Bexley Park Aged Care - Quality Agency · PDF fileBexley Park Aged Care RACS ID 2570 3-5...

Bexley Park Aged Care

RACS ID 2570 3-5 Eddystone Road BEXLEY NSW 2207

Approved provider: Kenna Investments Pty Ltd

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 04 September 2018.

We made our decision on 03 September 2015.

The audit was conducted on 18 August 2015 to 19 August 2015. The assessment team’s report is attached.

Bexley Park Aged Care has been closed for rebuilding for the last two years. The audit was conducted was limited to an on-site assessment of their management systems and processes and this included interviews with management and staff, review of documentation including policies and procedures, and we reviewed the living environment.

There were no residents at the time of the audit because the building had only just been completed.

So we went back on 25 November 2015, once residents had started to arrive, and spoke to a sample of 11 residents about their satisfaction with the care and services being provided. We also spoke to four resident representatives.

All 11 residents and four representatives provided positive feedback about the care and services the home delivers to residents.

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

Home name: Bexley Park Aged Care RACS ID: 2570 2 Dates of audit: 18 August 2015 to 19 August 2015

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

Bexley Park Aged Care 2570


Introduction

This is the report of a re-accreditation audit from 18 August 2015 to 19 August 2015 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.


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 18 August 2015 to 19 August 2015.

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

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

Assessment team

Team leader: Kathryn Mulligan

Team member/s: Toby Hammerman

Approved provider details


Details of home

Name of home: Bexley Park Aged Care

RACS ID: 2570

Total number of allocated places:

71

Number of care recipients during audit:

0

Number of care recipients receiving high care during audit:

0

Special needs catered for: Dementia

Street/PO Box: 3-5 Eddystone Road

City/Town: BEXLEY

State: NSW

Postcode: 2207

Phone number: 02 9587 4555

Facsimile: 02 9587 4670

E-mail address: Nil


Audit trail

The assessment team spent two days at the Kennedy Group Healthcare head office, toured the building site of Bexley Park Aged Care and visited Endeavour Nursing Home from which staff and care recipients will be transferred when the new building is completed. We gathered information from the following:

Interviews

Category Number

General manager 1

Executive care manager 1

Managing director :Kennedy health Care Group (KHCG) 1

Other documents reviewed

The team also reviewed:

Care recipients’ clinical documentation tool examples- blank assessments, care plans, clinical forms and clinical file

Care recipients lifestyle documentation tool examples- assessment, care plan, monthly activity plan

Comments and complaints forms and brochures about the internal and external complaints scheme in various community languages on display in Endeavour Nursing Home (examples of those to be transferred to Bexley Park aged care facility)

Continuous improvement documentation including continuous improvement corporate plan, examples of blank improvement logs, internal and external audit schedules and audit results, external benchmarking reports to be used in the new facility

External services including preferred suppliers/contractors list with information about suppliers’ contracts and agreements, contact personnel, registration, certification and regulatory requirements and contract expiry dates, contractor criminal history assurances, service agreements, supplier performance feedback form

Human resource records - including staff handbook, recruitment information, induction manual, job descriptions, recruitment policies and procedures, letter to prospective employees transferring from Endeavour Nursing Home to new facility

Information newsletter – The Kennedy Press with building progress report of Bexley Park Aged Care

Information systems and processes including electronic information, organisational website, organisational chart, policies and procedures, complaint forms, executive care manager’s monthly reports, meeting schedule, agendas and minutes, memoranda, information flyers


Maintenance records –examples of the proposed planned maintenance program and routine maintenance requests and implementation records to be implemented in new building, preventative schedules for external contractor visits

New care recipient information kits (including recently updated care recipient handbook and care recipient agreements,

Planning documentation (including purpose, vision and values), organisation charts, committee minutes, operations commissioning plan, human resource commissioning plan, building plans and management reports

Policy and procedures

Self-assessment report for re-accreditation and associated documentation

Staff education including examples of practices to be implemented in new building : such as education calendar, training needs analysis, mandatory and non-mandatory education attendance records, education evaluations, competency assessments and educational resources

Workplace, health and safety (WH&S) information including electronic inspection audits and checklist, risk management system, hazardous chemical register

Observations

The team observed the following:

New building currently under construction

Solar panels on roof of new building


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service,

management systems are responsive to the needs of care recipients, their

representatives, staff and stakeholders, and the changing environment in which the

service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous

improvement”.

