Westhaven Nursing Home - welcome — Australian Aged Care · PDF fileWe will continue to monitor the performance of the home including ... 2.10 Nutrition and hydration Met 2.11 Skin

Westhaven Nursing Home

RACS ID 5439 McDowall Street

ROMA QLD 4455

Approved provider: Queensland Health

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 20 September 2017.

We made our decision on 25 July 2014.

The audit was conducted on 24 June 2014 to 25 June 2014. The assessment team’s report is attached.

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

Home name: Westhaven Nursing Home RACS ID: 5439 2 Dates of audit: 24 June 2014 to 25 June 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

Westhaven Nursing Home 5439


Introduction

This is the report of a re-accreditation audit from 24 June 2014 to 25 June 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 24 June 2014 to 25 June 2014.

The audit was conducted in accordance with the Quality Agency Principles 2013 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: Julie White

Team member/s: Anita Camenzuli

Approved provider details


Details of home

Name of home: Westhaven Nursing Home

RACS ID: 5439

Total number of allocated places:

40

Number of care recipients during audit:

36

Number of care recipients receiving high care during audit:

36

Special needs catered for: Dementia and related conditions

Street/PO Box: McDowall Street

City/Town: ROMA

State: QLD

Postcode: 4455

Phone number: 07 4624 2661

Facsimile: 07 4624 2755

E-mail address: [email protected]

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Director of Nursing/Facility Manager 1

Nurse Unit Manager 1

Service Improvement team leader 1

Registered staff 5

Care staff 5

Corporate support staff 2

Residents/representatives 6

Recreation Officer 1

Acting Manager, Operational Services 1

Operational Services staff 6

Maintenance Coordinator 1

Sampled documents

Category Number

Residents’ files 9

Personnel files 4

Medication charts 12

Other documents reviewed

The team also reviewed:

‘New admission resident’s dietary profile/care plan’ flowchart

Activities calendar, planner, attendance records and evaluations

Allied health referrals

Audit program and results

Bowel management charts

Cleaning schedules

Clinic lists


Clinical assessments, observations and monitoring tools

Communication and appointment books

Consumer feedback analysis

Controlled drug registers

Diabetic record sheets

Dietary profiles and resident dietary list

Electronic mail and facsimile communications

Evacuation drill report

Fire/evacuation plan and continuity/recovery plan

Food safety plan

Handover sheet

Incident reports

Infection incidence/surveillance record

Maintenance requests (electronic) and outstanding actions report

Malnutrition prevention flowchart

Mandatory reporting register

Mandatory training matrix

Medication order forms

Memoranda and notices

Minutes of meetings

Newsletter

Nutritional supplement orders

Pathology reports

Patient repositioning forms

Performance appraisals

Police certificate and professional qualification records

Policies, procedures and guidelines

Preferred supplier and external contractor lists


Preventative maintenance records (electronic)

Quick reference sheets

Record of continuous improvement, action plans and quality activity forms

Resident evacuation list

Residents’ information handbook

Restraint documentation

Residential care agreement

Roster

Safety data sheets

Self-assessment

Service and inspection records

Staff orientation manual

Temperature monitoring records

Training calendars and attendance records

Warfarin dose administration records

Wound assessments and management plans

Observations

The team observed the following:

Accreditation information on display

Activities in progress

Activity program on display

Administration and storage of medications

Charter of residents’ rights and responsibilities on display

Cleaning in progress

Clinical ‘follow up’ box

Complaints and advocacy information on display

Designated smoking area

Emergency kits


Equipment, chemical and supply storage areas

Evacuation diagrams, assembly areas and routes of egress

Firefighting and fire detection equipment

Fire panel

Hand sanitiser, hand washing facilities and personal protective equipment

Handover processes

Hazard signage

Interactions between staff, residents and representatives

Kitchen and laundry operations

Living environment

Meal and beverage service

Menu on display

Mobility aids and transfer lifting equipment

Noticeboards and whiteboards

Resident ‘birthday’ box

Sharps and waste disposal

Short group observation

Sign in/out registers

Staff practices

Suggestion box


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

Westhaven Nursing Home (the home) actively pursues continuous improvement. The home’s continuous improvement system identifies improvement opportunities against the Accreditation Standards. Staff and residents/representatives contribute to the improvement system through meetings, handover processes, the comments and complaints system, audits, review of hazards and incidents, and feedback forms. Improvements are discussed and monitored through meetings prior to being evaluated and completed.

