level care and services. They also discussed the support they receive from management to ensure they receive ongoing training and support in their roles. Staff are


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aware of the requirements of their positions through position descriptions and duty statements. The home monitors and maintains the skill level of staff through their education program and annual performance appraisals. Staff stated the level and skill mix of staff is appropriate for residents’ needs. Residents confirmed staff are responsive to their needs and are compassionate and caring. 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 meets this expected outcome Stocks of appropriate goods and equipment for quality service delivery are available in relevant areas of the home. Allocated staff are responsible for the regular ordering of goods and equipment across all areas of the home. Goods and equipment storage is appropriate, safe and secure. A scheduled preventative maintenance program, driven from the corporate head office, ensures equipment remains safe for staff and resident use and schedules also determine equipment cleaning. Corporate and on site teams assess the suitability of new equipment and staff said education on the use of new equipment takes place as necessary. Staff and residents said there are appropriate goods and equipment available in the home to meet residents’ needs. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The home has effective information management systems. The home continues to review and redevelop their information systems in response to changing needs to ensure information is accurate, responsive and evidence based wherever possible. Information is available on the organisation’s intranet to ensure version and quality control. Operational policies and practice standards, position descriptions, noticeboards, minutes of meetings, memoranda, emails and other relevant resources are available to guide staff practice. Residents’ clinical information is current and staff confirmed adequate communication mechanisms in relation to residents’ changing needs. Management collect, collate and analyse key information to identify potential risks and improvement opportunities. Confidential information is stored securely. Staff reported access to current and clear information to help them perform their roles. Residents and their representatives confirmed they are provided with specific information about their care requirements and general information about activities and events in the home. 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 meets this expected outcome The organisation's purchasing and facilities manager oversees the engagement of and contractual arrangements for externally sourced service providers. All contractors are


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orientated to the site and provided with a contractor's handbook. All contracts are reviewed two yearly or as required. Staff at the home monitor compliance with the agreed contractors and provide information to the purchasing and facilities manager regarding their satisfaction with goods or services provided. External service provider contracts require service providers to provide evidence of appropriate liability insurance, personnel qualifications and compliance with Australian Standards. The contracts also require service providers to comply with police record checking for personnel who have unsupervised access to residents. Staff, residents and representatives stated their satisfaction with externally provided services.


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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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Care staff contribute to the home's continuous improvement systems by submitting improvement logs, undertaking clinical audits and raising issues at staff meetings to facilitate improvements in resident health and personal care. A description about the home’s continuous improvement system is in expected outcome 1.1 Continuous improvement. Residents advised they were satisfied with the clinical care they receive. Staff are familiar with improvements that have occurred in resident health and personal care. Examples of continuous improvement in Standard two include:

In response to a gap analysis, new audit tools have been developed to better capture residents' needs in relation to other health and related services, palliative care, weights, nutrition and hydration, continence management, behaviour management, oral and dental care, sensory loss and sleep management. A new audit tool was also developed for the medication trolley and medication room. The manager said results of these audits now trigger education sessions and staff said the audits help them to provide more individualised care to residents.

In response to a Coroner's report recommendations the home has developed a smoking policy which requires a detailed assessment and guidelines for residents who wish to continue to smoke. The home provides a fire blanket and smokers' aprons and water based cigarette butt disposal containers in the designated smoking area. Residents have adjusted to the new requirements stating they understand it is for their safety and the safety of other residents and staff.

The focus over the past year at the home has been around palliative care and many initiatives were introduced that were supported by staff education. Initiatives included the introduction of advanced care planning and end of life pathways, updating of associated equipment and provision of palliative care boxes. Policies, procedures and checklists were developed to guide staff in the delivery of improved palliative care. Support services for families through the organisation's social worker and staff access to employee assistance program and counselling were promoted and encouraged. Staff are now more skilled to provide compassionate and skilled palliative care and residents and their families experience a dignified and supported death.