Team’s findings

The home meets this expected outcome

The organisation’s continuous improvement system incorporates a range of activities that will enable it to seek stakeholder feedback and to assess, monitor and evaluate performance in areas that relate to the four Accreditation Standards. The quality program being implemented in all the organisation’s homes will be duplicated in the new Bexley Park Aged Care. The system comprises the use of suggestion/improvement forms, staff and care recipients’ satisfaction surveys, internal audits, reviews, participation in a commercial benchmarking program, regular management reports incorporating key performance indicators and a comments and complaints system. The newly created assistant care manager position, amongst other duties, will assume responsibility for quality improvement recording, the review of audit results, identifying trends and creating improvement strategies that can be planned and implemented as required.

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 Kennedy Health Care Group’s senior management team identifies all relevant legislation, regulatory requirements, professional standards and guidelines through subscription to a regulatory publishing service and information forwarded by government departments, peak industry bodies and other aged care and health industry organisations. The communication practices being implemented in all the organisation’s homes will be duplicated in the new Bexley Park Aged Care. Regulatory information is currently disseminated to staff through the company intranet, updated policies and procedures, notices, regular meetings and ongoing training. Minutes of meetings include legislative changes as a standard agenda item. Relevant information is disseminated to care recipients/representatives through care recipients’ meetings, notices on display in the home and personal correspondence. Adherence to these requirements is monitored


through the home’s continuous improvement system, which includes audits conducted internally and by external bodies. Staff practices are monitored regularly to ensure compliance with regulatory requirements.

Management demonstrated the organisation’s system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard One.

In accordance with legislative requirements, the general manager has notified and updated the Australian Government Department of Social Services of the proposed commissioning date of the new building. The general manager advises this will allow for activation of the 71 beds of the former Eddystone Nursing Home and the implementation of 75 additional beds allocated by the Aged Care Approval Rounds (ACAR).

The organisation’s regulatory compliance processes identified that staff are required to inform management if there has been a change in their criminal history status during the three year police certificate expiry period. In order to facilitate this legal requirement a criminal history changes question has been included in the organisation’s annual staff appraisal form. All staff commencing employment or transferring to the new building are required to complete the annual appraisal form which will assist management to comply with the guidelines and determine any precluding offence during the three year period.

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 organisation’s systems, in place in all of the KHCG’s homes will ensure management and staff have the knowledge and skills to perform their roles effectively. We were informed the Assistant care manager, currently employed at The Bay Nursing Home, has been allocated the additional role of coordination of educational activities. Maintenance of staff knowledge and skills will be underpinned by a continuation of the existing staff education program that includes annual compulsory topics and presentations by company suppliers, as part of their contractual agreements. The commissioning team informed us there will be a series of intensive orientation programs, prior to the transfer date. This is to familiarise new staff with the home’s policy and procedures and will provide current staff with a base line of knowledge and expectations for the new building. The internal education programs, together with the external education schedule, will support staff to provide care and services in accordance with the requirements of the four Accreditation Standards. The effectiveness of the training provided will be measured through audit results, observation, staff appraisal and various competency skills tests.


1.4 Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and

other interested parties have access to internal and external complaints mechanisms".

Team’s findings


Care recipients will be informed of internal and external complaint mechanisms through the resident/relative handbook, residency agreement, orientation to the home and displayed notices. As is current practice in all KHCG’s homes compliment, suggestion and concern forms will be displayed and brochures about an external complaint mechanism will also be available in English and other languages. Management will maintain a folder of all comments and these will be responded to in a timely manner. Care recipients and their representatives will be invited to raise concerns and identify opportunities for improvement through residents’ meetings and satisfaction surveys.

