Published_decision_(SA_and_RA) - aacqa.gov.au · Web view2.5Specialised nursing care needsMet....

SummitCare SmithfieldRACS ID: 2822

Approved provider: Stelcom Pty Limited

Home address: 11 Nyora Avenue SMITHFIELD NSW 2164

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 01 April 2021.

We made our decision on 14 February 2018.

The audit was conducted on 09 January 2018 to 11 January 2018. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: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 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 carePrinciple: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.




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 MetHome name: SummitCare Smithfield Date/s of audit: 09 January 2018 to 11 January 2018RACS ID: 2822 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services 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 Care recipient security of tenure and responsibilities Met

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




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

Home name: SummitCare Smithfield Date/s of audit: 09 January 2018 to 11 January 2018RACS ID: 2822 3

Audit ReportName of home: SummitCare Smithfield

RACS ID: 2822

Approved provider: Stelcom Pty Limited

IntroductionThis is the report of a Re-accreditation Audit from 09 January 2018 to 11 January 2018 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

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


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 09 January 2018 to 11 January 2018.

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.

Details of homeTotal number of allocated places: 90

Number of care recipients during audit: 77

Number of care recipients receiving high care during audit: 77

Special needs catered for: Multi-cultural care recipients


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

Interviews

Position title Number

General manager 1

Manager care and services 1

Group manager care and services 1

Clinical care systems advisor 1

Manager accommodation services 2

Podiatrist (by phone) 1

Physiotherapist (by phone) 1

Consultant Pharmacist (by phone) 1

Registered nurses 4

Care staff 7

Physiotherapy aide 1

Activity staff 3

Care recipients and/or representatives 24

Manager customer support and administration

1

Administrator 1

Catering staff 2

Laundry staff 1

Cleaning staff (including supervisor) 3

Maintenance staff (including supervisor) 2

Sampled documents

Document type Number

Care recipients’ files 9

Medication charts 9


Document type Number

Incident reports 6

Comments/complaints and compliments (2017-2018)

15

Care recipient agreements 3

Personnel files 7

Other documents reviewedThe team also reviewed:

Accident and incident reports, medication incidents, behaviour incidents, with data collation and reporting

Activities documentation and resources

Allied health referral, assessment and care planning documentation

Annual fire safety statements; fire service/maintenance record service books and reports; emergency response flip-charts; emergency and site-specific emergency plan and master emergency plan, emergency evacuation lists

Behaviour assessment tools, behaviour management and monitoring tools, referral to external specialists, attendance by psycho-geriatric specialists, assessment of triggers and plans implemented

Care recipients’ information handbook, package and surveys

Cleaning schedules; cleaning, calibrating and sanitising records

Clinical documentation including: care plans, monitoring and evaluation of care documents, assessment and treatment records, risk assessments, referral to external specialists, hospital discharge documents, vital signs charting, weight monitoring, advance care planning documents and specialised nursing care documents; restraint authorisation and monitoring of usage; clinical monitoring records and observation monitoring records

Continence management including management plans, daily bowel monitoring records and continence aid allocation lists

Continuous improvement plan

Education calendar, training needs analysis, training records, attendance records, competency assessments

Hospitality: nutrition and dietary needs summaries held in kitchen; menu; NSW Food Authority report; cleaning programs and sign sheets; menu review by dietician

Infection control material including: trend data, outbreak management program, vaccination records

Job descriptions

Mandatory reporting register

Material safety data sheets

Medication management documents, Schedule 8 register for drugs of addiction, diabetic medication delivery tools, assessments and monitoring records


Meeting minutes – staff, care recipients, medication advisory committee, WHS and others

Nutrition and hydration management including: special diets, thickened fluids and nutritional supplements, care recipient food and beverage preferences and allergies, and weight monitoring charts

Other employment register

Pain assessment tools for verbal and non-verbal assessment of pain, pain management monitoring charts, referral to external specialists

Physiotherapy assessments, mobility assessments, falls risk assessments, mobility care plans, manual handling guidelines

Police certificates, statutory declarations and overseas staff visa log

Policies and procedures (intranet and hard copy)

Preventative and corrective maintenance records: reactive maintenance forms/register folders; preventative maintenance plan; maintenance service records; contractor sign in/out books

Recruitment policies and procedures

Registrations folder

Rosters and rostering books

Safe work practices – cleaning and maintenance

Self-assessment report for re-accreditation

Specialised nursing records including: diabetes management plans, catheter care, wound and pain management