2.2 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 about health and personal care”. Team’s findings The home meets this expected outcome The corporate systems identify changes to relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care. Refer to expected


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outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance processes. Examples of responsiveness to regulatory compliance relating to Standard two include:

appropriately qualified and trained staff plan, supervise and undertake specialised nursing care

a policy, procedures and documentation are in place to ensure the home complies with laws regarding absconding residents

demonstrated compliance with legislative requirements in relation to medication storage and management.

2.3 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 meets this expected outcome 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, management ensure staff have the knowledge and skills required to effectively perform in their roles. Clinical policies and procedures and duty lists guide staff practices. Managers monitor staff skills and knowledge through clinical competency tests.

In addition to corporate education sessions, self learning digital video disc training programs, attendance at conferences and support for graduate and post graduate nurse programs, recent education relevant to Standard two includes:

continence management

ceiling hoist and tracing system

palliative care

medication administration

skin integrity - preventing pressure ulcers

dementia care

wound care

advanced care planning 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Residents receive appropriate clinical care. All areas of care are assessed and management strategies are identified in consultation with the resident, or their representative. Assessments of residents care needs and preferences occur by appropriate staff on entry to the home. Completed assessments along with consultation with residents and representatives allow for the development of individual care plans. Care plans along with clinical policies and procedures guide staff practice when providing resident care. A review of resident care plans occurs regularly to capture changes in need or preference. The


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monitoring of clinical care takes place by scheduled audits, stakeholder feedback, clinical data analysis and staff attendance at clinical education. Staff said they have attended varied clinical education sessions. Residents and representatives said the care residents receive is appropriate and according to their needs and preferences and that consultation always occurs. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Appropriately skilled staff identify and meet residents’ specialised nursing care needs. Regular assessment of residents’ specialised nursing needs occurs on entry to home in consultation with residents, representatives and a number of other health professionals as needed. Developed care plans document specialised nursing care needs, preferences and the interventions required. Appropriate staff review residents’ care plans every three months, or more frequently if there is an identified need. Specialised care needs currently catered for in the home include diabetes management, tube feeding, catheter care and wound management. Management monitor specialised nursing care by conducting scheduled audits and by seeking residents and representative feedback. Staff said they attend education pertaining to specialised nursing care needs. Residents and representatives said residents receive specialised nursing care in accordance with their needs and preferences. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome Referrals to appropriate health professionals for residents occur in accordance with their needs and preferences. Assessments occur regularly to determine residents’ need for input from health related services. Referrals to health professionals occur as needed following the home’s referral system. Residents are able to choose preferred health professional services and support to attend appointments occurs as required. Some health professionals regularly visit the home including physiotherapists, medical officers, psychologists, podiatrists and dietitians. The home’s audits monitor the effectiveness of referrals to other health and related services. Staff said communication between allied health professionals’ and the home is appropriate to ensure implementation of recommendations. Residents and their representatives confirmed referrals to appropriate health specialists take place as necessary. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome The management of residents’ medication occurs safely and correctly. Residents have their medication administration needs assessed on entry to the home and as needed. Care plans and medication charts document the relevant information needed for staff to safely administer residents’ medication. Residents who wish to administer their own medications


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can do so if assessed as safely able to administer their medications. Medication is stored correctly following the home’s policies and procedures and legislative requirements. The monitoring of effective medication management occurs by audits, medication incident data analysis and residents and representative feedback. Staff said they were able to access medication out of pharmacy hours including on weekends. Residents and representatives said the administration of residents’ medications is timely. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome Residents are as free as possible from pain. The home has a focus on this area of care, and extensive research and training has been completed for staff in the area of pain management, targeting chronic pain. Staff conduct residents’ pain assessments on entry to the home and when there is an identified need. Care plans document the relevant triggers of pain and interventions’ required in guiding staff practice. Referrals to appropriate health professionals occur as needed and recommendations are documented and followed. The home’s physiotherapist is heavily involved in the pain management program at the home and is engaged for four days a week specifically to treat residents on the pain program. Residents’ pain levels are constantly monitored and strategies implemented to manage pain regularly. The home monitors pain management by audits and stakeholder feedback. Staff could describe verbal and non verbal cues for pain and a range of interventions to manage residents’ pain. Residents and representatives said they are satisfied with the management of residents’ pain. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome The home maintains the comfort and dignity of terminally ill residents. Palliative care has been another focus of the home in recent times. Extensive research and resource has been put into the development of a comprehensive approach to the management of residents in the terminal stages of their lives. The home's social worker has been extensively involved in this project, as has the pastoral care team. Consultation with residents and representatives in relation to end of life wishes occurs as necessary. Care documentation reflects palliative care needs and preferences and a review of these is ongoing. Palliative care specialist and medical officer input occur if assistance for staff is required. There is the provision of appropriate equipment and supplies to accommodate palliative care. Management monitor palliative care in the home by scheduled audits and stakeholder feedback. Staff said that they have had extensive training pertaining to palliative care and expressed a high level of satisfaction in being a part of residents' end of life decision-making. Residents and representatives said consultation occurs regarding residents’ palliative ongoing needs and preferences