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


Bexley Park Aged Care Facility’s mission and values is documented in the home’s publications. Representatives of the commissioning team informed us these statements and the charter of care recipients’ rights and responsibilities will be on display in the new building. We were further informed the home’s strategic plan and quality objectives are integral to the promotion of quality improvements in the home. The home’s philosophy of care will be promoted through staff orientation and the education processes.

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 new building will initially be staffed by current KHCG’s staff from their other homes, led by a recently recruited care manager with extensive experience in commissioning new aged care homes. This will ensure there will be appropriately skilled and qualified staff from the first day of operation. In addition these staff will have the added attribute of being familiar with the needs and preferences of the first cohort of care recipients to transfer from the other homes. As part of the commissioning process the home has recruited, and will induct, additional appropriately skilled and qualified staff sufficient to ensure that services in the new building are delivered in accordance with the needs of care recipients. We note the organisation effectively implements a human resource policies and procedures. These cover staff recruitment, orientation, staff performance and competency assessment. Staff


records are maintained including job descriptions, duty lists, registration details and police probity checks. Initial staffing budgets for the new building have been formulated to meet the specific needs of the site, and the proposed two stage opening process. Staffing levels will be monitored and adjusted on an ongoing basis in accordance with care recipients’ changing needs and based on care recipient /representative feedback, staff feedback, and the results of management’s observations of the physical demands/requirements of the new environment. The organisation has a reward and recognition strategy to ensure that the home attracts and continues to attract and maintain sufficient numbers of appropriately skilled and qualified staff. These strategies include an above award collective agreement, accessibility to training for career path progression purposes, access to an employee assistance program and an annual staff recognition award program.

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 organisation has systems that are ensuring that appropriate stocks of goods and equipment are available at all times. There are processes to identify the need to re-order goods, address concerns about poor quality and maintain equipment in safe working order. The process is underpinned by negotiated service agreements to guarantee the availability of stocks of appropriate goods and equipment for quality service delivery. The current employee nominated to be the on-site maintenance officer in the new building utilises a system with records that show equipment is serviced according to a planned schedule and external tradesmen are engaged when necessary. The system is currently monitored, and will be in the new building, by the organisation’s maintenance manager through regular audits, surveys, meetings and the feedback mechanisms of the home. The home’s commissioning plan includes arrangements for the initial stocking and ongoing ordering practices, of adequate supplies of goods and equipment available for the provision of care, to support care recipient’s lifestyle choices and for all hospitality services.

1.8 Information systems

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

place".

Team’s findings


Based on current organisational practices it is expected the home will have an effective information management system. Care recipients and their representatives who are candidates for transfer to the new building will be provided with individualised information prior to entry and will be provided with a new accommodation agreement and a revised residents’ handbook. Newsletters, notices and special meetings have been used to update prospective care recipients about the timetable and conditions for transfer. The organisation’s information technology system, documentation and publications currently ensure management and staff have access to policies, procedures and information relevant to their role. The commissioning team are in the process of ensuring there will be a comprehensive orientation of current and new staff and a revised staff handbook. In the


new building there will be a range of methods to effectively convey information including noticeboards, memoranda, handover, education and staff and care recipient meetings.

Electronic information will be backed up off-site, password protected and with restricted access appropriate to position. There will be systems for archiving and documentation destruction to ensure confidentiality of care recipient information. The new care manager will be responsible for monitoring the effectiveness of the information systems through reporting mechanisms, meetings, case conferences, audits and verbal feedback. The commissioning team said care recipients and their representatives and staff who will be transferring to the new building have been kept well informed of matters of importance to them.

1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way

that meets the residential care service’s needs and service quality goals".

Team’s findings


All externally sourced services are to be provided in a way that meets the home’s needs and quality goals. The organisation has an effective system to identify preferred and major suppliers of goods, equipment and services. In addition, the performance of major or regular suppliers is measured against agreed objectives contained in documented external service agreements or contracts. Contracts and/or simple service agreements are in place with suppliers of services and goods such as fire system maintenance, physiotherapy, pharmaceutical and continence aids. There are centrally managed mechanisms to track and resolve ongoing issues with suppliers.


