Fronditha Anesi Aged Care Services - Thornbury 4535...

Name of home: Fronditha Anesi Aged Care Services - Thornbury RACS ID 4535 RPT-ACC-0016 v15.1Dates of re-accreditation audit: 12 May 2015 to 13 May 2015 SENSITIVE

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Audit ReportFronditha Anesi Aged Care Services - Thornbury 4535

Approved provider: Fronditha Care

IntroductionThis is the report of a re-accreditation audit from 12 May 2015 to 13 May 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.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


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Audit reportScope of auditAn assessment team appointed by the Quality Agency conducted the re-accreditation audit from 12 May 2015 to 13 May 2015.

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

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

Assessment teamTeam leader: Mary Murray

Team members: Bradley McKenzie

Heather Pearce

Approved provider detailsApproved provider: Fronditha Care

Details of homeName of home: Fronditha Anesi Aged Care Services - Thornbury

RACS ID: 4535

Total number of allocated places: 120

Number of care recipients during audit:

118

Number of care recipients receiving high care during audit:

118

Special needs catered for: Care recipients living with dementia

Street: 335 Station Street State: VIC

City: THORNBURY Postcode: 3071

Phone number: 03 9495 2300 Facsimile: 03 9495 2323

E-mail address: [email protected]

http://www.comlaw.gov.au/Details/F2011L00821


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

InterviewsNumber Number

Management 5 Care recipients/representatives 25

Registered/enrolled nurses 10 Environmental/maintenance staff 6

Care staff 8 Catering staff 4

Lifestyle staff 6 Support staff 2

Sampled documentsNumber Number

Care recipients’ files 16 Medication charts 12

Lifestyle care plans 8 Personnel files 10

Care recipients’ agreements 12 Other documents reviewedThe team also reviewed:

Activity calendar, evaluations and associated records

Care recipients’ information package

Clinical assessments, care plans and progress notes

Clinical care review schedule

Clinical observations and charting

Clinical records on the management of specialised and complex care needs

Clinical trending on key performance indicators

Comments, complaints and feedback forms including related actions

Emergency management plans and essential service inspection records

Human resource records and education matrix

Legislative and regulatory compliance registers

Maintenance records and preventative maintenance plan

Medication charts and drugs of addiction registers

Menu, dietary preference documentation and food safety plan

Newsletters

Policies, procedures, meeting minutes and memoranda

Quality system documents, audits, incidents and continuous improvement plan

Roster

Service agreements

Staff and volunteer orientation documentation


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ObservationsThe team observed the following:

Activities in progress

Equipment and supply storage areas

Infection management kits and supplies

Information brochures including external and internal complaint processes

Interactions between staff and care recipients

Internal and external living environment

Mission, vision and values statements on display

Notice boards and information displays

Short observation in the memory support unit.


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

Standard 1 – Management systems, staffing and organisational 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 improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The organisation has a continuous improvement system, identifies improvement opportunities and monitors performance across the Accreditation Standards. The feedback form drives the continuous improvement system and additional information is collected from audits, incidents, surveys, risk and hazard alerts, meetings and verbal feedback. Suggestions for improvement are logged, actions tracked and outcomes monitored for their effectiveness. Regular collation of statistics and trend analysis inform future improvement opportunities. Feedback is provided to stakeholders according to their identified preference and via memoranda, meetings and newsletters. Evaluation of improvements and satisfaction with outcomes is sought at meetings, from resident, representative and staff feedback, during audits and via incident trending. Residents, representatives and staff are satisfied the organisation actively pursues continuous improvement.

Improvements implemented by the home in relation to Standard 1 Management systems, staffing and organisational development include:

To meet workforce demand the organisation has entered into a partnership with the Department of Immigration to implement an aged care labour agreement for Greek speaking personal care workers. Several of the personal care workers who have joined the organisation said they have already embarked on improving their qualifications. Management, staff, residents and representatives have welcomed the new staff members and said their presence has improved communication throughout the home, and further strengthened cultural connections.