Residents/representatives and staff are confident suggestions are responded to in a timely manner and are satisfied the home actively pursues continuous improvement.

Examples of recent improvements undertaken by the home in relation to Standard 1 Management systems, staffing and organisational development include:

Management has replaced its individual folders dedicated to quality improvements, meeting minutes, audits, fire and service and maintenance reports with monthly ‘quality action’ folders containing information relating to each of these organisational responsibilities. The home’s Nurse Unit Manager is responsible for updating the folders; they informed us the re-organisation of this system has given management improved control over the accuracy and currency of information it uses to pursue continuous improvement at the home.

After identifying a deficit in staff response to clinical incidents, the home has improved its information management and monitoring processes by adding a residents’ file ‘follow up’ box in the work station. Staff have been educated on use of the box for incidents where action for affected residents has not been able to be taken or completed prior to the end of shifts; registered staff make a relevant notation in the resident’s progress notes and use a colour coded marker in the resident’s file to alert the next shift. We observed staff using this process to indicate a resident had not yet been assessed for the effectiveness of an ‘as required’ medication. Staff reported the process is “very good” in supporting information transfer between staff.


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 and processes to identify and ensure compliance with relevant legislation, regulations, professional standards and guidelines. The home is supported by the organisation ensuring management is informed of current legislation, industry practice and professional guidelines with regular updates and the development of policies and procedures to guide staff practices. Staff are informed through meetings, electronic and paper communication tools and training. Monitoring of the home’s regulatory compliance systems occurs through audits, the observation of staff practices by key personnel and the flagging of key review dates. Training mandated by regulation is scheduled and staff attendance and participation is monitored.

Particular to this Standard, the organisation has systems to ensure police certificates are current and residents/representatives are advised of scheduled accreditation visits.

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


Management and staff have appropriate knowledge and skills to perform their roles effectively. New staff are provided with position descriptions and duty statements to ensure they are aware of their position requirements. New staff attend orientation and are supported through ‘buddy’ shifts. All staff attend annual mandatory training sessions (local and organisational) to ensure skills and knowledge remain current. Education and training needs are developed in response to legislative requirements, performance appraisal and development sessions and observation of staff practice. Staff are encouraged to attend internal and external training opportunities with further educational needs being identified through observation of staff practice, meetings, audits and review of residents’ care needs. Staff demonstrate skills and knowledge relevant to their roles and are satisfied with the support they receive from the home to identify and develop their skills.

Particular to this Standard, staff have attended education sessions in workplace bullying and harassment, new products and equipment, documentation and the home’s Code of Conduct.


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 has processes to ensure residents/representatives have access to internal and external complaints mechanisms. Information is provided about internal and external avenues of complaints during the entry process, in the residential care agreement and resident handbook and through information on display. Complaints are raised on internal feedback forms, via organisational mechanisms such as audits, at meetings and through discussions with management and staff. Issues raised are investigated in a timely manner by management and addressed until resolution. Staff and resident/representative feedback is discussed at meetings. Residents and/or their representatives are satisfied with approaching management with comments or complaints.

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 philosophy of care, values and objectives are documented in the resident handbook, disseminated to staff during the orientation process and displayed within the home. Management and staff at the home are knowledgeable about the home’s vision and values.