Staff handbook

Web site (organisation)

Wound assessment and management records

ObservationsThe team observed the following:

Activities in progress and associated resources, programs and notices

Assyrian Mass

Care recipients knitting, reading and completing word puzzles

Charter of care recipients’ rights and responsibilities on display

Dining environment during morning and afternoon tea, midday meal service including staff supervision and assistance; menu on display

Doctor attending the home for medical consultation with care recipients

Electronic and hardcopy record keeping systems – clinical and administration

Equipment and supplies in use and in storage such as lifting equipment, manual handling aids, mobility equipment, low-low beds, pressure relieving mattresses and aids in use and in storage; linen, clinical stores and continence aids, chemical stores

Fire safety: emergency evacuation maps and signage; fire-suppression equipment; fire doors; fire panels; emergency evacuation supplies

First Aid kits


Garbage and clinical waste disposal facilities and storage areas

Infection control resources including: outbreak supplies, spill kits, sharps disposal containers, hand-washing facilities, waste disposal, hand sanitiser dispensers around the home, general and contaminated waste disposal systems, colour coded cleaning equipment and personal protective equipment

Interactions between staff, care recipients and representatives

Living environment – internal and external including gardens and water feature

Medication administration across the home; secure storage of medication

Noticeboards for staff, visitors, and care recipients (including work, health and safety and education)

Notices advising stakeholders of the dates for the re-accreditation audit on display

Orthodox Christmas Party and entertainment

Pamphlets in a range of languages including external complaints service and aged care services

Secure key pads

Senior services information

Sign in books

Small observational group during activities on day one

Staff access to and use of information systems including computers


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 developmentPrinciple:Within the philosophy and level of care offered in the residential care services, 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 home demonstrated it has a continuous improvement system and actively pursues continuous improvement across the Accreditation Standards. SummitCare, the organisation, has consistent systems and processes designed to capture and analyse information relevant to continuous improvement. The home’s management team demonstrated this system and the processes are effectively applied and relevant to the care recipients residing in the home. Staff, care recipients, representatives and other stake holders are actively encouraged to contribute to continuous improvement. Improvements are also drawn from analysis of information such as clinical and incident data, audits, surveys, meeting minutes, comments, complaints and compliments. The organisation team work closely with the home’s management to support continuous improvement. Improvements are evaluated for effectiveness. Care recipients and staff were able to describe a range of recent improvements and their satisfaction with these.

Continuous improvements related to Standard One include the following:

Major building work in the vicinity of the home caused a drop out of internet response times. Reviewing why this occurred, the general manager identified the information technology system in place in the home was piece-meal and not fit for purpose. For example intranet connectivity was inconsistent, there were not sufficient phone lines for incoming calls and computers were outdated and operating with insufficient memory. The system was rebuilt and an extra landline connected into the administration area. Computers were replaced and small electronic books bought to increase clinical and care support. Reliable Wi-Fi and fibre optic cable installed. The management team’s computer systems had additional back up including printer connectivity. As a result of the update, 80% of the call bell system has been replaced and a new large printer purchased. Staff can now receive their payslips by email and a SMS system enables the home to bulk message representatives such as if there is an outbreak-all representatives can be informed immediately. The new system is more efficient and reliable. Although on day two of this visit one of the external provider main programs used went down across Australia. The program provider is accountable for this fault and the home demonstrated its back up plan for such an event worked effectively resulting in minimal disruption to work practices. Staff said the new system is ‘fantastic’. Representatives said they appreciate the ability to be contacted by SMS.

When the general manager commenced in the home some two years prior, they identified staff work culture and morale appeared to be an issue in the home. It appeared