Management identified its audits were not providing the depth of information they wanted and as a result, they introduced a new suite of audits. Staff have been trained on the use of the audits and a staged implementation has taken place. All audits are now undertaken according to an annual schedule and issues identified have been incorporated into the continuous improvement system. Management said the information gathered using the new audit tools has improved their ability to proactively identify opportunities for improvement.

Fronditha Care introduced new uniforms for staff. A uniform committee was convened so staff from each area were able to participate in choosing the uniforms. Each designation of staff now wear a different colour uniform so they can be more easily identified. Staff also suggested they wear name badges. Badges are designed to incorporate the corporate emblem, the staff name and their designation. Informal feedback, feedback from meetings and a formal evaluation revealed staff comfort and pride wearing the uniforms. Residents and representatives said it is easier to recognise staff members and commented on how professional they now look.


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


Management has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The organisation subscribes to legislative services and receives further notifications and updates from professional bodies and via government communiqués. Corporate services distribute information in line with the organisation’s reporting structure and make information available to staff via meetings, memoranda and noticeboards. Monitoring of regulatory compliance occurs through internal and external audits. Staff said management inform them of relevant legislation and any regulatory changes.

Examples of regulatory compliance in relation to Standard 1 include:

Management has a system to ensure each staff member and volunteer has a current police certificate and if necessary, a statutory declaration.

Management has a system to monitor the currency of professional registrations.

The organisation notified care recipients and representatives of the accreditation audit in line with legislative requirements.

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


The organisation has a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. In consultation with management and staff, the human resource team develop an annual training program. The team deliver mandatory training in both English and Greek, as many employees are bi-lingual or Greek speaking. Staff undertake skills competencies and specialised training as required. Staff participate in learning and development plans linked to career pathways. Management and staff are satisfied with the type, frequency and availability of education provided. Staff said the organisation has sponsored their career development and offered courses in learning Greek to assist them in meeting the care needs of the residents. Residents and representatives are satisfied with staff knowledge and skills.

Examples of education in relation to Standard 1 include:

understanding accreditation

incident management and reporting requirements

managing documentation and information effectively.


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


The organisation’s feedback form is used by care recipients, representatives, staff and other stakeholders to inform management of issues of concern, suggestions, compliments or complaints. Information about the internal system and external avenues for complaints or advocacy are documented in key organisational documentation, on noticeboards and in newsletters. Brochures and forms are available throughout the home in English and Greek. Secure suggestions boxes are located on each floor and forms can also be given to staff or the manager. Feedback forms are logged, actioned and closed out by the manager who collates regular statistics and undertakes trend analysis. Relevant feedback is discussed at resident, representative and staff meetings. Staff said they assist residents if they are unable to complete the form themselves. Residents and representatives are aware of the processes for raising an issue and are satisfied with the comments and complaints processes at the home.

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


The organisation has documented the residential care service’s vision, mission, values and commitment to quality throughout the service. Publications the organisation distributes to care recipients, representatives and external parties consistently reflect the organisation’s commitment to the quality care.

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


Management has a system to ensure sufficient and appropriately skilled staff deliver services in accordance with the Accreditation Standards and the organisation’s goals. Recruitment processes guide the appointment of staff and position descriptions outline the skills, qualifications and scope of practice relevant to each role. New staff participate in an orientation program and receive ongoing support. Staff are rostered in line with residents’ needs and the roster is reviewed if needs change. Reflecting the resident population the home employs a large number of Greek speaking staff and has implemented a labour agreement to recruit additional Greek speaking personal carers. Residents, representatives and staff said there are sufficient numbers of appropriately skilled and qualified staff to provide care and services to residents.


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


Management has processes to ensure appropriate levels of equipment and inventory are available to staff to meet care, lifestyle, environmental and operational needs. Storage areas are accessible, clean and where required secure. Staff receive training on the appropriate use of equipment and monitor items to ensure they remain fit for purpose. A preventative maintenance program ensures regular mechanical and electrical safety checks occur. Staff said equipment and supplies are readily accessible and there is a process to obtain supplies urgently or out of business hours. Residents and representatives said there are sufficient supplies and equipment.