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


Management monitors residents’ level of care needs, resident/staff feedback, staff availability and skill mix to ensure adequacy of staffing across the home. A registered nurse is available 24 hours a day to guide registered and care staff in the delivery of residents’ care. The home has established relief and on-call processes and staff are supported by the organisation in undertaking their duties. The home maintains policies for the recruitment and selection of staff including reference checks, criminal history checks and ensuring current professional registrations. New staff are aware of the requirements of their positions through contracts of employment, ‘buddy’ shifts, orientation processes, position descriptions, duty statements and ongoing mandatory education sessions. Key personnel conduct six monthly staff performance appraisals to ensure education needs are identified and staff are aware of their performance requirements. Residents and/or their representatives are satisfied with staff’s skill levels and responsiveness of staff to residents’ care needs.


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 processes to ensure there are stocks of appropriate goods and equipment available to provide care and services. Standing offer arrangements are used by the home for the provision of various goods and these are checked upon receipt to determine their suitability. Supplies of stock are rotated and monitored to ensure sufficiency for both care and service delivery. New equipment is assessed prior to purchase and training provided to staff. The home undertakes regular servicing and inspection to ensure equipment is in good working condition. Any unsafe or broken equipment is reported and maintenance action taken. Staff and residents/representatives are satisfied there are sufficient goods available and equipment is in good working order.

1.8 Information systems

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

Team’s findings


The home's information management systems are effective in ensuring continuity of care and service delivery and communicating organisational requirements. The clinical care management system is designed to manage the assessment of residents' care and lifestyle needs, the development of care plans, and the communication of changes to ensure nursing and other staff have current and accurate information. Communication tools (electronic and paper), progress notes and handover processes are used to record care need changes. Staff are satisfied they have access to appropriate information for the delivery of care and services. Effective information systems are used for the documentation, analysis and reporting of complaints, incidents, infections and hazards. Information systems that support human resource management, staff education, use of external service providers and continuous improvement are effective. There are processes to ensure the security of electronic and hardcopy information and to manage the archiving and destruction of obsolete records. Residents and/or their representatives are satisfied they have access to relevant information and are kept informed.

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 has processes to ensure that externally sourced services are provided in line with the home’s needs and service requirements. Contracts are coordinated organisationally with standing offer arrangements used for the provision of external services. Ongoing performance is monitored by key staff and feedback is provided where performance is not to the required


standard. Management, residents and/or their representatives and staff are satisfied with the provision of current external services.


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.



Team’s findings


Refer to Expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

Examples of recent improvements undertaken by the home in relation to Standard 2 Health and personal care include:

After reviewing residents’ weight loss, the home has developed a malnutrition prevention flowchart in conjunction with its dietitian and speech pathologist. The identification of nominated levels of weight loss prompts actions such as the introduction of supplements, food and fluid charting, allied health referrals and weekly weighing. Review of documentation and discussions with staff indicated staff had been trained in use of the process and strategies had been implemented for identified residents. Management reported the “structured” process has resulted in improved outcomes for residents with unintentional weight loss.

The home has installed half doors to some residents’ rooms to minimise the intrusiveness of other residents’ wandering behaviours. The doors were installed after trialling other strategies such as screens, which were evaluated as ineffective in reducing these behaviours. Ten residents identified by management as most affected by the behaviours were consulted and have had the doors added to their rooms; management advised it plans to introduce the doors for all interested residents. Review of documentation indicated positive feedback from residents, including from one resident who stated the door was the “best thing”.


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

Team’s findings


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to health and personal care.

Particular to this Standard, the home has systems to ensure registrations of registered staff remain current and unexplained absences are managed according to legislative requirements.




Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills. Staff demonstrate skills and knowledge relevant to their roles and are satisfied with the support they receive from the home to identify and develop their skills.

Particular to this Standard, staff have attended education sessions in duty of care, malnutrition prevention, dysphagia, responding to behaviours and continence management.

2.4 Clinical care

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

Team’s findings


Residents receive clinical care appropriate to their needs and preferences. Assessment processes commence on entry to the home and information is gathered from residents and/or their representatives with input from medical and allied health assessments.

