arcare overton lea - aged care quality · home name: arcare overton lea racs id: 3578 3 dates of...

Arcare Overton Lea

RACS ID 3578 31-51 Trickey Avenue SYDENHAM VIC 3037

Approved provider: Arcare Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for two years until 17 November 2016.

We made our decision on 13 October 2014.

The audit was conducted on 26 August 2014 to 27 August 2014. The assessment team’s report is attached.

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

Home name: Arcare Overton Lea RACS ID: 3578 2 Dates of audit: 26 August 2014 to 27 August 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Arcare Overton Lea 3578


Introduction

This is the report of a re-accreditation audit from 26 August 2014 to 27 August 2014 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 26 August 2014 to 27 August 2014.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 1998. 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 1997.

Assessment team

Team leader: Marian (Sandra) Lacey

Team members: Leah Kane

Lorraine Davis

Approved provider details


Details of home

Name of home: Arcare Overton Lea

RACS ID: 3578

Total number of allocated places:

120

Number of care recipients during audit:

108

Number of care recipients receiving high care during audit:

N/A

Special needs catered for: N/A

Street: 31-51 Trickey Avenue

City: Sydenham

State: Victoria

Postcode: 3037

Phone number: 03 9449 6100

Facsimile: 03 9390 1453

E-mail address: [email protected]

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Management 6

Registered nurses 5

Care staff 4

Administration assistant 4

Catering staff 3

General practitioner 1

Care recipients/representatives 19

Volunteers 1

Laundry staff 1

Cleaning staff 2

Maintenance staff 1

Sampled documents

Category Number

Care recipients’ files 10

Summary/quick reference care plans 20

Lifestyle care plans 8

Medication charts 12

Personnel files 10

Resident agreements 7

Other documents reviewed

The team also reviewed:

Activity calendars

Call bell response time records

Care recipients’ information package, surveys, handbook and newsletters

Catering records

Cleaning / laundry guidelines and schedules


Comments and complaints register

Competency assessments including clinical, lifestyle and environmental

Consolidated mandatory reporting register

Continence management system

Continuous improvement register and plan

Contractor and supplier lists, letters of compliance

Controlled substance registers

Dietary information for texture modified food and drink

Education records and evaluations

Emergency procedures manual, risk management reports

Employee information guide

Essential safety measures manual, log books and compliance records

Evacuation list

Fire equipment and maintenance records

Food safety program, external food safety audit and certification

Gastroenteritis guidelines

Generic and industry approved risk assessments

Hazard register

Incident reports and consolidated register

Infection control data and analyses

Internal audits

Job descriptions

Maintenance register including reactive and periodical maintenance

Material safety data sheets

Medication imprest stock audit and sign sheet

Meeting minutes

Memoranda

Menu and dietary information


Nursing registration report

Nutritional and hydration assessment of menu

Poisons plan and permit

Policies and procedures (selected)

Position descriptions

Privacy and consent forms

Quality performance planner

Recruitment policies and procedures

Restraint assessments and authorisations

Risk assessments

Rosters and staff replacement records

Selected policies and procedures

Staff and volunteer police check reports and statutory declarations

Staff handbook

Supply ordering forms and records

Workplace health and safety register records and audit results.

Observations

The team observed the following:

Activities in progress

Archiving room

Brochure displays

Chapel

Cleaning in progress

Clinical and general waste management and blood spill kits

Comment/complaint information displays

Complaints and feedback boxes

Equipment and supply storage areas

Evacuation pack


Fire egress and access

Fire safety equipment and signage

Gastroenteritis kits

Hand wash stations and hand sanitiser units

Interactions between staff and care recipients

Internal and external living environment

Key pad access

Lifting machines and mobility aids in use

Living environment

Meal and refreshment service

Medication round (partial)

Noticeboards

Occupational health and safety information displays

Re-accreditation audit notice displayed

Re-accreditation notices in languages other than English

Short observation in sensitive care unit dining room

Staff and care recipient noticeboards with information on display

Staff room

Storage of medications.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

Management actively pursues continuous improvement across all Accreditation standards through “Quality Improvement Request” forms, “Resident/Representative/Visitor Comments” forms, audit results, issues raised at meetings, hazard and incident reporting. Continuous improvement registers are analysed by the home’s management and corporate management for identification of improvement opportunities. Documentation indicates timely actioning of improvement opportunities with appropriate feedback, follow-up, completion and review.