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2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Residents receive adequate nourishment and hydration. Residents’ dietary needs and preferences are determined on admission and this includes the identification of any culturally specific and modified diets. Developed care plans document identified allergies, dietary needs, special utensils and the level of assistance staff provide when assisting with meals. The monitoring of residents weights occurs regularly and referrals to dietitians take place as needed. The home’s menu allows for choice and input of residents and representatives. The monitoring of nutrition and hydration occurs by audits and resident and representative surveys. Staff said the implementation of dietitian and speech pathologist recommendations occurs. Residents and representatives said they were satisfied with the home’s approach to meeting residents’ nutrition and hydration needs. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Residents’ skin integrity is consistent with their general health. Assessments of residents’ skin integrity take place on entry to the home and as needed. Care plans document relevant strategies to maintain residents’ skin care needs, a review of these strategies takes place regularly. The documentation of skin integrity incidents occurs and follow up is taken including the implementation of wound care charts to guide staff practice. Access to wound care specialists occurs to seek support and guidance if necessary. We observed sufficient and appropriate stock available to meet residents’ skin care needs. Staff said attendance to education pertaining to wound management occurs and guidelines on maintaining residents’ skin integrity are available. Residents and representatives said they were satisfied with the care provided in relation to residents’ skin care. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome The management of residents’ continence is effective. Continence assessments occur on entry to the home and as needed. Care plans document relevant interventions, equipment and the level of assistance required by staff to maintain residents’ continence levels. Management monitor residents’ urinary tract infections for trends and information collected is discussed with staff. Referrals to medical officers and continence specialists take place if needed. Management monitor continence in the home by infection data analysis, audits and resident and representative feedback. Staff said attendance to education in relation to continence management occurs and there is enough stock and equipment available to meet residents’ needs. Residents said consultation occurred in regards to the management of their continence needs.


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2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The management of residents with challenging behaviours is effective in the home. The home has a secure dementia unit that has its own garden with a number of raised garden beds, activity boards, a bus stop and a path for residents to wander safely. This unit is staffed by staff with a particular interest in caring for residents’ with challenging behaviours. Behaviour management assessments occur on entry to the home to ensure identification of residents with challenging behaviours. Care plans document relevant triggers for behaviours if any and relevant interventions required. Referrals to a psychologist specialising in aged care occurs as needed and diversional therapy is utilised to manage residents’ behaviours if appropriate. The monitoring of behaviour management takes place by behavioural incident data analysis, audits and stakeholder feedback. Staff have received training regarding behaviour management strategies. Residents said other residents did not infringe on their rights. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome Management of residents’ optimum levels of mobility and dexterity occurs effectively. The identification of residents’ mobility and dexterity needs takes place on entry to the home. The home’s physiotherapist assesses residents and identifies the need to attend the exercise falls programs, pain management program and implements exercise regimes. Care plans document the equipment and aids needed and the level of assistance staff are to provide to meet residents needs. Incident reports document resident falls and follow up interventions occur as necessary. Management monitor mobility, dexterity and rehabilitation by falls incident data analysis, audits and residents and representative feedback. Staff have attended education relating to residents’ mobility and dexterity needs. Residents and representatives said they were satisfied with the home’s approach to optimising residents’ mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome The maintenance of residents’ oral and dental health occurs effectively. Oral and dental care assessments occur on entry to the home and the development of a care plan occurs. Care plans document oral and dental care regimes, equipment and the level of assistance by staff needed. Access to residents preferred oral and dental health specialists occurs and staff arrange assistance to attend appointments where necessary. The monitoring of oral and dental care takes place by scheduled audits and stakeholder feedback. Staff said there is adequate stock and equipment to assist residents with maintaining oral and dental regimes. Residents and representatives said residents received assistance as required to maintain their oral and dental care.