Assessment information is used to formulate a plan of care to guide staff practice. Care plans are regularly reviewed by registered nurses in conjunction with enrolled nurses, care staff and allied health professionals. Changes in resident care are communicated via handover processes, the handover sheet and through documented progress notes. Residents are attended by a medical officer of their choice and referred to allied health professionals as needs indicate. Monitoring of clinical care is undertaken through reporting and review of clinical incidents, audits, resident and representative feedback and monitoring of staff practice. Residents and/or their representatives are satisfied with residents’ clinical care.

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


Residents have their specialised nursing care needs identified and met by appropriately qualified nursing staff. Registered nurses conduct initial assessments in consultation with residents/representatives and allied health professionals and in liaison with the resident’s medical officer or treating specialist. Care plans identify specialised care needs and are communicated on a treatment room white board, on the handover sheet, and through progress notes. Registered nurses oversee specialised nursing care needs and care delivery and are on site 24 hours a day. The home has educational resources and external advisors available if further information is needed. Residents are assisted to attend appointments outside the home if and when the need arises. The home is currently providing and has equipment and skills to


support care needs such as diabetes management, anti-coagulant therapy, wound management, catheter management and oxygen therapy. Residents and/or their representatives are satisfied specialised nursing care needs are met by appropriately qualified staff.

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 has processes to support referral to appropriate health specialists where residents’ health needs dictate. . Residents have access to a variety of medical and allied health professionals including dietetics, speech therapy, physiotherapy, podiatry, optometry, audiology, dental services and palliative care services. The home has a formal referral process in place which includes processes to manage urgent referrals. Wherever possible the home facilitates review of the resident in the home but where this cannot occur, strategies are implemented to assist residents to attend external appointments.

Documentation of the health specialist’s visit is incorporated into the resident’s plan of care as appropriate. Implementation of recommended strategies are monitored and the effectiveness of care is evaluated. Follow up appointments are organised by the home as needed. Residents and/or their representatives are satisfied with the range and access to appropriate health specialists and the follow up care provided.

2.7 Medication management

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

Team’s findings


Residents’ medication needs are managed safely and correctly. Registered staff administer medications from original packaging. Medication charts and care plans contain information to guide staff regarding allergies and assistance required when administering medication to residents. Policies and procedures guide staff in administration, recording, ordering and disposal of medications. As required medications are administered after consultation with a registered nurse and monitored for effectiveness. Medications are stored securely and records of controlled medication are maintained; those medications requiring storage at specific temperatures are stored within the appropriate environment. A stock control system is available for commonly used medications. Effectiveness of medication management is monitored through audits, incident reporting, observation of staff practice and medical officer and pharmacist review. Residents and/or their representatives are satisfied with the management of medications and with the assistance provided by staff.


2.8 Pain management

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

Team’s findings


The pain management needs of residents are identified through assessment undertaken on entry to the home and on an ongoing basis. Consultation occurs with the resident and/or their representative regarding their needs and preferences for pain management. Pain interventions are recorded on care plans and in progress notes. The home utilises a number of pain management strategies including pharmaceutical and non-pharmaceutical measures such as repositioning, exercise and distraction. The effectiveness of pain management strategies are monitored by staff and ongoing pain is referred to the medical officer for review. Residents and/or their representatives are satisfied residents’ pain is managed effectively.

2.9 Palliative care

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

Team’s findings


Residents and/or their representatives indicated staff are caring and ensure the comfort and dignity of terminally ill residents is maintained. Residents’ terminal care wishes are determined by consultation with residents and/or representatives and documented in plans of care. Information such as enduring power of attorney and advance health directives are located in the resident records. The home has its own palliative care resources and is supported by local hospital services as required. Relatives and significant others are encouraged to participate in the care of palliative residents and are able to stay with residents if they wish. Specific care instructions are communicated to staff using care planning guidelines, end of life pathways, handover processes and progress notes. Staff have access to palliative care resources such as mouth care products, specialised bedding and pain relief to ensure appropriate care provision. Pastoral support is arranged according to resident preference. Staff are aware of the care needs and measures to provide comfort and dignity for terminally ill residents.