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


The organisation has a system for the creation, endorsement, distribution and management of information. A meeting structure supports the effective flow of information to relevant stakeholders. Appropriate security levels to access information are evident and privacy and confidentiality of information respected. Policy and procedure reviews ensure information remains relevant and current. New residents and staff receive information packs and meetings, noticeboards and newsletters inform interested parties on current issues and events. The organisation hosts a weekly radio segment to inform residents, families and the Greek community more broadly, of events at Fronditha Anesi and to discuss topics of interest. Staff said they have access to information to support them deliver services. Residents and representatives said relevant information is available to them and communication within the home is good.

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


Management has processes to ensure external service providers deliver goods and services in a way that meets the organisation’s needs and service quality goals. Preferred suppliers are utilised to ensure consistency of service and contracts outline the standard of work expected and any regulatory compliance requirements. External services delivered include essential fire and safety services, allied health and specialised maintenance tasks. Monitoring processes include observation, work inspection and stakeholder feedback. Management, staff and residents are satisfied with the products and services currently supplied to the organisation from external providers.


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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.



The home pursues continuous improvement related to Standard 2 Health and personal care with the overall system described in expected outcome 1.1 Continuous improvement. Policies and procedures guide staff in their practice and results from scheduled audits, incident and infection reporting, data analysis and meetings identity opportunities for improvements. Staff said they contribute to the continuous improvement system. Residents said they have opportunities for input into health and personal care services at the home

Examples of improvement initiatives related to Standard 2 include:

Following education and a successful trial, the organisation introduced a monthly clinical care report. The report has evolved to include information related to continuous improvement activities and education. Key staff and management said the report has added a level of sophistication to their analysis and trending of statistics enabling them to develop strategies to improve care outcomes. Residents and representatives confirmed their satisfaction with the clinical care provided by staff.

Management identified an opportunity to improve residents’ nutrition and hydration and engaged an external dietetics company. As a result, dietitians regularly visit to monitor weights, conduct audits, observe practices and offer dietary advice. A new weight-tracking tool has been introduced and education on nutrition and hydration has been provided to staff, residents and representatives. Staff and management said their knowledge and management of residents’ nutrition and hydration needs has improved and residents said they are satisfied with the range of food and beverages offered and the management of their weight.

In liaison with the physiotherapist, management identified an opportunity to improve residents’ range of movement by implementing a mobility and dexterity exercise program. The program is incorporated into the resident’s day-to-day activities as well as the lifestyle program. In consultation with the physiotherapist, a range of additional exercise equipment has been purchased including portable foot pedals, arm pedals and dumbbells. The physiotherapist has trained staff in the correct use of the equipment. Participation records show there has been high attendances at these sessions and residents’ feedback has been positive. Management said resident falls are trending down and this may be attributed to improved levels of mobility as a result of the program.


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


The organisation has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care. For details on the organisation’s overarching regulatory compliance system refer to expected outcome 1.2 Regulatory compliance.


Medications are stored and administered according to legislated requirements.

The organisation has processes to follow in the event of an unexplained resident absence.

Registered nurses undertake the initial assessment and ongoing care planning of residents with specialised nursing care needs.

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


Management and staff have appropriate knowledge and skills to perform their roles effectively. For details on the organisation’s overarching education and staff development system in relation to health and personal care, refer to expected outcome 1.3 Education and staff development.

Examples of education and staff development in relation to Standard 2 include:

the experience of pain in the elderly

nutrition and hydration including gastrostomy tube feeding

nursing management of people living with motor neuron disease.

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


Care recipients receive appropriate clinical care according to their needs and preferences. A multidisciplinary team complete resident assessments and care planning. Staff use an interim care plan derived from admission information to provide care to residents until the assessment and care planning process is complete. Staff report significant changes to individual care needs to the resident’s doctor and the allied health team. Handover information and staff feedback is consistent with care plan documentation. Management monitor clinical care through audits, a resident of the day program, care plan reviews,

https://www.google.com.au/search?biw=1064&bih=609&q=gastrostomy+tube+feeding&revid=258902000&sa=X&ei=zv9TVfGUIsXwmAX7pYHgCQ&sqi=2&ved=0CJIBENUCKAQ






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consultation with the resident or their representative and a daily manager’s report. Residents and representatives said they are satisfied with the clinical care provided.