Standard 2 – Health and personal care

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



improvement”.

Team’s findings


Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s planned continuous improvement system.




professional standards and guidelines about health and personal care”.

Team’s findings


The home’s regulatory compliance system is referred to in expected outcome 1.2 Regulatory compliance. The home will use those processes to identify and implement a range of compliance measures relevant to Accreditation Standard Two Health and Personal Care.




Team’s findings


The organisation has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home will use these systems to identify and implement a range of educational measures relevant to Accreditation Standard Two. Care staff will be required to have achieved a minimum requirement of certificate III in aged care.


2.4 Clinical care

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

Team’s findings

Bexley Park Aged Care will have a system to ensure care recipients receive appropriate clinical care. The registered nurses will be responsible for the assessment, care planning, documentation and evaluation of a care recipient care needs. The assistant care manager will support the registered nurses to ensure appropriate clinical governance occurs for all care recipients. Medical officers will review care recipients routinely and as requested. There will be three monthly and as needed evaluations of the effectiveness of the care provided to recipients’. Annual and as needed case conferencing will support consultation with care recipients/representatives in relation to aspects of care.

2.5 Specialised nursing care needs

This expected outcome requires that “care recipients’ specialised nursing care needs are

identified and met by appropriately qualified nursing staff”.

Team’s findings

The home will have systems to ensure appropriately trained staff are utilised to meet the needs of care recipients who require specialised nursing care. Registered nurses will undertake clinical assessments of any care recipient who will require this type of care. Care plans will be in place and will be evaluated every three months and/or as needed. There will be documentation in the care recipients’ progress notes and/or care plan relating to consultation with other health care specialists when they occur.

2.6 Other health and related services

This expected outcome requires that “care recipients are referred to appropriate health

specialists in accordance with the care recipient’s needs and preferences”.

Team’s findings

The home will have a system to ensure care recipients are referred to appropriate health care specialists in accordance with their assessed needs. The home has access to a number of health professionals/specialists who will visit care recipients at the home. These include but are not limited to a speech pathologist, physiotherapist, dietician, dentist, podiatrist, medical specialists and staff from the local mental health services. Care recipients who visit health professionals outside the home will have a detailed transfer letter send with them to facilitate effective communication.

2.7 Medication management

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

correctly”.

Team’s findings

The home will have systems and processes to ensure care recipients’ medication is managed safely and correctly. A medication incident reporting and auditing process will form part of the home’s system. Medication administration will be administered from the original medication boxes/bottles by registered nursing staff who have a current


medication competency. There will be a register of schedule eight (S8) and schedule four (S4D) which will be counted each shift.

2.8 Pain management

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

Team’s findings

The home will have a system for assessing, monitoring and treating care recipients’ pain. Care plans will be formulated and will include individual pain management and monitoring strategies to meet the care recipient’s need. The home will use a range of strategies to manage care recipients’ pain including heat, massage, the use of electronic nerve stimulation (TENS) and pain relieving medication. These strategies will be undertaken by the registered nurses and physiotherapists. Referral to specialists will be in line with care recipients’ assessed needs.

2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill care recipients

is maintained”.

Team’s findings

The home will have a system for palliative care that is to ensure the comfort and dignity of the terminally ill care recipient is maintained. Care recipients and/or their representative will be asked as they enter the home if they have any end of life wishes in place. Consultation and communication will be used in order to ensure care recipients, representatives, medical officers, care staff and other health professionals are aware of the individual needs and choices of the care recipient. The local community based palliative care team will be consulted as needed to provide care recommendations. Religious, spiritual and culture preferences at the end of life will be respected and supported as needed.

2.10 Nutrition and hydration

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

hydration”.

Team’s findings

The home will have a system to ensure each care recipient receives adequate nourishment and hydration. When a care recipient enters the home an assessment and diet card will be completed and information regarding nutrition and hydration is provided to the kitchen. Care recipients will be weighed monthly and as needed. Nutritional supplements will be available for care recipients who require extra nutritional support. There will be specialised eating equipment available for care recipients with an assessed need.