2.10 Nutrition and hydration

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

Team’s findings


Residents’ dietary needs, allergies, likes and dislikes are identified on entry to the home and on an ongoing basis. Relevant information is provided to the kitchen and included in plans of care to guide staff practice. Residents are weighed in accordance with their individual requirements and weight variations outside of acceptable parameters are actioned through use of supplements and/or referral to the medical officer, dietitian and speech pathologist as required. Directives from allied health personnel relating to nutrition and hydration are communicated to staff and implemented. Strategies to assist residents to maintain adequate nourishment and hydration include assistance with meals, increased fluid rounds in hot weather, specialised cutlery and dietary supplements. Residents and/or their representatives


are satisfied with the quality and quantity of food and fluid and staff support to meet resident’s needs.

2.11 Skin care

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

Team’s findings


Residents are assessed for their skin care needs on entry to the home and on a regular basis. Skin care needs and changes are reviewed by staff during hygiene routines and communicated in daily handover reports and progress notes. The incidence of injury/skin tears is captured on incident reports and interventions are implemented as appropriate. Wound care is managed by registered staff and healing progress is monitored and evaluated through wound assessment charts and progress notes. Advice is sought from medical officers and a wound consultant for complex wounds. Staff attend education and specialised training to assist in delivery of appropriate wound care The home has sufficient supplies of wound and skin care products to ensure effective skin care management when required Residents and/or their representatives are satisfied with the care provided in relation to skin integrity.

2.12 Continence management

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

Team’s findings


The home has processes to ensure the continence and toileting needs of residents are met effectively. Residents’ continence needs are assessed on entry to the home and on an ongoing basis. Care plans direct staff practice and ensure individual residents’ preferences are met. Staff have an understanding of continence promotion strategies such as the use of aids and toileting programs. Staff assist residents with specialised continence needs. Staff complete bowel monitoring charts and registered staff receive alerts when residents’ bowel patterns fall outside of their normal routine to allow for appropriate action. Staff are provided with education to enable them to manage residents’ continence needs. Residents and/or their representatives are satisfied residents’ continence needs are managed effectively and staff support resident privacy and dignity.

2.13 Behavioural management

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

Team’s findings


Residents are assessed on entry to the home and indicators for challenging behaviours are identified. Care staff monitor and chart challenging behaviour to enable assessment by the registered staff and the development of care plans that identify appropriate triggers and interventions. Staff are knowledgeable of individual resident needs and risks. Care and recreational staff support residents in maintaining their abilities and interests as well as


providing distraction and one-on-one support when they are unsettled. External mental health services and dementia advisory bodies can be accessed to assist in the management of complex behaviours and to provide education to staff. Residents requesting or requiring protective assistive devices have relevant authorities which are reviewed regularly. Staff are aware of their reporting responsibilities in the event of a behavioural incident and documentation supports appropriate nursing and medical intervention. Residents and/or their representatives are satisfied with the way challenging behaviours are managed in the home.

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 has processes to ensure optimum levels of mobility and dexterity are achieved for all residents. Mobility and dexterity needs and preferences are assessed on entry to the home by registered staff and a physiotherapist. A care plan is formulated which includes mobility and transfer needs, and any equipment required. The recreation officer conducts exercises and regular walking programs with residents. Falls are reported and monitored and interventions are implemented where possible to prevent recurrence. Staff are provided with mandatory training in manual handling techniques. Residents were observed using a range of mobility aids and residents and/or their representatives are satisfied with the support residents receive to maintain optimum levels of mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


Residents are assisted to maintain their oral and dental health. Each resident’s oral and dental needs are assessed on entry to the home and their individual needs and preferences reflected in the care plan. Staff monitor and review residents’ ability to self manage their oral and dental care needs and assist as necessary. Residents and staff have access to appropriate oral and dental care equipment. Oral and dental issues are investigated and referred to the appropriate medical officer or dental services as required. Residents and/or their representatives are satisfied with the support and assistance provided by staff to maintain residents’ oral and dental health.