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


Clinical staff identify care recipients’ specialised nursing care needs on entry to the home and through daily monitoring and evaluation. Specialised nursing care assessments are developed on entry for conditions which require ongoing supervision such as catheters, complex wounds, stoma sites, diabetes and enteral feeding. Specialised nursing care plans detail strategies and interventions which reflect specialist assessment orders. Expert advice is readily available through allied health consultants and general practitioner support. The home has appropriate supplies to provide for the identified range of specialised care requirements. Residents and their representatives said they have input into the specialised care provided at the home and trust in the skills and knowledge of staff.

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


Referrals to health specialists occur in accordance with the care recipient’s needs and preferences. The home has a regular onsite physiotherapist who provides assessment and care direction for mobility, falls management, pain management and specialised equipment assessment. Residents have access to a range of medical and allied health care providers including podiatrists, dietitians and speech pathologists through visiting arrangements and the referrals process. Residents can also access providers of their choice if preferred. Staff ensure there is consultation with residents and their representatives should the need for referral be identified. Care plans and clinical documentation include updates to care occurring as a result of referrals. Audits and care reviews monitor outcomes of referrals. Residents and representatives are satisfied with the assistance residents receive to access other health specialists.

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


Registered nurses oversee the management of care recipients’ medications administered by endorsed enrolled nurses and medication competent personal care workers according to the home’s policies and procedures. The initial assessment, completed when the resident enters the home, identifies medication requirements and preferences, allergies and any assistance needed. Medication charts are detailed and include medication orders, identification information and special considerations for administering as needed medication. General and regulated medications are stored securely and there is a system for pharmacy returns.


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Policies and procedures detail administration protocols for medications requiring dose monitoring. The medication advisory committee, medication reviews, audits and the incident reporting system contribute to the monitoring of safe medication systems. Residents and representatives are satisfied with the management of residents’ medication.

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


All care recipients are as free as possible from pain. When a resident arrives at the home staff complete a pain chart and conduct a pain assessment to identify the types and location of pain experienced. A physiotherapist oversees the pain management program and develops and reviews strategies of care on a regular basis in conjunction with the medical practitioner and the care team. Reassessment of residents’ pain occurs as required using either verbal or non-verbal pain assessment tools. A range of treatments besides pharmaceutical interventions assist with relieving residents’ pain. These include gentle massage, heat packs, exercise, electronic muscle stimulation, comfort measures and sensory activities. Residents expressed satisfaction with pain management provided by staff.

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


Management and staff described the processes followed to ensure the comfort and dignity of care recipients at end of life. Staff support and assist residents and their representatives to document end of life wishes. Based on this information the care plan is updated to reflect the resident’s medical, cultural and spiritual preferences as the resident enters the palliative phase of their life. Ongoing communication with general practitioners and outreach palliative care services about the resident’s condition occurs as their general health deteriorates. Staff described care measures they undertake when providing palliation for residents including comfort and dignity measures. Residents and representatives expressed satisfaction with the care consultation and particularly the emotional, spiritual and cultural support provided by staff in discussions about end of life care.

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


Care recipients receive adequate nourishment and hydration. A nutrition and hydration assessment is completed for all residents upon entry to the home and a copy provided to the catering service. The assessment identifies dietary requirements, residents’ likes and dislikes as well as required levels of assistance from staff during the meal service. Staff record residents’ weights monthly and as required. The organisation utilises an electronic weight recording system whereby consistent or unexpected weight loss generates an alert. Staff commence the appropriate interventions for weight loss or gain and referrals are made as


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appropriate. A system for information sharing with catering staff ensures compliance with delivery of residents’ dietary needs and preferences. Additional strategies to support nutrition and hydration include resident and representative input into menu options and fortified meals and supplements. Residents and representatives are satisfied with the provision of food and fluids offered.