Systems and processes enable and ensure tracking and monitoring of the improvement system by management and at the organisational level. Residents and representatives said they are informed of changes made at the home and are welcome to make suggestions and give feedback. Staff said they are familiar with the system for managing continuous improvement, and are encouraged to communicate suggestions for improvement.

Examples of continuous improvement relating to Standard 1 Management systems, staffing and organisational development include:

A dedicated staffing system was introduced at the organisational level and at the home in the sensitive care unit in September 2013. Rostering ensures the same care staff are allocated to the same residents for at least three days per week to aid in managing the behaviours of residents living with dementia by providing consistency. Dedicated staffing also allows care staff to gain greater insight into the specific behaviour triggers and personal preferences of each individual resident. Management evaluation verifies a decrease in resident behavioural incidents in the sensitive care unit and staff and family members have provided positive feedback.

A new electronic care document management system was introduced at the home in Mach 2014. The system allows for the development of more detailed resident care plans as it replaces care plans that were not adequate to document resident care needs and preferences. Evaluation demonstrates greater staff satisfaction with the electronic system as resident care needs are more precise with streamlining of the auditing system through the scheme’s electronic search function.


1.2 Regulatory compliance

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

Team’s findings


Management and the organisation have systems to identify and ensure compliance with relevant legislation, regulatory requirements and guidelines. The organisation receives regulatory compliance information and changes from update services including peak, industry and government bodies and internal legal staff. Information and changes are actioned and disseminated by senior staff through the organisation’s and the home’s information systems and processes. Regulatory compliance is a standing agenda item for staff meetings and staff have access to information through the organisational intranet.

Regular audits and staff training monitor and maintain compliance and regular policy reviews and updates occur.

Examples of regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

A system for ensuring the currency of police certificates, statutory declarations and visas as appropriate for staff, volunteers and contractors

Annual renewal of professional registrations

Notification to staff, residents and representatives of re-accreditation site audits

Confidential documents are stored and destroyed securely

Information is available to residents and representatives on external complaints and advocacy services.

A continuous improvement plan.

1.3 Education and staff development

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

Team’s findings


Management and staff have the skills and knowledge to perform their roles effectively. Corporate support is provided enabling the home to operate a projected in-service education planner, which includes topics across the Accreditation Standards and is flexible to include other education needs if the need arises. Mandatory and other relevant topics are delivered through in-service, self- paced learning packages and opportunistic learning sessions.

Attendance records are monitored, sessions are evaluated for effectiveness and staff undertake appropriate competencies to ensure their skills are maintained. Management support staff attendance at seminars, conferences and workshops, and encourage staff to


progress their career pathways. Staff said they are satisfied with the education opportunities offered to them.

Examples of education relating to Standard 1 Management systems, staffing and organisational development include:

assessing the standards

leadership skills for supervisory staff

legal aspects of documentation

professional behaviours in the work place.

1.4 Comments and complaints

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

Team’s findings


Management has systems, which ensure residents and representatives access to internal and external complaints mechanisms. Residents and representatives said they feel comfortable raising issues of concern with staff and management and any complaints or issues are actioned in a timely manner. Management captures complaints and comments through ‘Resident/Representative/Visitor Comments’ forms, resident meetings, audits and verbal feedback which is recorded in the comments and complaints register for analysis and trending. Information in the resident information pack outlines the system for expressing any comments and complaints and includes contact details for external complaints mechanisms.

Management displays brochures including external complaints bodies in public areas at the home.

1.5 Planning and leadership

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

Team’s findings


Information displays and documentation including resident and staff handbooks consistently document the home and the organisation’s values. These statements articulate the home’s commitment to providing high quality care and services responsive to the needs of residents through relationships, uniqueness, partnerships and flexibility.


1.6 Human resource management

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

Team’s findings


Management ensures staff are appropriately skilled and qualified and in sufficient numbers to ensure delivery of appropriate care and services to residents. Organisational policies and procedures guide staff recruitment, orientation, rostering, staff replacement and management processes. Management develop rosters and review staffing levels in response to residents’ changing care needs. Staff said they have access to information about their roles and responsibilities including position descriptions and confirm the staffing levels are flexible and appropriate. Residents and their representatives are satisfied with staffing levels and staff knowledge.