staff were using excessive sick leave and many staff using ‘new’ sick leave immediately it accrued. They also identified staff were not taking annual leave. The general manager reviewed sick leave across the home to ensure they had evidential data on its use. This showed that although it appeared high, it was steady and in line with benchmarked leave in other like homes. However, they put in place strategies to reduce sick leave such as requiring sick leave certificates on single day leave and encouraging staff to use accumulated annual leave. It was also identified there was a pattern of staff ringing in late to take sick leave making it difficult to replace them on short notice. Staff said it was because it was hard to get through on the home’s landline system. The review further identified some staff had secondary employment in other facilities and this was not recorded or monitored. A register was set up to maintain this information and staff reminded of their responsibility to inform the home of other paid work they were doing. Lastly the annual staff survey identified staff wanted more skills training to support their work practices but a review of the education program showed staff were not taking up the training options available. As noted above (concerning the IT improvements) an extra landline has made it easier to contact the home and additional computers, including the setting up of a quiet work place, allows staff to access electronic e-learning programs. The organisation actively supports staff in professional development and education programs are now more widely advertised and staff attendance encouraged. A number of staff described programs/courses they have attended recently. The management team have actively worked on developing a team culture with the general manager using an open-door policy for staff to raise any issues and a phone contact list if staff want to contact a member of the management team after hours. The general manager said absenteeism levels have dropped and staff are using their annual leave. Staff said they appreciate the team work and support from their managers and the majority said how much they enjoy coming to work and that recent education and skills training has given them greater ability in their work practices and better care and services for supporting the care recipients.

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”.


The organisation and home’s management has a range of policies, systems and processes in place to identify and ensure compliance with all relevant legislation, regulation, professional standards and guidelines. The organisation monitors industry standards and guidelines and subscribes to a range of organisations and agencies that provide current and updated regulatory information. This includes peak body, Department of Health, legal services, local authorities and Australian Aged Care and Quality Agency. The electronic intranet site ensures information populates relevant policy and documentation and sends electronic alerts and circulars as and when required. Homes are provided with information, training and education to ensure compliance is maintained across all Standards. Regulatory compliance under Standard One includes maintaining privacy requirements, ensuring currency of police certificates, statutory declarations are completed and that staff on restricted work visa conditions are monitored to ensure they comply with the required criteria of such visas.

1.3 Education and staff developmentThis 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. The home has an education program, which is based on educational needs identified through a wide range of mechanisms. These include a training needs analysis process, feedback from various meetings, and the quality improvement system. The program is comprehensive and covers a range of functional areas encompassing all four Accreditation Standards. New staff participate in orientation programs. Education is delivered through a range of means including individual, small group and larger sessions, together with online and self-directed learning. The education program is reinforced by competency assessments in relevant areas. Staff also have access to relevant external educational opportunities and where appropriate are supported to obtain formal qualifications.

Examples of recent education sessions related to Accreditation Standard One Management systems, staffing and organisational development include: the accreditation process, care documentation, Aged Care Funding Instrument (ACFI) and using equipment.

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 and home actively support care recipients and their representatives to access internal and external complaints processes. The home maintains a register of comments, complaints and compliments and uses this to initiate change as and where appropriate. The home’s management ensure complaints can be made confidentiality and a process is in place to ensure these are responded to in a timely and effective manner. The general manager was seen to operate an open door policy. Regular case conferencing allows concerns to be addressed and solutions developed as part of ongoing care and services delivery. Comments and complaints were seen to be discussed at care recipient, representative and staff meetings. Care recipients and their representatives were familiar with the complaints processes available in the home and confident that if they did raise concerns these would be addressed.

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 home has documented it’s (and the organisation’s) vision, values and philosophy throughout the service. It includes how these support the delivery of care and services. Care recipients, representatives and staff commented on their satisfaction with the home’s leadership team.

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".



A comprehensive system is in place to support recruitment based on meeting the needs of care recipients. Reference checks and police certificate clearance are attended prior to employment. New staff receive orientation and complete ‘buddy’ shifts and a period of probation. Position descriptions and work schedules support delivery of care and services. Management regularly review rosters and staff numbers to ensure care and service needs are being met. The roster hours and staff numbers are consistent across the week. There is a system for replacement of sudden and planned absences using overtime and the existing staff pool. The home does not use agency staff. Staff have at least an annual appraisal and are actively encouraged to pursue professional development. Staff said they have sufficient time and skills to complete their duties. Overall care recipients and representatives said there are sufficient and appropriately skilled staff available to meet their requirements.

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


The home has a system in place for ordering all appropriate goods and equipment. This is monitored by the management team and at organisational level. Auditing processes and feedback from stakeholders ensures stock is appropriate for use in the home and matches what was ordered. Systems are in place to return goods unsuitable to purpose, faulty or below the required quality (such as fresh food). A review of inventory and equipment showed adequate supplies and appropriate storage including a system, where required, of stock rotation and when goods needed to be replenished. The home has recently replaced a range of equipment including beds, sensor mats, drapes, mattresses and furnishings. Care recipients, representatives and staff expressed their satisfaction with the sufficiency of and access to appropriate goods and equipment.