2.16 Sensory loss

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

Team’s findings


The home has processes to identify residents’ sensory losses and ensure they are managed effectively. Residents’ care needs in relation to sensory loss and communication are assessed on entry to the home and reassessed as needs change. Care plans are formulated to guide


staff and include information and strategies regarding sensory loss and personal preferences including reference to use of assistive devices and staff assistance required.

The lifestyle program includes activities to stimulate residents’ senses such as musical activities and cooking. Audiology and optical specialists are accessed as required to identify and address concerns and/or provide ongoing management. Residents and/or their representatives are satisfied with the care and support offered to residents to minimise the impact of any sensory loss.

2.17 Sleep

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

Team’s findings


The home has processes to assist residents to achieve natural sleep patterns. Each resident’s natural sleep pattern, settling routine and personal preference is collected through assessment and review processes. Care plans identify preferred sleep routines such as preferred level of lighting and toileting needs. Staff at the home maintain a quiet environment and lighting is kept to a minimum to assist residents to settle and remain asleep. Residents who wake in the night are assisted to resettle utilising strategies such as repositioning, warm shower, provision of food and fluids and emotional support. Residents’ medical officers are consulted if interventions are considered to be ineffective and pharmacological strategies are utilised as prescribed. Residents and/or their representatives are satisfied with interventions to manage sleep.


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.



Team’s findings



Examples of recent improvements undertaken in relation to Standard 3 Resident lifestyle include:

Following a staff suggestion for a central store of birthday items for its residents, the home has created a ‘birthday box’. The box contains hats, streamers, cards and other party items to enhance the celebration of residents’ birthdays. With the consent of residents/representatives, night staff decorate residents’ rooms for their birthday mornings and staff and residents/representatives celebrate with birthday cake and party items at lunch time. Review of documentation indicated the initiative is intended to ensure the birthday resident feels ‘special all day’. We observed the birthday box in use and a decorated resident’s room during the audit.

As a result of volunteer feedback, the home has introduced increased musical activity to its recreation program. After trialling organ music and evaluating residents’ response, a volunteer now attends for 90 minutes weekly to play the organ and sing to the residents. Management reported this has encouraged participation from residents, who sing, dance and tap their hands to the beat. We observed residents enjoying this activity during the audit.


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


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to resident lifestyle.

Particular to this Standard, the home has systems to ensure reportable and non-reportable events are managed according to legislative requirements.




Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills.

Particular to this Standard, staff have been provided with education in mandatory reporting processes, elder abuse, cultural diversity and ethics.

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


Information about the home is provided to residents prior to and on entry to the home, and orientation is provided to residents to assist their adjustment to the new environment.

Residents’ emotional needs and preferences for support are identified, and a care plan including social and support needs for the resident is developed. Emotional support is further enhanced through assisting residents to personalise their rooms, one to one interaction with staff and encouragement to participate in the life of the home. Family members and friends are welcomed to take meals with residents and continue as part of the supportive network.

Pastoral care workers can be arranged if the resident or representative request and psychologist and social worker referral is available should the emotional needs of the resident require. Residents and/or their representatives are satisfied with the support residents receive from staff during the settling-in period and with the ongoing support provided by management and staff.

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


Residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Regular assessment of residents’ independence needs is conducted and translated into plans of care to guide staff. Residents are assisted with those aspects of personal care and other activities they are unable to manage unaided, and appropriate equipment such as mobility aids and eating utensils are provided to support residents’ independence. Residents are assisted to continue to participate in activities of interest both in the home and in the wider community and staff assist as


necessary. Residents’ families and significant others are informed of events and functions at the home and encouraged to attend. Residents and/or their representatives are satisfied with interventions to maintain residents’ independence and the assistance they receive from staff.