1.7 Inventory and equipment

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

Team’s findings


Management ensures there are appropriate and sufficient stock supplies and equipment to meet residents’ needs. Allocated staff order goods through their preferred suppliers, ensuring effective ordering and stock rotation processes are in place. Management selects new equipment based on staff input and residents’ needs. Staff trial or rent new equipment before purchase and management ensures staff are trained in the use of new equipment.

Management has an effective maintenance request system for unexpected equipment breakdown, with access to external contractors as needed. A preventative maintenance schedule ensures equipment is fit for purpose. Staff, residents and representatives stated there are appropriate supplies of goods and equipment to meet resident needs.

1.8 Information systems

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

Team’s findings


Management ensures effective information management systems are available and staff have access to current policies and clinical and other relevant resource documentation. Information is disseminated at shift handovers and by memoranda, meetings, newsletters the intranet and text messages. There are processes for document review and control, computers are password protected and back up of electronic information is done off site.

Secure storage, archiving and destruction of confidential documents processes ensure regulatory compliance requirements are met. Staff, residents and representatives confirmed


they are satisfied with the level of information provided including opportunities for feedback and communication with management.

1.9 External services

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

Team’s findings


The organisation manages the home’s external services including local contractors. Systems and processes ensure these services meet the home’s needs and quality goals. These include regular organisational contract reviews and contractor performance monitoring through the home’s audits, stakeholder feedback and regular management reports and meetings.

Preferred repairer/suppliers lists are in place with service agreements and processes to ensure the on-going maintenance of regulatory requirements. A contractor sign- in and identification process is maintained. Residents and staff said they are satisfied with the home’s externally sourced services.


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.



Team’s findings


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

Examples of continuous improvement relating to Standard 2 Health and personal care include:

Organisational management recognised historically care staff did not have adequate training in managing residents living with dementia. Management arranged for all care staff working in the sensitive care unit to undertake formalised Certificate III and in some cases Certificate IV in dementia management through a registered training organisation. Certificates were completed by March 2014. Feedback from staff in the evaluation process indicates high level of satisfaction with the training and increased understanding of dementia. Incident records verify a decrease in resident behaviours with no incidents of resident-to-resident incidents in the sensitive care unit in the last four months.

Management instigated a continuous improvement initiative for any residents who enter the home with a history of behavioural issues, or existing residents who develop behavioural issues. Referrals are made to a service provider who specialises in developing strategies for the management of residents with challenging behaviours who visit the home and work with staff to support them in managing the displayed behaviours. Evaluation indicates staff are more confident and feel more supported in managing challenging behaviours, and incidents have decreased.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about management’s regulatory compliance system and processes.

Examples of regulatory compliance at the home relating to Standard 2 Health and personal terms include:

Maintenance and monitoring of appropriately qualified staff including nursing registrations.

Medication management including a poisons plan and permit for imprest medications in the Argyle unit.

Secure storage of medication.

Processes for reporting missing residents including notification processes.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education and staff development systems and processes. There are systems and processes to monitor the knowledge and skills of management and staff to enable them to perform their roles effectively in relation to health and personal care.

Examples of education relating to Standard 2 Health and personal care include:

assessing the standards

leadership skills for supervisory staff

legal aspects of documentation

professional behaviours in the work place.


2.4 Clinical care

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

Team’s findings


Management demonstrate residents receive the care appropriate to their needs and preferences. Staff assess all residents when they first enter the home for their care needs. Care plans are developed based on the assessed needs of the resident and strategies are developed to ensure the needs are met on a daily basis. There is development of interim care plans until the initial assessment time elapses and a full care plan is completed. Staff have easy access to care plans and they keep residents’ general practitioners informed of changes to residents’ care needs. Qualified staff evaluate residents’ care. Residents and representatives said they are satisfied with the care provided to residents by staff.

2.5 Specialised nursing care needs

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

Team’s findings


Management demonstrate there are appropriately skilled staff to meet residents’ specialised nursing care requirements. Qualified staff met residents’ assessed needs for specialised nursing care in the prescribed manner pertaining to clinical requirements. Staff assess all residents for any specialised nursing needs upon entry to the home and as required thereafter. Consultation with residents, representatives and health professionals inform the development of care plans. Nursing staff have appropriate qualifications relative to the tasks they perform.