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


The organisation has a comprehensive and effective information management system in place. This is both electronic and hard copy and supports a consistent approach to use of documentation and procedures. Staff and management in the home demonstrated they apply these systems in the delivery of care and services. Management and staff have access to accurate and controlled information sufficient to help them perform their roles. These include care plans, clinical documentation, work schedules, position descriptions and the intranet. Care recipients and representatives have access to information appropriate to their needs. This includes agreements, handbooks, newsletters, brochures, meeting minutes, and noticeboard information. Information was seen to be in a range of languages relevant to care recipients in the home. Information was seen to be stored in a way which was secure, such as password protected and accessible to only those with authority to do so. The computer system is backed up. Staff, care recipients and representatives said they are satisfied with the information available to them.

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".



The organisation has a procurement officer and they manage contracts and preferred contractors used by the home to ensure external services are provided in a way which meets the needs of the service and care recipients. However, the home is also able to draw on local services where this is more relevant and cost effective. Laundry and cleaning services are contracted. The management team ensure contractors attending the home have legislative requirements such as police certificates, insurances, qualifications and registrations. Stakeholders are actively encouraged to provide feedback around satisfaction with the quality and standard of services provided. There is a system to monitor contractors when they are on site and to evaluate completed work. Staff, care recipients and representatives said they are confident in raising any concerns regarding the quality of the external services.


Standard 2 – Health and personal carePrinciple: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.



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

Continuous improvements related to Standard Two include the following:

A managers forum identified staff would benefit from further education in assessing and identifying pain where care recipients have dementia symptoms or cognitive issues resulting in reduced verbal communication. A project ‘Panacea’ was commenced in August 2017 to train champions in pain management. Staff were identified who wanted to take on these roles and attended a master class where they received education, training and resources to take back to their work sites. In September 2017, two modules on how to identify and assess pain were provided to all staff. A third module with attached training points was compulsory for all registered nurses on pain management. The model used critical thinking and how to develop a structure for information sharing and improved communication around pain management. This included improved communication to families and other health providers such as medical officers. As a result of this training, care recipient care is more immediate when pain is screened by cognitive factors. Overall this has improved the management of pain in the home resulting in a lowering of incidents of behaviour and in falls.

At the beginning of 2017, the management team identified there was an issue with the number of falls in the home. It was also identified that the home was accepting more care recipients with identified risk of falls. Monthly data on falls was collected, collated and analysed and results given to staff for discussion and feedback. The physiotherapist and physio aide looked at effective strategies to minimise falls (such as through exercise and yoga) and at the effectiveness of existing mobility/falls equipment. This resulted in replacement and increase of equipment (to ensure availability) and some changes to practices such as the cleaning of eye glasses and ensuring care recipients had appropriate footwear. The management team asks for and receives regular feedback from staff regarding the effectiveness of the strategies used and there has been a decrease in fall numbers. Falls are also discussed in family conferences as and where appropriate in particular as the home is maintaining a restraint free environment and is educating families about the available alternatives to restraint.

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”.



Refer to expected outcome 1.2 Regulatory compliance for further information regarding the home’s system in this area.

The home demonstrated it has systems to ensure the currency of professional registrations. Safe systems for the delivery and storage of S8 medications and the administration of medications are in place.



The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 2 Health and personal care.

Examples of recent education sessions related to Standard Two include: medication management, oral and dental care, palliative care, pain management, diabetes management, behaviour management, skin integrity and wound management, continence management and falls prevention and management.

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

Team's findingsThe home meets this expected outcome

Care recipients receive appropriate clinical care. Their preferences are assessed from pre-entry through to the development of the care plan and regular evaluation of care. Family care conferences are documented, and changes communicated to care staff. This occurs as the care recipient’s needs change and is routinely reviewed every three months or as changes occur. The assessment process is guided by the home’s policies and procedures. Assessment of care, implementation of the plan and evaluation of interventions are attended by registered nurses. Variations to the plan for care recipients are discussed in an environment of collegial support and teamwork. There are registered nurses on duty in the home across 24 hours. Care recipients and representatives interviewed said care recipients’ clinical care was appropriate to their needs.

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”.


Care recipients and representatives are consulted regarding specialised nursing needs and plans are in place to direct this care. The home provides policies and procedures to guide staff in the delivery of specialised nursing care. Specialised nursing care is delivered by registered nurses, in consultation with care recipient’s chosen doctor and other specialised services when required. Protocols and communication systems are in place to ensure follow up of specialised nursing needs such as pathology and x-ray results, pain management effectiveness, dietetic involvement, catheter care, wound and diabetes management. Parameters are set by the doctor for blood glucose monitoring consistent with the care recipient’s plan for management of diabetes. Care recipients and representatives said they are happy with the management of these care needs.