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2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome An assessment of residents’ sensory loss needs occurs on entry to the home. Care plans document interventions required to guide staff practice in regards to aids required and the level of assistance required to maintain sensory loss aids. Referrals to sensory specialists occur as needed and support is provided to attend appointments as necessary. Devices to assist in sensory loss are available if needed. Sensory loss audits monitor the effective management of residents’ sensory loss needs. Staff carry out recommendations from health professionals in relation to sensory loss needs. Residents and representatives were satisfied with the home’s approach to managing residents’ sensory loss needs. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Following a settling in period an assessment of residents’ patterns and preferences in relation to maintaining optimal sleep takes place. Care plans document the required interventions including environmental factors, rising and settling times and if residents have any naps during the day. Developed care plans include environmental factors, rising and settling times and specific resident rituals. Referrals to medical officers occur as needed in relation to maintaining optimal sleep. The monitoring of sleep management occurs by scheduled audits and stakeholder feedback. Staff said appropriate resources to meet residents’ needs are available. Residents said they were able to communicate their needs to staff.


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Standard 3 – Resident lifestyle Principle: Residents 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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Staff contribute to the home's continuous improvement systems using improvement logs, undertaking lifestyle audits and raising issues at staff meetings to facilitate improvements in resident lifestyle. A description about the home’s continuous improvement system is in expected outcome 1.1 Continuous improvement. Residents advised that they are supported to retain their personal, civic, legal and consumer rights as far as they are able and are satisfied with the variety of lifestyle activities offered. Staff are familiar with improvements that have occurred in relation to resident lifestyle. Examples of continuous improvement in Standard three include:

The home developed new audit tools for independence, choice and decision making, culturally appropriate care and leisure interests and activities. The audits provide a better indication of residents' satisfaction with care and services provided to them so staff can provide more person centred care and services. Residents confirmed their high levels of satisfaction with the care and services provided to them.

At a recent residents' meeting, residents indicated that they would like a cat at the home. Following support from residents who did not attend this meeting and approval from the manager a staff member donated a kitten to residents. The home held a naming competition so all residents could participate in naming the kitten. Staff developed a care plan for the kitten and it has been spayed and is receiving its immunisation according to veterinary requirements. Staff said they observe residents interacting with the kitten and it often naps on one resident's lap. Residents stated they love having a kitten in the home.

The manager identified a need to better support staff in regard to grief at the time of the loss of residents. Staff participated in self assessments and discussion at specially arranged meetings so feelings and thoughts could be collated into a report. The home conducted a staff survey to provide all staff with the opportunity to contribute. The results of the survey and the report assisted staff to develop a grief and loss strategy. From the strategy a policy and procedures have been developed implemented and utilise the skills of pastoral carers. Staff said they feel more equipped to deal with a resident death and to deal with residents' representatives following a death.

3.2 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, about resident lifestyle”. Team’s findings The home meets this expected outcome The home uses the systems described in expected outcome 1.2 Regulatory compliance to identify and ensure compliance with all relevant legislation, regulatory requirements and


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professional standards. Residents, representatives and staff confirmed their awareness of residents’ rights and responsibilities. Examples of responsiveness to regulatory compliance related to Standard 3 include:

Policies, procedures and a register are in place to record reportable incidents such as elder abuse.

The home uses corporate systems and personnel to manage and monitor compliance related to residential agreements and residents' security of tenure.