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


Care recipients skin care is consistent with their general health. The initial skin assessment identifies risk for skin problems and findings contribute to the development of care plan strategies. General moisturisers and specialist equipment are available to prevent skin breakdown, alleviate pressure and assist wound care. Registered nursing staff coordinate and oversee skin and wound care management. Staff attend wound care education and external wound services provide support as needed. Management monitor skin care using wound data, incident reports and clinical review. There are adequate supplies of wound dressings and moisturisers to protect residents’ skin and to promote healing and optimal skin integrity. Residents and their representatives said they are satisfied the home appropriately manages their skin care.

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


Care recipients’ receive effective continence management appropriate to their individual needs and preferences. Staff assess each resident and determine the optimal continence aid they require and the level of assistance needed to manage their continence care. Assessments consider individual hygiene patterns and these assist staff to help residents maintain their continence. Management monitor staff practices for the delivery of continence care and regularly review continence care plans as clinical needs change. Staff document incidents of urinary tract infection which are later reviewed by management. Consultation with individual medical practitioners occurs for prescribed treatments. Staff described how they maintain residents’ dignity while providing continence care and were knowledgeable of resident’s individual needs and preferences. Residents said staff manage their continence needs well.

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


Staff provide care for care recipients’ with challenging behaviours. Staff assess each resident on entry and document if additional behaviour monitoring is required. Where changes in behaviours are identified or following an incident, staff commence charting and review care plans. The home’s memory support unit aids staff to assist residents with challenging


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behaviours as a result of a diagnosed condition. Staff document behavioural incidents which management review to identify strategies and minimise recurrence. General practitioners and external services are available for residents who require additional review and management of challenging behaviours. Staff attend education focused on identifying, minimising and managing challenging behaviours in a calm and respectful manner. Residents and representatives are satisfied staff manage the needs of residents with behavioural issues effectively.

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


Care recipients have access to care and equipment to maintain optimum levels of mobility and dexterity. On entry to the home staff conduct a mobility assessment with further consideration by the physiotherapist. A risk management approach to falls and information gathered on mobility, transfers and dexterity informs care plan development. A range of strategies including exercise, walking, adapted cutlery and sensory aids and equipment assist in supporting residents’ mobility, dexterity and independence. Staff implement plans as directed by the physiotherapist for maximising resident mobility. Staff report on resident falls and near miss events as they occur through the incident reporting system. Residents said they have access to mobility aids and are encouraged and assisted by staff to walk and exercise on a regular basis.

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


Care processes contribute to the maintenance of care recipients’ oral and dental health. Nursing staff in consultation with the resident or their representative conduct assessments to develop an oral and dental care plan. Care plans document individual preferences for cleaning natural teeth, dentures and other oral care. Management and staff in conjunction with the resident’s representative support residents to attend dental services within the community and according to their preference. Residents unable to or preferring not to leave the facility have access to visiting dental and dental technician services. Referrals are made to dietitians and speech pathologists for residents’ with an oral or dental status which would impact their ability to manage a normal consistency diet. Residents said they are satisfied with the dental care provided at the home.

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


Staff assess care recipients’ communication and sensory needs on admission to the home and regularly thereafter. Assessments result in individual strategies to manage sensory losses and subsequent needs. Referral to allied health professionals occur when requested


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or required and residents’ optometry needs are assessed annually. The lifestyle program offers residents a range of culturally focused sensory activities based on resident need. Staff use a range of communication strategies to interact with residents experiencing sensory loss and a predominantly Greek workforce ensures greater continuity in meeting residents’ communication and sensory needs. Staff monitor residents’ sensory needs through care plan review and resident and representative consultation. Residents are satisfied with the identification and management of their sensory losses.

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


Staff ensure care recipients are assisted to achieve natural sleep patterns in the home. Staff assess residents’ natural sleep patterns on entry to the home and when required thereafter. Staff support residents’ natural sleep patterns through the care planning and actioning process. Staff follow assessed routines to promote sleep including respecting individual settling habits, providing evening drinks and snacks and administering medication as prescribed. Staff described strategies to help resettle any resident who wakes during the night including offering emotional support, attending to hygiene and providing positional changes. Residents said they are satisfied with staff assistance in helping them get adequate rest and sleep.