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


Each resident’s right to privacy, dignity and confidentiality is recognised and respected. The home provides secure storage of residents’ information and files containing residents’ personal information are stored in secured areas, with access limited to authorised stakeholders. Staff are respectful of appropriate practices, such as knocking on residents’ doors, closing doors when providing personal care, and addressing residents by their preferred names. Personal information regarding residents and their care needs is not discussed in public areas. Residents whose preference is to be attended by staff of a particular gender are accommodated. Rooms with shared ensuites have separate storage for personal items and toiletries. Residents and/or their representatives are satisfied residents’ privacy and dignity is maintained and they are treated in a respectful manner.

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


Residents are encouraged and supported to participate in a wide range of interests and activities of significance to them. Residents’ interests are identified through interview with residents and their representatives and a recreational plan of care is formulated. A monthly activity program is displayed in common areas of the home and daily activities are listed on a whiteboard. Residents are invited, encouraged and supported to attend to interests and activities of their choice. The recreation officer, volunteers and community visitors provide one to one visits for residents who do not wish to or cannot attend activities. Activities and events are evaluated and resident feedback sought to ensure resident choice and satisfaction is being met. Residents and/or their representatives are satisfied with the leisure and activity program offered by the home.

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


Individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. The home has a system for identifying and recording residents’ specific spiritual and cultural needs and preferences on entry to the home. The home is able to provide culturally


appropriate diets if requested or identified as a resident preference. Regular church services of different denominations are held in the home and residents are supported to attend. Staff have access to information relating to cultural differences and can call on a pastoral carer and ministers from various denominations when residents and/or their representatives request. Days of personal, cultural and spiritual significance are celebrated. Residents and/or their representatives are satisfied residents’ cultural and spiritual needs and preferences are 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


Each resident or their representative participates in decisions and exercises choice over the resident’s lifestyle. The home has processes to identify and assess the choice and decision- making needs of residents on entry and when changes occur. Residents are encouraged to maintain control over their lives. Resident choice is incorporated into care plans and supported by staff in activities of daily living. Residents and representatives are given opportunities to have input into care and the environment at meetings, through case conferencing, satisfaction surveys and the home’s feedback system. Residents are offered a choice of meals and are provided with a safe area to smoke supported by staff supervision and safe practices. Residents whose preference is not to participate in activities are respected by staff. Residents and/or their representatives are satisfied with their ability to exercise choice and make decisions in the home.

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


Residents have secure tenure within the home and understand their rights and responsibilities. Residents and their representatives are provided with this information through the resident handbook and the residential care agreement and in discussion with management prior to and/or on entry to the home. If a resident’s care needs change, they can be relocated within the facility. Consultation is undertaken with the resident and/or their representative and their medical officer prior to this occurring. Information regarding internal and external complaints mechanisms and advocacy services is contained in the resident handbook and brochures are available in the home. There is a system in place to ensure residents with advance health directives and/or alternative decision makers are identified.

Residents and/or their representatives are satisfied with secure tenure and are aware of their rights and responsibilities.


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.



Team’s findings



Examples of recent improvements undertaken in relation to Standard 4 Physical environment and safe systems include:

In response to feedback at a residents’ meeting, the home has installed a large shade sail over an external communal area popular with residents for gardening. Residents who had enjoyed gardening and relaxing in the area were not using the area during the hotter months. Management reported residents/representatives were kept informed about the construction of the shade structure and had used the area as soon as installation was complete. The home is yet to evaluate this initiative.

The home has purchased 35 wheeled recliner chair covers, at a staff suggestion, to enhance the residents’ living environment pending the delivery of new chairs. Management researched covers which wouldn’t impede the pressure relieving effects of the chairs but which would be aesthetically pleasing and comfortable for residents. Management reported the stretch fabric covers have been a good interim measure and will be useful in the event of future wear and tear on chairs. We observed the covers in use during the audit.


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


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to physical environment and safe systems.

Particular to this Standard, the home has a food safety program and processes for monitoring fire and occupational health and safety requirements.




Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills.

Particular to this Standard, staff have been provided with education in manual handling, food and chemical safety, infection control, fire safety and workplace health and safety.