Staff follow corporate policies and procedures to ensure residents' personal information is used and stored confidentiality.

3.3 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 meets this expected outcome 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 three. Management ensure staff have the knowledge and skills required for effective performance in their roles. Managers monitor staff skills and knowledge in relation to resident lifestyle needs through stakeholder feedback. In addition to corporate education sessions, self learning digital video disc training programs and attendance at conferences, recent education relevant to Standard three includes:

orientation program

ethical response

elder abuse

person centred approach

laughter workshop 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home has processes to support residents’ emotional needs in adjusting to their new home and on an ongoing basis. Management and staff assist residents to settle in by encouraging them to bring personal mementos, providing tours, introducing them to staff, volunteers and other residents, providing them with comprehensive information and spending time with them to establish relationships. The homes social worker and pastoral care team see all residents, and they play an integral role in providing emotional support not only on admission, but also on an ongoing basis. Residents’ individual emotional support needs are clearly documented in their care plans and are monitored and re-assessed regularly through observation and clinical tools. Documentation and staff interviews confirmed staff are perceptive to residents’ individual needs and are able to administer effective interventions. Staff can access external mental health professionals for support and advice if required. Residents and their representatives reported that staff are very compassionate and caring.


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3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome The home assists residents to achieve maximum independence, maintain friendships and participate in community life. The home’s assessment process identifies residents’ ability and preference for social interaction and community participation and documentation confirmed staff work towards meeting residents’ individual requests. The home has a very dedicated group of volunteers who visit the home regularly and provide assistance with special events, and company for isolated residents. Physical independence is encouraged through regular exercise and physiotherapy programs. Friendships are encouraged amongst the residents and by welcoming family, friends and volunteers to visit regularly. Offering regular outings, facilitating attendance to external groups and inviting community groups to the home maintain community links. Residents and their representatives confirmed that staff encourage and assist residents to achieve maximum independence. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Residents’ right to privacy, dignity and confidentiality is recognised and respected at the home. Staff ensure all personal and health information remains confidential and is securely stored. On entry, residents or their representatives complete consent forms and are given information on privacy. The home has areas both internally and externally for visitors and residents to meet privately. Staff are provided with information about confidentiality on commencement and residents’ rights are discussed regularly at meetings. Observation of staff practice and interviews confirmed staff respect residents’ privacy and dignity. Residents are satisfied with the way staff preserve their dignity and respect their privacy. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome. The home’s leisure and lifestyle program encourages and supports residents to participate in a range of individual and group activities. A lifestyle and leisure profile assessment is completed shortly after residents move into the home, following consultation with the resident and their representative and is used to develop an individualised care plan. The home’s lifestyle program offers a variety of activities to accommodate spiritual and cultural preferences, cognitive stimulation, community involvement, physical needs, social and emotional support and sensory stimulation. Residents’ attendance and participation is recorded and their care plans are evaluated three monthly. Barriers to participation are recognised and effective strategies and assistive devices are used as required. The home evaluates the effectiveness of their program through formal evaluations of each activity, taking into consideration resident feedback and participation. We observed residents actively


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engaged in a range of meaningful activities and residents report high levels of satisfaction with the program. 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 The home meets this expected outcome The home identifies, fosters and respects residents’ individual interests, spirituality, beliefs and culture. The home uses a number of different resources to assist them to maximise opportunities to celebrate different cultures and spirituality. Lifestyle staff complete cultural and spiritual profile assessments shortly after residents move into the home, to identify residents’ preferences. This is reflected throughout their care plan including consideration in catering services, palliative care, communication processes and lifestyle activities. The home provides an area for religious services and outdoor garden areas for reflection and relaxation. The home acknowledges culturally specific celebrations such as birthdays, ANZAC day, and Christmas, as per residents’ request. The home monitors the effectiveness through resident feedback, surveys and meetings. Residents and their representatives confirmed that residents’ cultural and spiritual needs are met and respected. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident 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 The home meets this expected outcome Residents’ right to make decisions and exercise control over their care and lifestyle is recognised and respected by staff at the home. The pastoral care team and all staff are aware of their roles in ensuring residents are able to exercise choice and control over their life’s, acting in appropriate advocacy positions when needed. Residents are invited to participate in their care planning and are consulted frequently about individual preferences in all aspects of care and service. Authorised representatives are identified and consulted on behalf of residents if they are unable to make their own decisions. Advanced care planning provides residents with opportunities to express their wishes for end of life. Resident meetings, care consultations and feedback processes provide residents with opportunities to voice their opinions and exercise control over their life. Complaints and advocacy information is included in the resident handbook and is on display throughout the home. We observed staff consulting with residents about care and lifestyle choices. Residents expressed a high degree of satisfaction with the opportunities provided to participate in decisions about their life and their home.