2.11 Skin care

This expected outcome requires that “care recipients’ skin integrity is consistent with their

general health”.

Team’s findings

The home will have a system to assess and monitor care recipients’ skin integrity. Care recipients skin care needs will be assessed on their entry to the home by a registered


nurse. The home will use an accident/incident reporting system to report any breaches in skin integrity which will be reviewed by the registered nurses and monitored by the assistant care manager. Registered nurses will be responsible for wound management procedures within the home.

2.12 Continence management

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

Team’s findings

The home will have a system to ensure care recipients’ continence needs are managed effectively. Continence management strategies will be developed for each care recipient following an initial assessment of urinary and bowel patterns. There will be link nurses with the responsibilities for ensuring the care recipients are allocated appropriate aids and that there is sufficient supply.

2.13 Behavioural management

This expected outcome requires that “the needs of care recipients with challenging

behaviours are managed effectively”.

Team’s findings

The home will have a system to ensure that the needs of care recipients with responsive behaviours are managed effectively. All care recipients will be assessed on their entry to the home. Any responsive behaviour identified will have management strategies developed by registered nurses and monitoring charts commenced. There will be a specific unit (to be named Eddystone) for care recipients who are living with dementia. Referral to behaviour management specialists will be used to assist the effective management of care recipients’ responsive behaviours.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved

for all care recipients”.

Team’s findings

The home will have systems to optimise the care recipients’ levels of mobility and dexterity. The home will contract physiotherapy services that will assess care recipients’ mobility and dexterity. There will be staff to implement the care recipients’ programs which have been developed by the physiotherapist. An accident and incident reporting system will include analysis of incidents to identify trends and strategies to be implemented to reduce the number of falls a care recipient incurs. The home will have a range of mobility and manual handling equipment available for use by care recipients.

2.15 Oral and dental care

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

Team’s findings

The home will have a system to ensure care recipients’ oral and dental health is maintained. This will includes initial and ongoing assessment of care recipients’ oral and dental needs by a registered nurse. Care recipients’ day-to-day oral care will be attended


in line with individual care plans and referral to specialists will be arranged according to care recipients’ needs and choices. There will be a dentist available to review care recipients at the home if they choose or are unable to access external services.

2.16 Sensory loss

This expected outcome requires that “care recipients’ sensory losses are identified and

managed effectively”.

Team’s findings

Care recipients’ sensory losses will be identified and managed by staff at the home. The home will have an assessment process that ensures any sensory loss is identified. There will be referrals to appropriate specialists made or where required. The home’s activity program will incorporate activities that promote stimulation of the senses. A sensory garden will be outside the secure dementia unit to promote the taste, touch and smell of care recipients living with dementia.

2.17 Sleep

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

patterns”.

Team’s findings

The home will have systems to assist care recipients’ achieve their natural sleep patterns. On their entry to the home, care recipients’ sleep patterns will be assessed. Care plans will be developed using the data obtained from the assessment. Care recipients will be encouraged to settle quietly in their rooms at night and staff will be able to offer snacks and drinks during the night when required. The home will ensure care recipients who are accommodated in shared rooms are able to achieve natural sleep patterns. This will be by use of bed screens and the clinical management of all care recipients in a shared room.


Standard 3 – Care recipient lifestyle

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



improvement”.

Team’s findings






professional standards and guidelines, about care recipient lifestyle”.

Team’s findings


The organisation’s regulatory compliance system is referred to in expected outcome 1.2 Regulatory compliance. The home will use those processes to identify and implement a range of compliance measures relevant to Standard Three Care recipient lifestyle.




Team’s findings


The organisation has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home will use these systems to identify and implement a range of educational measures relevant to Accreditation Standard Three.

3.4 Emotional support

This expected outcome requires that "each care recipient receives support in adjusting to

life in the new environment and on an ongoing basis".

Team’s findings

Care recipients being transferred to Bexley Park will be supported by staff who will be familiar with their care and emotional needs. Care recipients will be introduced to other


care recipients and to the community of the home. Assessments and discussions with care recipients and/or their representative will identify any specific needs relating to emotional support. Once a care recipient’s emotional needs are identified the registered nurses in conjunction with the lifestyle staff will develop a care plan and monitor a care recipient’s mood. This will be through observation and discussion with staff and care recipients/ representatives.