Care plans describe specific needs, including any specialised equipment and general practitioners’ instructions. Residents and representatives said residents receive clinical care according to residents’ needs and preferences.

2.6 Other health and related services

This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the resident’s needs and preferences”.

Team’s findings


Referrals are arranged for appropriate health specialists in accordance with assessed needs and preferences. Management demonstrate residents are referred promptly to specialists as needed and as preferred. There are assessments of residents for their health and related services when first entering the home and at regular stages thereafter. There are mechanisms for urgent referrals and provisions to reduce waiting times for services. The home provides information about health professionals for residents and representatives to make informed choices. Residents and representatives said staff arrange for referrals for residents to appropriate specialists as needed and as preferred.


2.7 Medication management

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

Team’s findings


Management demonstrate care recipients’ medication is managed safely and correctly. Staff comply with the medication management system. Management demonstrate the medication management system is safe, according to relevant legislation, regulatory requirements, professional standards and guidelines. Qualified staff administer medications to residents.

The storage of medication includes a level of security appropriate to the medication and circumstances, including refrigeration and documenting dates of opening. There is a process for residents who choose to self-administer medications to have appropriate assessments and authorities for their ongoing ability to self-administer. Residents and representatives said they are satisfied medication management is safe and correct.

2.8 Pain management

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

Team’s findings


Management demonstrate the pain management approach ensures all care recipients are as free as possible from pain. When residents first enter the home, staff assess them for pain, through a variety of industry-approved methods. Medications administered for pain are evaluated. Qualified staff develop pain management programs, reflecting residents’ needs and preferences regarding pain. Policies reflect the requirement for regular assessments for pain, determining and documenting type, source, intensity, frequency, pattern and other factors, for effective development of a pain management program. Residents and representatives said they are satisfied with the home’s pain management system for residents.


2.9 Palliative care

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

Team’s findings


Management confirmed staff practices maintain the comfort and dignity of residents who are terminally ill. Staff ensure assessment for palliative care forms part of an ongoing documented assessment process of residents’ health status. This includes consultation with stakeholders, medical officers and other health professionals regarding palliative care needs and preferences. Documentation confirmed staff record and respect residents’ terminal wishes.

Palliative care plans reflect a multidisciplinary approach, including the provision of emotional and spiritual support to residents and representatives and any specialised equipment and supplies as required. Residents and representatives said the home’s practices maintain the comfort and dignity of residents who are terminally ill.

2.10 Nutrition and hydration

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

Team’s findings


Management demonstrate residents receive adequate nutrition and hydration. Staff assess all residents on entry for their nutrition and hydration needs and thereafter on a regular basis.

Development of care plans is in consultation with residents and representatives using a systematic approach, involving appropriate professionals as required. Staff ensure documentation of food allergies, regular monitoring of body weight and food and fluid intake to ensure residents receive appropriate levels of nutrition and hydration. Increased monitoring of identified residents at risk of poor nutrition occurs and may result in the provision of texture- modified diets or thickened fluids. Residents and representatives are satisfied with the home’s approach to meeting residents’ nutrition, hydration and associated support needs.

2.11 Skin care

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

Team’s findings


Management, staff and documentation confirmed the home’s practices maintain care recipients’ skin integrity consistent with their general health. Staff identify residents at risk of impairment to skin when first entering the home and during the development of care plans. Care plans reflect specific directions for maintaining and improving skin integrity with processes to ensure appropriate available equipment as required. Staff make referrals to relevant professionals as needed, including wound management plans if required. Qualified staff evaluate care plan interventions ensuring skin care delivery is meeting the residents’ skin


care needs. Residents and representatives said they are satisfied with the care provided in relation to residents’ skin integrity.

2.12 Continence management

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

Team’s findings


The continence management practices are effective in meeting residents’ needs. Staff asses all residents for their continence needs when first entering the home and create an interim care plan. Information gathering includes detailed histories including symptoms, possible triggers and conditions affecting continence and medication use in care plan development.

Staff put in place strategies for maintaining or restoring residents’ continence where possible. There is consultation with residents and representatives regarding continence needs and preferences. Residents and representatives said they were satisfied with the methods used in meeting residents’ individual continence needs.

2.13 Behavioural management

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

Team’s findings


Management’s approach to behavioural management care planning is effective in meeting residents’ needs. Staff assess all residents for challenging behaviours and instigate referrals to specialist services to gain a diagnosis and/or appropriate treatment. Staff develop care plans in consultation with residents and representatives and any health professional as required.