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3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome The home's admissions coordinator and the manager organise the pre-admission and admission processes and these include a pre-admission interview, tour of the home and provision of financial information. If residents are entering the home from hospital the manager visits the prospective resident where possible to meet with them to discuss their care needs and suitability of the home to meet these needs. Residents receive a copy of the handbook on entry to the home. Residents are welcomed to the home through the introduction to other residents with similar needs or backgrounds to assist them to settle in. Care and lifestyle staff visit the resident to introduce themselves and provide the resident with information on the services they provide. The resident handbook includes information about all aspects of living in the home, internal and external avenues for complaint, fees and charges, privacy and dignity, clinical care services, lifestyle opportunities, meal services, changing room processes and residents' meetings. Residents and their representatives confirmed they feel secure in their tenure in the home and appropriate consultation occurs.


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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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Staff contribute to the home's continuous improvement systems using improvement logs, undertaking audits and raising issues at staff meetings to facilitate improvements in the physical environment and safe systems. Information about the continuous improvement system is in expected outcome 1.1 Continuous improvement. Residents and staff advised they are satisfied with the home's environment and safe systems. Staff are familiar with improvements that have occurred in relation to physical environment and safe systems. Examples of continuous improvement in Standard four include:

The home has developed new audit tools to assist staff to improve service delivery and these include management of soiled linen, care of sharps, health safety and wellbeing and first aid. Associated education has also been provided as required. Staff said undertaking the audits has improved their knowledge of requirements in these areas. The health, safety and wellbeing manager said that there has been a significant reduction in Worksafe claims since she implemented these changes.

Following ongoing complaints regarding the standard of cleaning in the home the manager reviewed all aspects of cleaning services and appointed a new member of staff to undertake the cleaning services. This staff member has undertaken additional education and works to newly created cleaning schedules. The hours allocated for cleaning duties have been increased by three hours per day and an external service provider has been engaged to clean the floors in all communal areas twice per week. Since these actions have been implemented the cleanliness of the home has improved and complaints about cleaning have significantly reduced. A high proportion of respondents to the December 2011 resident satisfaction survey indicated that they were happy with the cleanliness of their room. Residents stated the cleanliness of the home is now at a high standard.

The home has developed a comprehensive emergency relocation management plan and a business continuity plan. To supplement the emergency relocation plan staff have put together an evacuation kit that contains resident identification tags, torches, medication cups, a first aid kit, stationery and the relevant policies and procedure documentation. In addition there are contact lists of local hospitals, all residents' doctors, health and other services and managers. Every resident has been assisted to prepare a striped evacuation bag that is stored in the same place in every resident's room and contains a change of clothing. Staff have been trained on the procedures for evacuation using these resources. Residents said they are confident that staff know what to do to keep them safe in the event of an emergency.


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4.2 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, about physical environment and safe systems”. Team’s findings The home meets this expected outcome The home uses the systems described in expected outcome 1.2 Regulatory compliance to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards relating to the physical environment and safe systems. Staff uphold safe working practices and report hazards within the home. Examples of responsiveness to regulatory compliance relating to Standard 4 include:

Staff store chemicals in dedicated locked store rooms within the home and update material safety data sheets as required.

The home has an audited food safety plan and staff attend to scheduled auditing of kitchen systems.