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”.


Documentation shows the home refers care recipients to external health professionals and any changes to care following these visits are implemented in a timely manner. Allied health professionals are accessed via a referral system, through the care recipients’ preferred doctor. Pathology services, psycho-geriatrician, mental health and other allied health services visit the home using the external referral process. Representatives and care recipients report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Implementation of specialists’ recommendations is followed up by registered nurses. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care recipients’ care are implemented.

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


Management described, and observation confirmed the safe and correct administration of medications. Staff were observed making appropriate checks, administering medication and assisting care recipients, while also keeping the medications within their safe observation. All medications are administered by staff assessed as competent to do so. Policies and procedures guide the safe delivery of medications. Meeting minutes’ show review of legislation changes, medication and pharmacy issues and medication reviews are completed by a consultant pharmacist. Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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


All care recipients are assessed for pain on entry to the home and as needed. Pain is also assessed as medication is administered and effectiveness monitored by care staff and registered nurses. The registered nurses provide feedback to the care recipient’s chosen doctor to ensure the comfort of care recipients. Allied health and care staff collaborate on the care recipient’s pain management strategies. Physiotherapy staff and registered nurses provide massage for pain relief, based on clinical assessment. Care recipients and representatives report care recipients are as free as possible from pain and staff respond in a timely manner to requests for pain control.

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



The comfort and dignity of terminally ill care recipients is maintained. There are records of care recipients’ preferred care at end of life and education programs are in place for staff of the home. The registered nurses consult with care recipients’ doctors and the care recipients/representatives where appropriate. Spiritual support is provided as needed. Staff ensure the care recipient’s wishes and comfort are observed while delivering palliative care. Interviews confirm care recipients trust the home’s staff with all aspects of their care.

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


Care recipients' nutrition and hydration requirements, preferences, allergies and special needs are identified and assessed on entry. Care recipients' ongoing needs and preferences are monitored, reassessed and care plans updated. There are processes to ensure catering and other staff have information about care recipient nutrition and hydration needs. Staff monitor care recipients' nutrition and hydration and identify those care recipients who are at risk. Visiting speech pathology and dietician specialists visit the home for assessment and management of care recipients identified at risk. The home provides staff assistance, equipment, special diets and dietary supplements to support care recipients' nutrition and hydration. Staff have an understanding of care recipients' needs and preferences including the need for assistance, texture modified diet or specialised equipment. Staff practices are monitored to ensure nutrition and hydration needs are delivered in accordance with care recipients' needs and preferences. Care recipients and representatives interviewed are satisfied care recipients' nutrition and hydration requirements are met.

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


Care recipients and representatives confirm they are satisfied with the care provided to care recipients in relation to skin integrity. Skin integrity assessments and risk of impairment to skin integrity, are conducted on entry to the home and reviewed as necessary including at the three-monthly care review and evaluation. Risk assessment guides the pressure area care as care recipients’ mobility, nutrition status and cognition alter. Care recipients with specific skin conditions are closely monitored and treatments applied as directed by the care recipient’s chosen doctor. Referrals are made to specialist services as required. Wound monitoring and wound charts show regular review of wound management and improvement strategies. Pressure relieving equipment is available for those care recipients who are identified at risk of skin breakdown.

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


Care recipients and representatives confirm continence needs for urine and bowel function are being met. On entry to the home the care recipient’s continence needs are assessed by staff obtaining the history from the care recipient, their representatives, doctor’s referral and pre-entry assessments. Flow charts are initiated, voiding times and bowel evacuation


patterns are recorded to enable assessments to be made. Care plans are developed and reviewed at regular intervals including consultation with care recipients and representatives. Staff continence education includes toileting programs, bowel management and the relationship to privacy, dignity and choice for care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behaviour management is identified by initial assessments and care plans are formulated. Management strategies include one-on-one and group activities with care staff and lifestyle staff. The programs are regularly reviewed in consultation with the care recipient, their representatives and other specialist services if consultation is required. Staff confirm they have received education in managing care recipients who express challenging behaviours through access to specialist health professionals and consult with these services as needed. Staff were observed to use a variety of management strategies and resources to effectively manage challenging behaviours. Care recipients and representatives were satisfied with the staff management of these situations and communication with families, regarding the interventions used to assist the care recipient and the impact of care recipients’ behaviours on other care recipients.