Staff are educated on appropriate methods for managing residents with challenging behaviours, including strategies to reduce behaviours. Staff practices are consistent with the planned behavioural management strategies. Residents and representatives said they are satisfied with the home’s approach to managing residents’ challenging behaviours.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings


Management and staff demonstrate plans of care optimise residents’ level of mobility and dexterity. Qualified staff assess all residents for their mobility, dexterity and rehabilitation requirements when first entering the home. Qualified staff complete falls risk assessments, assess assistive devices and develop falls prevention program. Staff make available mobility aids for residents to use only after appropriate assessment of the equipment. Care plans are regularly evaluated and updated. There are rehabilitation strategies as appropriate to each


resident’s needs including referral to specialists as required. Residents and representatives said they are satisfied with the home’s approach to optimising residents’ mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


Management demonstrate the maintenance of residents’ oral and dental health. Staff assess all residents for their oral and dental care when first entering the home. Staff identify eating or swallowing difficulties or poor oral health and make appropriate health professional referrals as required. Care plans include details about daily oral care, dental appointments, increased or decreased salivary flow and strategies for maintaining the oral hygiene of residents living with dementia, including regular replacement of toothbrushes. Residents and representatives are satisfied with the approach to managing residents’ oral and dental care.

2.16 Sensory loss

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

Team’s findings


Management demonstrate its approach to residents’ sensory losses is effective in identifying and managing residents’ needs. When residents first enter the home, staff assess residents’ sensory losses. Care plan development includes consultation with residents and representatives. Care delivered is consistent with plans to effectively manage sensory loss. Qualified staff evaluate care plans on a regular basis and care plans detail assistive devices required. Residents and representatives said they are satisfied with the approach to managing residents’ sensory losses.

2.17 Sleep

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

Team’s findings


Management and staff practices demonstrate effective strategies that enable residents to achieve natural sleep patterns. Staff assess all residents on entry to the home for their sleep requirements. Development of care plans includes consultation with residents and representatives. The assessment process includes identification of sleep patterns and habits, including living environment issues and the impact on natural sleep. There is identification of appropriate sleep aids, in consultation with medical officers, resulting in implementation of effective interventions. Management consider environmental factors to ensure residents can achieve natural sleep patterns. Residents and representatives said residents are able to achieve a good night sleep.


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.



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about management’s continuous improvement system and processes.

Examples of continuous improvement relating to Standard 3 Care recipient lifestyle include:

Lifestyle staff recognised an improvement opportunity to increase resident exercise and relaxation and introduced Tai Chi as a new activity. Management sourced a Tai Chi master who attends the home one day per week to undertake the class. The master has also developed a DVD for staff to use on other days to keep residents engaged in Tai Chi. Evaluation demonstrates the activity is well attended, residents and representatives have provided positive feedback and staff have also joined the activity with residents.

Staff who attended a workshop on the use of iPads and tablets in residential aged care through Alzheimer’s Australia, requested the purchase of tablets to engage residents in activities to promote cognitive ability. Management purchased three tablets and downloaded the appropriate applications. Evaluation indicates the activity has received positive feedback from residents and some residents have requested their families purchase a tablet for their personal use.



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

Team’s findings



Examples of regulatory compliance at the home relating to Standard 3 Care recipient lifestyle include:

There are appropriate systems to record incidents of elder abuse and mandatory reporting matters.

Privacy and dignity policies and practices.

Security of tenure, residents’ rights and responsibilities is contained in handbooks and agreements.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education and staff development systems and processes. There are systems and processes to monitor the knowledge and skills of management and staff to enable them to perform their roles effectively in relation to care recipient lifestyle.

Examples of education relating to Standard 3 Care recipient lifestyle include:

customer service

privacy and dignity

resident’s rights

sensitive care values and relationship.


3.4 Emotional support

This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".

Team’s findings


Residents receive support in adjusting to life in the new environment of the home. Staff identify residents’ emotional needs upon entry to the home and on an ongoing basis. Staff encourage residents to decorate their rooms with personal items. Family members are welcomed and invited to participate during the settling in phase and on an ongoing basis. Assessment of residents’ emotional profile, current situation and needs occurs and lifestyle activities are individualised for residents’ enjoyment to support emotional needs. Volunteers and lifestyle staff visit isolated residents to give them comfort and support. Residents are satisfied with the emotional support provided by staff to promote their well-being.