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


There are processes to support a safe and comfortable environment for residents in accordance with their care needs. Residents and visitors have access to a common lounge and dining area with other private areas available if required. Individual assessment of residents requiring behaviour management strategies is undertaken on entry and regularly reviewed. There are processes for the reporting of safety issues, hazards and resident/staff incidents. The living environment is maintained through the completion of cleaning schedules, preventative maintenance processes and the maintenance request system. There is an expenditure request process to support the replacement of furniture and equipment as required. Management monitors the environment through observation and completion of regular audits to ensure a safe and comfortable environment for residents. Residents and/or their representatives are satisfied with the safety and comfort of the living 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


Management is actively working to provide a safe environment that meets regulatory requirements. The organisation has policies to ensure safe practices throughout the home including the identification and investigation of hazards and resident/staff incidents. Regular monitoring of the internal/external environment and staff practices occur through observation by key personnel and the auditing program. There is a preventative maintenance program to ensure equipment and the working environment is maintained in a safe working condition.

Staff are trained in safe working practices through the orientation process and annual mandatory training sessions and have access to manuals and operational guidelines to assist and guide them in the operation of equipment. The home has a workplace health and safety officer who is supported by organisational personnel. Staff have opportunities to provide input


into the safety program through meetings, improvement forms, hazard reporting and incident forms. Staff are satisfied management is responsive to safety issues raised.

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


Management and staff are actively working to provide an environment and safe systems of work to minimise fire, security and other emergency risks. The home has processes and a fire and evacuation plan to enable management and staff to respond to fire and other emergencies. Fire safety equipment and detection systems are inspected and serviced in accordance with legislative requirements and action is undertaken to resolve any defects in a timely manner. Staff receive instruction in fire and emergency procedures at orientation and ongoing mandatory training sessions. Processes to ensure the security of the home include coded access to the home, nightly lock up, timer lighting and a sign in/out register.

Inspections/audits and observations are conducted to monitor the safety of the environment for potential hazards. Staff demonstrated knowledge of how to respond in the event of a fire or emergency.

4.7 Infection control

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

Team’s findings


The home has an effective infection control program to identify and contain potential and actual sources of infection including in the event of an outbreak. The program includes a food safety plan, a vaccination program for residents and staff and pest control measures.

Infection control education is provided to all staff at orientation and on an annual basis. Residents’ infection statistics are recorded and reviewed by the home’s Nurse Unit Manager. Personal protective equipment is in use and hand washing facilities, hand sanitisers, sharps containers and spill kits are readily accessible. Cleaning schedules and laundry practices are monitored to ensure infection control guidelines are followed and food is handled in accordance with the food safety plan. Staff are aware of infection control measures, including the appropriate use of personal protective equipment, hand hygiene procedures and precautions to be taken in the event of an outbreak.


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


Hospitality services at the home are provided in a way that enhances residents’ quality of life and staff’s working environment. Residents’ dietary needs and preferences are assessed on entry and updated as needs and preferences change, and this information is communicated to relevant staff. Meals are prepared and cooked daily in the co-located hospital kitchen, delivered to the home’s kitchenette, plated and then served in the dining area or residents’ rooms if preferred. Menus are reviewed by a dietitian and alternatives made available where residents have special requirements or dislikes. Residents have input into menu planning through resident meetings and feedback to management and staff. There is a cleaning program to guide staff to ensure cleaning of residents’ rooms and the environment seven days a week. Residents’ personal clothing and linen items are laundered at the co-located hospital laundry five days a week. There are processes to reduce the incidence of missing laundry and residents’ clothing is labelled on entry to the home. Staff are provided with ongoing education relating to hospitality and safety. Monitoring of the provision of hospitality services is conducted through comments and complaints, resident/staff feedback, observation of staff practice by key personnel and audits. Residents and/or their representatives are satisfied with the provision of hospitality services at the home.

Documents

Westhaven Nursing Home - welcome — Australian Aged Care · PDF fileWe will continue to monitor the performance of the home including ... 2.10 Nutrition and hydration Met 2.11 Skin