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


Each care recipient has their mobility and dexterity assessed by the health care team including the registered nurse and the physiotherapist. Information is gathered from the care recipients, representatives, and hospital discharge documents. Mobility information and the care recipient’s need for assistance are detailed in the care plan and programs are instigated by the physiotherapist to optimise care recipients’ mobility function. The home has a physiotherapy aide who carries out the programs developed by the physiotherapist. There is a range of aids to effectively and comfortably move care recipients. There is a system to indicate the level of assistance required with mobility described on the mobility plan and discussed at the care staff hand-over meetings. Care recipients and representatives said they are satisfied with the assistance and therapy provided to care recipients.

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


Each care recipient’s oral and dental health needs are assessed by the registered nurses on entry to the home. The care recipient’s needs, preferences and interventions are recorded on the care recipient’s care plan. The care recipients’ care plans are reviewed regularly and adjusted as necessary to meet their oral health needs. The home has access to dental services and arrangements can be made for care recipients to attend external services. The home has access to visiting dental services for those who are unable to attend external


services. Staff interviewed, confirmed their understanding of the oral care process and care recipients and representatives expressed satisfaction with this service.

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


Each care recipient’s sensory losses are assessed by the registered nurse through completion of the entry assessments and the specific sensory assessment tools. This occurs in consultation with the care recipient and their representative. The methods for communication and compensation for sensory losses are also located on the care plan. The home has a number of visiting allied health professionals to assess and meet vision and hearing loss. Strategies to assist care recipients who have declining cognition include speaking clearly and slowly, making eye contact, using simple statements and speaking with warmth, caring and using gestures as required. Care recipients and representatives interviewed said they are satisfied with the assistance provided to the care recipients.

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


Care recipients and representatives confirm care recipients are able to achieve natural sleep in the home. Information about the care recipient’s sleep patterns is entered in to their assessment and recorded in the care plan. Observations by care staff are recorded on assessment tools and in the care recipient’s progress notes to ascertain their normal sleeping pattern. Sleep patterns are reviewed each three months and as required. Disturbance of care recipients is kept to a minimum at night. Activity is provided for those care recipients who go to bed late or rise early. Documents and interviews confirm staff receive education regarding the promotion of sleep.


Standard 3 – Care recipient lifestylePrinciple: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.




Continuous improvements related to Standard Three include the following:

In 2017 a grant was applied for a ‘Fusion’ (Fun, Unite, Smile, Ignite, Older) project. This is an intergenerational integration program connecting schools with residential aged care. The grant allowed the home’s activity staff to purchase equipment for the project and these included books, boards, gardening materials, a pizza oven, and art and other craft materials. The project matches school to home and every second Friday for two semesters pupils from the high school selected attended the home. Pupils were initially orientated to the home and provided an oversight of aged care (including dementia and physical conditions relevant to ageing). A gala was held at the home where pupils attended and met care recipients and their families. As well as one on one conversation, a number of activities were taken up including gardening, baking, art work, crafts and mosaic making. Activity staff said the project was a resounding success. Care recipients gained a lot from the interaction and a number of school pupils said they did not have any elderly people in their immediate lives and found this contact highly rewarding. The home is keen to repeat this project.

The home has a very multi cultured care recipient population base, primarily Assyrian, Italian and Spanish. It was identified the menu, although fresh cooked was not always meeting the specific cultural food preferences of care recipients. The home also has staff from these and a range of other cultures. Management decided it would source more basic ingredients for the kitchen appropriate to the cultures in their home in consultation with care recipients, families and staff. Discussions with relatives identified recipes which could be produced in the home’s kitchen. A nearby bakery was able to provide Middle Eastern pastries, other baked items and desserts. The home is also sourcing precooked and packaged meals appropriate for use (such as purees). As a result the daily menu can have up to three options available to care recipients. The management team said there is less wastage, more evidence care recipients are eating well and families are also choosing to eat with their loved one.

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”.




As an example of meeting regulatory compliance under this Standard the home maintains a consolidated record. This shows incidents where mandatory reporting has occurred or discretion not to report has been used. All incidents are reported up through the organisation and decisions on appropriate action are made by the designated key person only. Staff demonstrated an understanding of how they would report alleged assaults and said they had received mandatory education on reporting elder abuse. The home has the link to the updated reporting form as is now required by the Department of Health for missing care recipients and the reporting of alleged assaults.