3.5 Independence

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

Team’s findings


Residents’ independence is fostered and encouraged. Assessment of independence includes the resident’s physical, cognitive, emotional, social and financial status and any subsequent impact. Staff assist residents with communication, mobility and cognitive difficulties to maintain independence according to their preferences. Representatives, friends and volunteers are welcome to assist residents in maintaining their individual interests, in participating in outings, controlling their financial matters where appropriate, and maintaining their civic responsibilities. Continued links with local organisations including churches and local shopping activities are encouraged and residents attend many activities and events held within and outside the home. Residents said they are assisted to maintain their independence and the opportunity to continue friendships and links with community groups.

3.6 Privacy and dignity

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

Team’s findings


Residents said management and staff recognise and respect their right to privacy, dignity and confidentiality. Staff and volunteers are provided with information relating to confidentiality and respect for residents’ privacy and dignity through orientation, meetings, education and policy. Staff described ways to promote residents’ privacy and dignity such as knocking before entering rooms, addressing residents by their preferred names and ensuring privacy when delivering personal care. Files containing residents’ personal information are stored in locked areas with access limited to authorised staff and visiting health professionals. Electronic


information is password protected with limited access according to roles. Residents said staff are respectful of their privacy and dignity at all times.

3.7 Leisure interests and activities

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

Team’s findings


The lifestyle program supports residents to participate in a wide range of interests and activities according to their choice and abilities. Following entry to the home, lifestyle staff complete intense profiles of the resident’s life history, social and leisure preferences and interests and important events. In consultation with residents an individualised care plan is developed. Care plans are updated regularly in response to residents’ changing preferences and needs. An activity calendar is on display and staff assist residents to participate in activities. A wide range of activities allowing for cultural, cognitive and individual interests is offered. Volunteers assist and support the lifestyle program. Evaluation of the program occurs through observation, attendance records, newsletters, meetings, resident consultation and verbal feedback. Residents said they are satisfied with the activities offered, the lifestyle program is well-resourced and provides results for residents.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


Residents’ individual cultural, spiritual beliefs and background are respected and fostered. On entering the home staff discuss residents’ cultural, spiritual and related dietary needs documenting and communicating this information to relevant staff or work areas. Residents are supported to maintain contact with cultural groups as their preference. Cultural resources are available to assist staff in fostering and valuing residents’ customs. Culturally specific and spiritual days reflective of residents are celebrated. Spiritual services are offered for a number of denominations on a monthly basis and a chapel is available for private worship.

Residents stated they are satisfied with the support provided to enable care recipients to maintain their cultural and spiritual lives.


3.9 Choice and decision-making

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

Team’s findings


Residents or their representatives make decisions and exercise choice and control over lifestyle, services and care. Assessments, care plans and records document choices and preferences and are reviewed regularly by clinical and lifestyle staff. Residents have input into the services they receive including personal care, choice of general practitioner, rising and retiring times, food choices and their level of participation in activities. Residents have the opportunity to provide input regarding the care and services the home provides via the complaints and suggestion systems. Residents said they are involved in choice and decision making and are encouraged to express their opinions and comments through meetings and face to face feedback.

3.10 Care recipient security of tenure and responsibilities

This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".

Team’s findings


Management demonstrate they provide information on security of tenure to residents and representatives during the initial enquiry stage with corporate support and on entry to the home. The residential agreement and resident handbook includes information on the home’s internal security of tenure provisions and resident’s rights and responsibilities. Consultation regarding relocation occurs with the resident and or their representative if the need arises.

Residents said they felt secure living in the home and had an understanding of residents’ rights.


Standard 4 – Physical environment and safe systems

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about management’s continuous improvement system and processes.

Examples of continuous improvement at the home relating to Standard 4 Physical environment and safe systems include:

Management introduced a resident food focus forum in November 2013 in response to requests from residents who wanted to specifically discuss food related issues. The forum was held monthly and attended by the home’s manager, lifestyle staff and catering staff. Residents discussed their individual likes and dislikes which enabled the catering staff to increase the individualisation of resident meals. Evaluation indicates a high level of satisfaction with this forum and addressing issues raised at the forum, and residents decided to cease the forum in June 2014, to be reconvened in the future if required.