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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.



The organisation pursues continuous improvement related to Standard 3 Care recipient lifestyle, with the overall system described in expected outcome 1.1 Continuous improvement. Monitoring of resident and representative satisfaction occurs through formal and informal feedback. Regular stakeholder meetings provide opportunities for residents and representatives to raise concerns and to discuss any issues related to residents’ lifestyle. Residents said they have opportunities for input into the lifestyle services at the home.

Examples of improvements in relation to Standard 3 include:

The organisation has sourced Greek speaking clinical psychologists to assist in supporting residents’ emotional wellbeing. On referral from their medical practitioner, residents are entitled to six sessions with a psychologist free of charge. A number of residents have utilised the service. Staff reviews of participating residents note positive changes in their wellbeing.

In response to a new resident’s difficulty in using their call bell, the home sourced and implemented a ‘jelly bean’ touch call bell. The ‘jelly bean’ button trigger is sensitive enough to recognise the slightest touch in order to activate the call bell. Ongoing monitoring and liaison with the resident confirmed it is suitable and working well. The home has since purchased a second ‘jelly bean’ touch call bell for another resident who also found the normal call bell difficult to use. Staff confirmed they monitor residents’ access to call bells.

In response to residents’ spiritual and cultural practice needs lifestyle staff sourced ikon displays (ikonastasi) and maintenance staff installed these, together with battery operated candles on a wall in each resident’s room. Residents are able to decorate these to their liking. Some residents have also added their Saint name to this display. Lifestyle staff, residents and representatives confirmed that this is an important part of Greek culture and religious celebration and this initiative has helped residents to continue their religious practices in the privacy of their own rooms.

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


The organisation has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about care recipient lifestyle. For details on the organisation’s overarching regulatory compliance system refer to expected outcome 1.2 Regulatory compliance.


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Management has processes to ensure staff are aware of compulsory reporting requirements.

The organisation has developed policies and provided education to guide management and staff in relation to privacy principles and confidentiality of resident information.

Each care recipient receives a residential agreement informing them of the Charter of care recipients’ rights and responsibilities and the responsibilities of management relating to security of tenure.



Management and staff have appropriate knowledge and skills to perform their roles effectively. For details on the organisation’s overarching education and staff development system in relation to care recipient lifestyle, refer to expected outcome 1.3 Education and staff development.


caring for residents living with dementia for non-nursing staff

upholding residents’ privacy and dignity

security of tenure.

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".


Prior to and on entry to the home care recipients are provided with relevant information in English and Greek and staff assistance to help them adjust to living in their new home. Residents are orientated to the living environment and introduced to key staff and other residents. Following a collaborative assessment of residents’ emotional needs and preferences, staff develop a social profile and care plan to guide staff in providing individualised emotional support. Staff review residents’ emotional support needs during scheduled care plan reviews, in consultation with their representatives and at times of distress, grief or loss. Strategies used to support residents’ emotional health include religious or cultural care services, visitor programs, psychology services and one-on-one support from Greek speaking staff. Staff interact with residents in a caring and supportive manner. Residents and representatives expressed their satisfaction with the emotional support residents receive.


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


Staff assist care recipients to remain as independent as possible, to maintain friendships outside the home and to participate in the life at the home and in the Greek community more broadly. In consultation with the resident and their representative, staff identify strategies to support each resident’s preference for independence and incorporate preferences into relevant care plans. Staff consider each resident’s independence during scheduled care plan reviews and as their needs or wishes change. Physiotherapy and exercise programs assist residents to maintain their mobility and staff provide equipment and adaptive aids to optimise independence as needed. Residents and representatives said staff help residents to maintain their independence.