The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 3 Care recipient lifestyle.

Examples of recent education sessions related to Standard 3 include: elder abuse and compulsory reporting, privacy and dignity, grief and loss and Assyrian language skills.

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the recreational activities officers, care recipient/representatives meetings and involvement of family in activities and day to day life in the home. Front office staff are trained in assisting care recipients and their families to familiarise themselves with the service and entry to the home such as through showing them their room and layout of the home. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors are welcomed and encouraged to participate in the life of the home. Care recipients and representatives are satisfied with the way care recipients are assisted to adjust to life at the home and the ongoing support they receive.

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".


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Visitors are encouraged and a variety of entertainers arranged. Care recipients, their representatives and their friends can and do participate in activities. Management actively support care recipients and representatives to


speak openly and participate in the life of the home. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.

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


There are systems to ensure privacy and dignity is respected in accordance with the individual needs of care recipients. The home is an old style home with a number of shared rooms. Staff were seen to use dignity curtains as well as ensuring care and service practices and interactions do not compromise care recipient dignity. The assessment process identifies the care recipient’s preferred name, cultural requirements and how they wish to be interacted with. For example, activity staff respect the wishes of care recipients’ who don’t want to socialise or take part in activities by providing a range of one-on-one contact and engagement. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and staff were able to speak to how this is applied. Confidential information is discussed in private and care recipients’ files seen to be securely stored. Care recipients and representatives said staff treat care recipients with respect and are satisfied with how privacy and dignity is maintained in the home.

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".


Activity staff actively support and encourage care recipients to take part in a range of activities and interests. This was observed during the course of the visit and included exercise programs, music, entertainment (including an Assyrian musician and singer), crafts and dancing. The activity staff assess care recipients for their preference for activities and this is maintained and updated on a regular basis. Formal activity sessions run from Monday to Saturday and a program was seen in place showing a wide range of activities are offered. Activities are evaluated for meaningful engagement and reported on to the management team. One to one activities such as newspaper reading, hand massage are provided and the home has a number of comfortable outdoor landscaped garden spaces for care recipients and their representatives to use. Activities which are ongoing include Assyrian language classes (for staff, care recipients and representatives), Yoga, clowning around, doll therapy, Men’s and Women’s clubs, Happy Hour, footie tipping, painting and colouring. Care recipients and representatives said activities are enjoyable and stimulating and they look forward to being part of them.

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


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates


culturally specific days consistent with the care recipients residing in the home. Orthodox Christmas was celebrated during the week of this audit and an Assyrian Mass took place on the final morning of the visit. Spanish and Italian days occur regularly and staff said they have learned basic words in a range of languages with a high number of staff being fluent in languages other than English. Memorial services are held for care recipients who have passed on. Catholic, Anglican and other services are also held on site. A range of material including books, DVDs and music were seen in a range of languages. Care recipients and representatives said they are very pleased with how the home supports cultural and spiritual needs.

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".


The home’s staff actively encourage care recipients to make decisions in all aspects of the life of the home and support them to exercise choice and control over their lifestyle. The general manager has an open door policy and we observed timely interactions between the management team, staff and care recipients and representatives. Observation of staff practices and staff interviews show care recipients have choices available to them including for example, meals, extra snacks, whether to attend activities, and waking and sleeping times. Care recipients/representatives meetings and surveys occur regularly to enable care recipients and representatives to discuss and provide feedback about the services provided and documentation showed this occurs. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

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".


The home demonstrated care recipients and their representatives have been provided with information about security of tenure and understand care recipient rights and responsibilities. The front office staff provides information on the home and discusses with potential care recipients and their families all aspects of the agreement and the operation and layout of the home. The care recipient handbook and care recipient agreement outlines security of tenure and potential care recipients are supported to consider the contents of the agreement before signing and becoming a resident in the home. Any change of room is only done in consultation with the care recipient and/or their designated representative and seeking their agreement to the change. The Charter of care recipients’ rights and responsibilities was seen to be on display around the home and is available in core languages of the care recipients residing in the home. Care recipients and representatives were very complimentary of the front of the office staff for their support around security of tenure and understanding care recipient rights and responsibilities.


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.