3.5 Independence

This expected outcome requires that "care recipients are assisted to achieve maximum

independence, maintain friendships and participate in the life of the community within and

outside the residential care service".

Team’s findings

The home will have a system to encourage care recipients’ independence and participation in community life. Each care recipient’s level of independence and their need for assistance will be assessed on entry to the home and reviewed three monthly and as needed. The home and activity program will promote a care recipients link to the community through voting, outings, entertainers and in providing opportunities for care recipients to interact with other visitors.

3.6 Privacy and dignity

This expected outcome requires that "each care recipient’s right to privacy, dignity and

confidentiality is recognised and respected".

Team’s findings

A care recipients’ right to privacy, dignity and confidentiality will be recognised and respected by all staff. Information on care recipients’ rights and responsibilities will be included in documentation provided to all care recipients and/or their representatives when a care recipient enters the home. Care recipients’ personal information will be stored securely with access by authorised staff only. Care recipients will have access to a confidential process for reporting comments and complaints. Any computers containing personal information of a care recipient will be password coded.

3.7 Leisure interests and activities

This expected outcome requires that "care recipients are encouraged and supported to

participate in a wide range of interests and activities of interest to them".

Team’s findings

Care recipients will be encouraged and supported to participate in activities of interest to them. When entering the home, information about a care recipient’s life will collected. Activity care plans will be developed based on this information and in conjunction with care recipients/representatives. The recreational activity officers will be responsible for the activity program in both the dementia and general areas of the home. The home will have a lifestyle supervisor who will be responsible for ensuring the program meets care recipients’ needs. A monthly activity program will be displayed. The program will include physically and mentally stimulating activities and general activities that provide general social interaction.


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 will have processes to promote care recipients’ interests, customs, beliefs and cultural backgrounds which will be identified during the assessment process. Care recipients will be actively encouraged to maintain cultural and spiritual links in the community. Regular religious services will be held at the home. Days of cultural significance will be celebrated at Bexley Park.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative)

participates in decisions about the services the care recipient receives, and is enabled to

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

people".

Team’s findings

The home will have processes to ensure that each care recipient (or their representative) will participate in decisions about the services received by the care recipient. These processes will uphold the care recipient’s right to exercise choice and control over his or her lifestyle.

Care recipients will be kept informed and given opportunities to provide input into the home through systems such as family conferences, surveys and care recipients’ meetings. Where a care recipient is unable to make choices for themselves, an authorised decision maker will be identified when a care recipient enters the home. Care recipients will be provided with choices concerning their personal care regimes, cultural and spiritual needs, waking and sleeping times. Choices will also available regarding meals, participation in activities and choice of medical officer

3.10 Care recipient security of tenure and responsibilities

This expected outcome requires that "care recipients have secure tenure within the

residential care service, and understand their rights and responsibilities".

Team’s findings


The organisation has a system to provide care recipients and/or representatives with information about security of tenure. This will be in order for care recipients and/or representatives to understand their rights and responsibilities. The process will include new care recipients being offered a residency agreement. This agreement includes information for care recipients about their rights and responsibilities, complaints handling, fees and charges, their security of tenure and the process for the termination of the agreement. The Charter of care recipients’ rights and responsibilities will be displayed in the home.


Standard 4 – Physical environment and safe systems

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



improvement”.

Team’s findings



An example of a recent improvement implemented in relation to Accreditation Standard Four includes:

The organisation has engaged the services of a workplace health and safety (WH&S) consultant who will attend the home regularly to advise on all aspects of WH&S. The consultant has introduced in the other KHCG’s homes a new monthly electronic inspection auditing and risk management system and will train Bexley Park key personnel in the home in the use of this tool. An external contractor register is included in the system to ensure contractors provide safe work method statements to the home prior to commencement of work. These measures will improve environmental safety in the home.




professional standards and guidelines, about physical environment and safe systems”.