The home engages appropriately qualified service providers in conjunction with its maintenance staff to monitor its essential services systems and equipment and staff are trained appropriately in how to use fire and evacuation systems.

4.3 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 meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. Management ensure staff have the knowledge and skills required for effective performance in their roles in relation to Standard 4 Physical environment and safe systems. Management monitor attendance to education pertaining to the home’s mandatory safe systems and assess staff skills and knowledge through competency testing and practical interactive demonstrations. In addition to corporate education sessions, self learning digital video disc training programs and attendance at conferences, recent education relevant to Standard four includes:

orientation program

fire and emergency

special diets and fluids (for catering staff)

occupational health and safety - five day and refresher courses

hand washing techniques


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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 residents’ care needs". Team’s findings The home meets this expected outcome The home provides residents with accommodation in single en-suite rooms within four adjoining houses. Safe paths and garden areas are maintained to support resident safety. Private and communal areas are available inside an outside and these are easily accessible for residents. Residents are able to personalise their rooms with belongings from home. The home maintains comfortable noise, temperature and lighting levels and has measures in place to ensure the safety and security of residents. A preventative maintenance program ensures plant and equipment is maintained to manufacturers' specifications and staff log corrective maintenance issues in to an electronic system that is managed from the organisation's head office. Residents and staff said maintenance staff attend to requests promptly. Residents said they were satisfied with the homes provision of a safe, comfortable and homely environment. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome The home has four occupational health and safety representatives who have attended the required training program and are supported by the organisation's health, safety and wellbeing manager. Health, safety and wellbeing meetings are held six weekly and discuss incident and accident data and hazard reports. Minutes of these meetings are available to all staff. Up to date material safety data sheets are available in appropriate work areas. The representatives, together with the home's manager, undertake environmental audits and provide the results of these to all staff at meetings and through minutes displayed on noticeboards. The organisation provides education at orientation and then annually on manual handling, infection control and bullying and harassment. Chemicals are stored safely and securely. Staff are knowledgeable about when and how to report hazards, incidents and accidents and said their work environment is safe. 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 meets this expected outcome Management and staff actively work to provide an environment and safe systems of work that minimise fire, security and emergency risks. Staff receive information about the home's emergency systems and processes during orientation and attend mandatory fire and emergency training annually thereafter. Managers monitor staff attendances at these sessions. The home displays emergency and evacuation plans throughout the home and emergency exit signs are clearly visible and free from obstruction. The home is equipped with an appropriate range of emergency and fire fighting equipment and qualified external service providers service them according to schedules. The home has comprehensive


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policies and procedures in place to manage an evacuation if this is required. Staff confirmed they participate in emergency and evacuation training sessions and are confident they know what to do in an emergency. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome There is an effective infection control program in the home. The collation, analysis and trending of residents’ infections occurs monthly and is displayed for staff information and discussed at staff meetings. Staff and residents are offered appropriate vaccines. The correct disposal of sharps and contaminated waste occurs across departments. A food safety program guides catering staff practice and an external contractor monitors the home for pests. Management monitor infection control processes by scheduled audits, infection data analysis and staff attendance to mandatory infection control education. Staff said there is adequate personal protective equipment available throughout the home. Residents said staff use infection control practices when they attend to their care needs. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome The provision of hospitality services enhances residents’ quality of life. The home’s menu is seasonal and a dietitian reviews it as necessary to ensure the menu meets residents’ nutritional needs. The menu allows for choice and adequate snacks and fluids are readily available at all times. The annual residents' surveys include questions about catering, cleaning and laundry. Meals times are staggered so staff assisting residents with their meals can do so without being rushed. The cleaners follow a cleaning schedule which ensures appropriate cleaning of all areas in the home. Cleaning occurs according to infection control and chemical handling guidelines and staff use appropriate personal protective equipment. The laundering of residents’ personal clothing takes place on site and linen is outsourced to a specialised service provider. Laundering services take place using infection control guidelines. Residents and representatives said they were satisfied with the hospitality services provided at the home.

Documents

Villa Maria Aged Care Residence Berwick