Continuous improvements related to Standard Four include the following:

The home has replaced all the linoleum in care recipient rooms as the floor surface had reached its use by date. This refurbishment was carried out two rooms at a time to minimise disruption and smell. Care recipients and representatives were informed and updated on progress. The contractors were orientated to site and risk assessments conducted to ensure ongoing work, health and safety. Management said the contractors were very sensitive to the needs of care recipients and of the environment they were working in. The base floor had to be resealed before new linoleum was laid. The glue used was powerful and extractor fans were used to minimise the smell. The new flooring has an aspect of wooden panels and is easier to clean and maintain and was seen to have freshened and lightened the appearance of the rooms. The home is planning to replace all the carpet in the other areas.

Following numerous complaints from care recipients and representatives regarding the outsourced laundry service the home decided to review this service. In particular complaints included personal items being washed out of shape or discoloured, going missing or significant delay in the return of laundered items resulting in care recipients running out of clean clothes. The general manager met with the laundry provider and raised these matters with them providing specific examples of complaints and items of clothing which had been ‘ruined’. The result of this meeting was to put the laundry provider on notice of non-conformance of contract. That the laundry provider would reimburse care recipients for the loss and damage to personal items and would work to improve turn-around times for the return of clothes. The general manager said they now have a direct contact at the laundry to manage any issues which arise. Care recipients and representatives were satisfied with this outcome and the general manager said the home is continuing to monitor laundry services.

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”.



Examples of meeting regulatory compliance under this Standard include: The home has a current fire certificate and NSW Food authority certificate. An emergency plan is in place and


was seen to be updated. The home has a work, health and safety committee. Catering staff have completed safe food handling training and staff have completed regular mandatory training under this Standard including fire and emergency and infection control.



The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard Four Physical environment and safe systems.

Examples of recent education sessions related to Standard Four include: fire safety and evacuation, manual handling, infection control, chemical safety and food safety.

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".


The home’s environment, both internally and externally, reflects the safety and comfort needs of care recipients. The home is an older home, observed to be well maintained with a mix of single and shared rooms. The safety and comfort of the living environment is assessed and monitored through feedback from meetings, surveys, incident and hazard reporting, audits and inspections. There are appropriate preventative and routine maintenance programs for buildings, furniture, equipment and fittings. Staff support a safe and comfortable environment through hazard, incident and maintenance reporting processes. Care recipients and representatives interviewed are satisfied the living environment is safe, clean and comfortable.

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 home has processes for identifying any potential and actual hazards. Appropriate goods, equipment and personal protective equipment are available to minimise risk to staff health and safety. There are resident and staff hazard, incident and accident reporting systems. The work, health and safety (WHS) committee meets regularly and minutes are available to staff. WHS is an agenda item on all meetings. Regular staff training is conducted, and supervision provided to ensure staff follow safe work practices in all care and service delivery areas. Staff were observed to carry out their work safely and are satisfied that management is actively working to provide a safe working 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".



There are documented procedures and current plans to manage fire, security and other emergencies including emergency evacuation processes. There are processes in place to ensure regular assessment, identification and reporting of risks, potential and actual, related to fire, security and other emergencies. There are processes to ensure emergency exits are clearly marked and free from obstruction. There are processes for ensuring fire detection and firefighting equipment is fit for purpose, appropriately located, and maintained. There are processes for ensuring all electrical equipment is safe for use and maintained. Staff interviewed are aware of fire safety and emergency procedures. Care recipients report they feel safe and secure in the home.

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


The home has an infection control program in place. This includes audits, ongoing monitoring of infection rates, staff education and policy and procedure relating to infection control. Infection data is collected and analysed internally as well as through the benchmarking program across the homes within the organisation. Infection control procedures such as colour coded equipment; personal protective equipment and monitoring of temperatures were observed. There are processes for the removal of contaminated waste and spills kits and sharps containers are available. Staff interviewed could describe the use of infection control precautions in their work such as the use of personal protective equipment and colour coded equipment.

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".


Hospitality services are provided in a manner which is friendly and responsive to the assessed needs and preferences of the care recipients. The hospitality services are subject to regular monitoring and audits to ensure they are operating at satisfactory levels. Care recipients and their representatives are surveyed about the menu and provide feedback through meetings and directly to staff. The home was observed to have a well organised and effective cleaning system. Laundry services are contracted out and care recipient representatives told us that there had been an improvement in laundry services. One care recipient told us that they were not satisfied with the food available. Feedback to management enacted a process where an item of equipment in the kitchen was replaced with the care recipient expressing their satisfaction with this outcome.


Date post:	13-May-2018
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