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for details about the organisation’s system for ensuring regulatory compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.




Team’s findings


The organisation has systems to ensure staff have appropriate knowledge and skills referred to in expected outcome 1.3 Education and staff development. The home will use


these systems to identify and implement a range of educational measures relevant to Accreditation Standard Four.

4.4 Living environment

This expected outcome requires that "management of the residential care service is

actively working to provide a safe and comfortable environment consistent with care

recipients’ care needs".

Team’s findings

Bexley Park Aged Care is expected to open in late September 2015 and a tour of the building site indicates, when completed, it will provide an aesthetically designed, well equipped, safe and comfortable environment. The home, with two accommodation levels and a services floor, will eventually accommodate 146 care recipients in 79 single rooms and 33 double rooms, including a 32 bed dementia specific wing. Rooms all have ensuite bathrooms and will be equipped with electrically lowered beds, ample storage, comfortable furniture and individual air conditioning and televisions. Amenities in the new building include a cinema, exercise and physiotherapy rooms, a library, quiet rooms and a reflection room for multi- denominational religious services. Dining and recreation areas are spacious and will be flexible to allow for intimate or larger gatherings and celebrations.

In order to facilitate an orderly entry process management has decided to open the building in two stages: The downstairs, 87 beds level will be stage 1 with 55 general beds and the 32 bed dementia unit. This will be followed by stage 2 with 59 single rooms in the upper level.

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 is planned to provide a safe working environment consistent with workplace, health and safety (WH&S) policy and regulatory requirements. A consultant advises the organisation and will oversee the home’s WH&S management. There is an organisational process to record, analyse and review staff incidents and any identified hazards. WH&S will be a standing agenda item at all of the home’s meetings. Staff currently employed by the organisation told us they receive WH&S education on orientation and on an ongoing basis. Management plans to monitor the WH&S system through regular inspections, audits, incident reporting and feedback. New equipment will be risk assessed for safety considerations and staff training to be provided as required. The organisation has a return to work program coordinator in head office and she is available, if required following any staff injuries. Safe work practices, devised by the consultant, will be implemented on the new site, as necessary.


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 will have systems to promote the safety and security of care recipients, visitors and staff. These include emergency and fire evacuation policy and procedures as well as regular checks of the fire indicator panel, sprinkler system and other fire safety equipment by an authorised contractor. We were told currently employed staff attend annual mandatory fire awareness, equipment and evacuation procedure training including a mock evacuation.

Orientation to the new building will include an additional fire lecture from the external fire services supplier. A senior staff member who is transferring to the new building is a trained level one fire safety officer and will receive specific training for her role. Fire safety and emergency flip charts and fire evacuation signs and diagrams have been ordered and will be displayed around the home. The homes emergency response and disaster management plan will be reviewed to ensure it reflects the new environment. There will be an evacuation bag with care recipient evacuation list and photographic identification and we were informed a site specific list will be in place on the first day of transfer. The new building has areas for safe storage of chemicals and safety data sheets will be available at point of use. Safety and security measures in the new building include security cameras, key pad locks, a lock-up procedure, sign in and out registers and a nurse call system. The home’s fire safety and security system will be monitored through audits and inspections.

4.7 Infection control

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

Team’s findings


The home will have systems for identifying and managing infections. The infection control program will include the offering of influenza vaccination for care recipients, waste management, cleaning and laundry processes and a food safety program. Registered nurses will monitor care recipients’ infections and data will be collated and analysed by the assistant care manager to identify and address matters related to infection control. Education will provided to staff as part of orientation and the education program. Staff will have access to sufficient supplies of appropriate infection control equipment including personal protective equipment, spill kits, sharps disposal and clinical waste bins.

4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that

enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings

Hospitality services will be provided in a way that enhances the care recipients’ quality of life and the staff’s working environment. Care recipients meals will be prepared in the


onsite kitchen using the fresh cook method. Planned cleaning programs will ensure that appropriate cleaning standards are maintained. The onsite laundry service will employ effective systems for the storage, identification, laundering (washing and ironing) and delivery of linen and care recipients’ personal clothing.

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