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


Management and staff recognise and support each care recipient’s right to privacy, dignity and confidentiality. On entry to the home residents receive information on how Fronditha Care protects their privacy and confidentiality. Staff receive training on their obligations in the use and release of residents’ personal information and policies outline staff requirements to obtain resident consent for the use of personal information. Residents are encouraged to personalise their room and to entertain guests privately and in communal areas throughout the home. Staff were knowledgeable on how to respect residents’ privacy and staff interactions with residents were respectful and courteous. Staff identify strategies to support privacy and dignity in care delivery and during palliative care. Residents and representatives expressed satisfaction with the manner in which staff support each resident’s privacy and dignity.

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


Care recipients are encouraged and supported to participate in a wide range of cultural and religious activities and to provide input into the development of the activities program. Following entry to the home lifestyle staff liaise with the resident and their representative to identify each resident’s leisure and lifestyle interests and incorporate these into a social profile and care plan. Staff review the care plans on a regular basis and in response to changing needs or preferences, participation levels or feedback. The activity program offers a range of group and individual activities reflecting residents’ emotional, physical, cognitive, sensory, cultural and spiritual needs. Most of the home’s activities are conducted in Greek. Special celebrations, excursions, volunteers, entertainers, school students and cooking add to the diversity of activities on offer. We observed residents participating in a variety of


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activities. Residents are satisfied with their opportunities to provide input into the lifestyle program and the range of activities offered.

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


Management and staff value and support each care recipient’s interests, customs, beliefs and backgrounds. The home strongly supports the Greek culture and customs. On entry to the home and in consultation with the resident and their representative, staff identify how each resident wishes to express their culture and spirituality and outline wishes in their social profile and care plan. Staff review the care plans on a regular basis and in response to the resident’s feedback. Visiting religious leaders and pastoral carers provide spiritual support and guidance to residents as requested and regular religious services and prayers take place. Residents have cultural icons and shrines in their rooms to enable them to practice their faith in private if preferred. The organisation celebrates cultural events, birthdays and days of significance for residents’ throughout the year. The menu offers culturally appropriate meals. Residents and representatives are satisfied residents have sufficient opportunities to pursue their cultural and traditional practices and to practice their faith and spiritual beliefs.

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


In consultation with the care recipient and their representative staff identify individual choices and preferences relating to the provision of care, lifestyle, food and other services, incorporating preferences into relevant care plans. Staff review care plans on a regular basis and in response to resident feedback. Residents are free to change their mind on any aspect of care and lifestyle at any time. Management makes information on advocacy services available and support residents and their representatives to appoint a power of attorney if required. Staff actively support residents’ choices and respect their decisions. Residents and representatives are satisfied that residents’ choices are promoted and their decisions are respected.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


Care recipients have secure tenure within the home and staff assist them to understand their rights and responsibilities. Prior to and on entry to the home care recipients and their representatives are provided with information that includes the ‘Charter of care recipients’ rights and responsibilities’ and the comments and complaints processes. All residents are


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offered an agreement upon entry to the home that includes information relating to security of tenure. Residents and representatives said they feel secure living in the home and understand their rights and responsibilities.


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Standard 4 – Physical environment and safe systemsPrinciple: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



The organisation pursues continuous improvement in relation to Standard 4 Physical environment and safe systems, with the overall system described in expected outcome 1.1 Continuous improvement. Management undertake regular workplace inspections and environmental audits. Together with staff training, equipment, resource information and safety representatives, these strategies promote and ensure safe work practices and a safe and secure environment. Staff outlined procedures for hazard and incident reporting and confirmed corrective actions occur promptly. Residents and representatives said they are happy with the comfort and safety at the home.

Examples of improvements in Standard 4 include:

The organisation recently completed a staged expansion from 30 beds to 120 beds. Existing and new staff were orientated to the upgraded building and grounds. The home’s maintenance systems and schedules, fire and emergency manuals and workplace inspection procedures and schedules have been updated accordingly. Staff received training on the new emergency procedures and the use of emergency equipment. Catering, cleaning and laundry staff were orientated to their new work environments, equipment and procedures. Management said the expansion has been successful and all areas of the home are operating smoothly. Residents and representatives said they are satisfied with the environment and services they receive in the home.