Management recognised the sensitive care unit was too large and was inadequate to manage residents with challenging behaviours. Management physically split the unit into two 20-bed units, separating the dining rooms with a large aquarium. Evaluation demonstrates positive feedback from staff and representatives regarding the peacefulness of the environment and behavioural incidents have decreased.



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

Team’s findings



Examples of regulatory compliance at the home relating to Standard 4 Physical environment and safe systems include:

An annual essential safety measures report is provided by an external contractor.

Fire and emergency equipment is maintained in accordance with accepted requirements.

Occupational health and safety systems including an occupational health and safety representative and occupational health and safety information provided to staff.

Infection control guidelines.

A food safety program with current kitchen external third party audit and certification.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information regarding the home’s education and staff development systems and processes. Management has implemented systems and processes to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to the physical environment and safe systems.

Examples of education relating to Standard 4 Physical environment and safe systems include:

fire and emergency training

food hygiene

infection control

manual handling.


4.4 Living environment

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

Team’s findings


Management demonstrate it is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. The home provides accommodation in spacious single rooms with private bathroom facilities. Residents are encouraged to personalise their rooms with their belongings. Management relies upon regular inspections, audits, incident and hazard analysis, and feedback mechanisms to monitor the provision of a safe and comfortable living environment. Private and communal areas are available inside and outside which we observed to be secure, clean and well maintained. Further, a specific unit accommodates individuals living with dementia, which we observed to be calm and quiet with lifestyle and care staff delivering regular activities. Residents and representatives said they are satisfied with the environment of the home and residents report they feel safe and comfortable.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


Management demonstrates a safe working environment in line with regulatory requirements. Organisational occupational health and safety systems and processes in the home include an appropriately trained representative, occupational health and safety is a standing agenda item at staff meetings, regularly reviewed policies and procedures, occupational health and safety information displays, incident/ hazard management, audits and a return to work program.

Documentation confirms stakeholder input and regular organisational reporting, monitoring and data analysis. Initial and on-going occupational health and safety training is mandatory for all staff. Chemicals are safely and securely stored and current material safety data sheets available. Interviews and observations confirm staff awareness of and satisfaction with occupational health and safety and the maintenance of a safe working environment.


4.6 Fire, security and other emergencies

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

Team’s findings


Management have implemented systems that staff follow to ensure the provision of a safe environment and one that minimises the risk of fire and other emergencies. Exit signs, clear egress routes, evacuation maps and emergency plans are located throughout the home.

Approved professionals test fire alarm systems and fire equipment on a regular basis. Staff are orientated to fire and emergency procedures on induction and annually thereafter. Staff can access evacuation kits that include evacuation equipment and current resident lists.

Emergency and disaster management plans also guide staff in responding to critical incidents. Security systems minimise the risk of unauthorised entry and ample car park facilities provide easy and safe access to the home for staff and visitors alike. Residents and representatives report the home provides a safe and secure environment.

4.7 Infection control

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

Team’s findings


There is an effective infection control program to identify and contain infectious outbreaks. Organisational policies and procedures are available for staff and collation, analysis and trending of residents’ infections occurs. Guidelines direct the management of outbreaks such as gastroenteritis, influenza and pandemics. Outbreak kits, sharps containers, personal protective clothing and hand hygiene facilities are available. Management promote annual influenza vaccinations for residents. Clinical, catering, cleaning and laundry procedures incorporate infection control guidelines as required. Staff said they receive infection control training and identified measures to minimise infection relevant to their work area.

4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Hospitality services enhance residents’ quality of life and the staff working environment. Meals are prepared on-site. Kitchen staff follow an approved food safety plan and the kitchen has current external registration. Documented processes for updating and communicating changes to residents’ dietary needs and preferences guide staff practices. Cleaning staff follow schedules to ensure regular cleaning of residents’ rooms and common areas and demonstrate effective cleaning practices. The laundry has collection and distribution processes to ensure the prompt return of residents’ clothing that follow appropriate infection control processes. An approved external provider launders linen. Staff label clothing and there is a minimal amount


of lost clothing. Management ensure staff receive chemical and infection control training and regularly audit hospitality services. Residents said they are satisfied with the quality of hospitality services at the home.

arcare overton lea - aged care quality · home name: arcare overton lea racs id: 3578 3 dates of...

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