The opening of sections of the new building facilitated the transition of the older section of the home into a secure memory support unit named ‘Anesi’. Fronditha Care held a grand opening celebration for the Anesi unit receiving positive feedback from participants. To support residents in the unit, management installed new garden beds, shade sails, safe walking paths, a bird aviary, raised garden beds and a culturally appropriate religious area for residents to use in the courtyard. Residents and representatives said they use the outside areas frequently and the internal environment is safe, clean and meets residents’ needs.

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


The organisation has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems. For details on the organisation’s overarching regulatory compliance system refer to expected outcome 1.2 Regulatory compliance.



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There is a food safety program and the catering service has a current third party food safety audit.

Management and staff are aware of infectious outbreak control policies, response and reporting procedures.

Chemicals are securely stored and corresponding material data sheets are available.



Management and staff have appropriate knowledge and skills to perform their roles effectively. For details on the organisation’s overarching education and staff development system in relation to physical environment and safe systems, refer to expected outcome 1.3 Education and staff development.


bullying and harassment in the workplace

infection control

emergency management.

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


Management is actively working to provide a safe and comfortable living environment for residents. The home, redeveloped in 2014, now includes a memory support unit. Resident rooms are single occupancy with ensuites or shared bathrooms. Maintenance and gardening staff ensure the living environment remains safe, inviting and well maintained. Staff and volunteers assist residents to maintain vegetable gardens and enjoy the garden and courtyard areas. Communal living areas are bright and well used by residents creating a lively atmosphere. Residents are encouraged to personalise their rooms and guests are welcome at any time. Residents said they feel safe and comfortable at the home and representatives said staff make them feel welcome.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


The organisation is actively working to provide a safe working environment that meets regulatory requirements. At orientation and on an ongoing basis, staff receive information


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and training to promote a safe environment and undertake their work safely. Aspects include training in resident transfer techniques and handling chemicals safely. Processes for identifying risks to staff safety include incident reports and hazard alerts. An occupational health and safety committee meets regularly. Staff delegates have attended appropriate training courses and said they are actively engaged in promoting the safety of colleagues. Observation of staff identified appropriate and safe work practices occurring. Management and staff are satisfied with the safety of their work environment.

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


Management and staff are actively working to provide a care and work environment that minimises the risk of fire, security and other emergencies. Management display emergency evacuation plans throughout the home, emergency exits are easily identifiable and entry and exit doors have security key pads. An emergency procedure manual is available, senior staff complete fire warden training and all staff undertake annual emergency competencies. An evacuation kit is easily accessible and the home is equipped with a smoke detection system, sprinklers, fire-fighting and other emergency equipment. Scheduled servicing of fire and emergency equipment occurs and flammable substances are stored safely and securely. Staff described the actions to take in the event of a fire alarm and said contingency plans are in place for dealing with other types of emergencies.

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


The organisation has an effective infection control program in place. Policies, procedures and a food safety program, guide staff in their infection prevention practices. Supplies of personal protective equipment and hand washing facilities are readily available and infectious outbreak kits prepared. Management observe staff to ensure they adhere to work practices designed to minimise infection and undertake infection control audits. Clinical staff record resident infections to identify trends or potential outbreaks. Residents and staff are encouraged to have annual influenza immunizations. Staff were knowledgeable of infection prevention strategies in line with their role. Residents and representatives are satisfied with the infection control practices of staff.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Staff provide environmental and hospitality services in a way that enhances care recipients’ quality of life. A seasonal, rotating menu, developed in consultation with residents, offers two hot meal choices at each service and caters for resident preferences and dietary requirements. Laundry services ensure personal items are well cared for and a labelling


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process minimises lost clothing. Cleaning staff follow documented schedules and respond to unscheduled requests in a timely manner. Staff described procedures relevant to their role, complete appropriate training courses and are satisfied with their work environment. Residents and representatives were complimentary of the quality of the catering, cleaning and laundry services.

Date post:	08-Mar-2018
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Fronditha Anesi Aged Care Services - Thornbury 4535...

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