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Braemar Village

RACS ID 7077 24-32 Charsley Street WILLAGEE WA 6156

Approved provider: Commissioners of the Presbyterian Church in WA

Following an audit we decided that this home met 32 of the 44 expected outcomes of the Accreditation Standards. We decided to vary this home’s accreditation period.

This home is now accredited until 24 June 2015. We made our decision on 24 December 2014.

The audit identified numerous failures to meet the Accreditation Standards.

We decided that the extent of these failures constituted a serious risk to the safety, health and well-being of care recipients. We reported our findings to the Department of Social Services which imposed sanctions on the home. These sanctions included requiring the home to contract a consultant nurse adviser to more urgently address required improvements in care for care recipients. During the period of serious risk, our assessors continued to visit the home daily to monitor care for care recipients and steps taken by the home to resolve the risk to care recipients.

Following the audit, Braemar Village implemented a number of actions to resolve the serious risk to care recipients and to address the extensive failure to meet the Accreditation Standards.

After considering the information submitted by the approved provider including the extensive work undertaken since the audit in November, we found that at the time of our decision in December, the home met 32 of the 44 expected outcomes.

In determining the period of accreditation, we considered the home’s recent failure to meet the Accreditation Standards, and the actions taken by the home to improve care and services to care recipients.

The decision maker’s view differed from the assessment team’s recommendation and found the home does not meet expected outcomes 1.1 Continuous improvement and 1.2 Regulatory compliance, and this is based on the lack of evaluation of the effectiveness of systems and processes in relation to these expected outcomes.

However, the decision maker found the home now met the following eight expected outcomes: 1.7 inventory and equipment

2.3 and 4.3 Education and staff development

2.10 Nutrition and hydration

3.1 and 4.1 Continuous improvement

4.4 Living environment

4.5 Occupational health and safety.

The period of accreditation will allow the home the opportunity to demonstrate the recent improvements in care and services are sustainable, and will mean the home will be assessed against the Accreditation Standards at a full audit within a relatively short period of time.

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

The audit was conducted on 24 November 2014 to 8 December 2014. The assessment team’s report is attached.

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

ACTIONS FOLLOWING DECISION

Since the review audit decision, we have undertaken assessment contacts to monitor the home’s progress and found the home has rectified the failure to meet the Accreditation Standards identified earlier. This is shown in the table of Most recent decision concerning performance against the Accreditation Standards.

Important information:

This home had sanctions applied by the Department. For information concerning the sanctions click here.

Home name: Braemar Village RACS ID: 7077 3 Dates of audit: 24 November 2014 to 8 December 2014

Most recent decision concerning performance against the Accreditation Standards

Since the review audit decision we have conducted an assessment contact. Our latest decision on 25 March 2015 concerning the home’s performance against the Accreditation Standards is listed below.

Standard 1: Management systems, staffing and organisational development

Expected outcome Quality Agency’s latest

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


decision




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


decision




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


decision




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

Braemar Village 7077


Introduction

This is the report of a review audit from 24 November 2014 to 8 December 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to assess the quality of care and services 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 make any changes to its accreditation period.

Assessment Team’s findings regarding performance against the Accreditation Standards

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

26 expected outcomes

The information obtained through the audit of the home indicates the home does not meet the following expected outcomes:

1.3 Education and staff development

1.4 Comments and complaints


1.6 Human resource management

1.7 Inventory and equipment

1.8 Information systems


2.4 Clinical care

2.7 Medication management

2.8 Pain management


2.12 Continence management

3.1 Continuous improvement




4.5 Occupational health and safety

4.7 Infection control

4.8 Catering, cleaning and laundry services.


Scope of audit

An assessment team appointed by Quality Agency conducted the review audit from 24 November 2014 to 08 December 2014.

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

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

Assessment team

Team leader: Alison James

Team member: Renee Sweet

Approved provider details


Details of home

Name of home: Braemar Village

RACS ID: 7077

Total number of allocated places:

52

Number of care recipients during audit:

51

Number of care recipients receiving high care during audit:

42

Special needs catered for: Nil specified

Street: 24-32 Charsley Street

City: WILLAGEE

State: WA

Postcode: 6156

Phone number: 08 9338 8801

Facsimile: 08 9338 8828

Email address: Nil

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


Audit trail

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

Interviews

Category Number

Manager care service 1

Clinical nurse 1

Enrolled nurse 1

Care staff 5

Executive manager corporate services 1

Manager support services 1

Assistant business manager 1

Executive manager of care and strategies 1

Physiotherapist 1

Therapy staff 1

Occupational therapist 1

Care recipients/representatives 16

Administration assistant 1

General practitioner 1

Maintenance staff 1

Catering staff 2

Laundry staff 1

Cleaning staff 2

Volunteers 1


Sampled documents

Category Number

Care recipients’ assessments, files and care plans 17

Care recipient medication competencies 13

Care recipient continence aid allocation wardrobe cards and aids 6

External contractors agreements 3

Personnel files 8

Medication charts, signing sheets and profiles 6

Care recipients’ dietary meals and drinks assessments 11

Care recipients’ physiotherapy records including one to one attendance records

6

Care recipient agreements 5

Other documents reviewed

The team also reviewed:

Activities program

Archive register

Cleaning schedules (kitchen, satellite kitchen and care recipients’ rooms)

Clinical monitoring records and treatment charts

Comments, compliments and complaints file

Communication books and diaries

Corrective and preventative maintenance records

Family conference electronic records

Fridges, cool room, freezer and meal temperature records

Hazards file

Incidents and accidents

Inspection, testing, and maintenance records for fire and emergency equipment

Internal and external audits file and resident surveys (x 4)

Mandatory reporting file

Medication refrigerator temperature and equipment monitoring records


Memoranda and newsletters

Menus and care recipient dietary information

Minutes of meetings

Plan for continuous improvement

Police certificate register, professional registrations and visa requirements

Policies, procedures and flowcharts

Position descriptions and duty statements

Resident and staff information handbooks

Safety data sheets

Sign-in/out book

Staff rosters

Staff training matrix and attendance records

Therapy statistics.

Observations

The team observed the following:

Access to internal/external complaints information and locked suggestion boxes

Activities in progress

Archive room

Charter of residents’ rights and responsibilities and mission, vision and core values statement displayed around home

Chemical storage areas

Cleaning in progress

Equipment and supply storage areas (including outbreak kits, paper products, continence aids, linen storage and personal protective equipment, pan room, chemical storage and sharps disposal and waste management areas)

External and internal living environment and care recipients’ appearance

Fire-fighting equipment including extinguishers and fire blankets, sprinklers, fire panel, site evacuation plans

Interactions between staff and care recipients

Kitchens and laundry


Meals and refreshment services

Noticeboards with displayed information including Quality Agency visit

Short group observations of care recipients in dining area

Storage and administration of medications

Tagged electrical equipment

Utility rooms

Wound care dressing products and trolley.


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.


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

Team’s findings

The home meets this expected outcome

The home has a framework for continuous improvement and encourages staff participation. The management team was able to describe a range of improvements across some of the Accreditation Standards. These improvements have recently been implemented. Information is not gathered on a regular basis or transferred to the home’s continuous improvement plan, actioned or evaluated. Progress of continuous improvement is not discussed at care recipient/representative meetings or staff meetings. Staff reported they are encouraged to participate in the home’s continuous improvement process.

Examples of improvements undertaken in the last twelve months in relation to Standard 1 – Management systems, staffing and organisational development are described below.

The executive management team identified complaints at the home were not being dealt with in a timely manner. In response, the executive team has reviewed the complaints process. The new process includes responding to complaints within three days and feedback upon completion of the investigation to the originator. The management team reported this is a new initiative, and evaluation will be undertaken at a later date.

It was identified via a hazard form that staff in the opposing wings of the home could not contact each other. In response, new lightweight DECT phones plus two extra DECT phones were purchased. Staff reported this allows them to call staff for assistance particularly after hours. The management team reported this will be evaluated at a later date.


1.2 Regulatory compliance

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

Team’s findings


The organisation has systems and processes to identify compliance with all relevant legislation and regulatory requirements. The home is advised of legislative changes to existing regulations through peak bodies, government departments and other regulatory bodies. However, changes to legislation and existing information is not consistently updated or disseminated by the facility manager and information is not provided to relevant staff. The home does not monitor their systems and processes to ensure compliance. The home monitors police certificates and visas for new and current staff.

1.3 Education and staff development:

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

Team’s findings

The home does not meet this expected outcome

The home was unable to demonstrate management and staff have appropriate knowledge and skills to perform their roles effectively. Recruitment processes require care staff to have the basic skills for the position applied for. Education is not provided to all staff relevant to all Accreditation Standards. Effectiveness of these sessions are not consistently monitored or evaluated. Monitoring of staff performance has not been undertaken as per the home’s policies and procedures. Staff reported, and documentation reviewed confirmed, staff have limited education and training sessions in relation to topics relevant to the Accreditation Standards. Care recipients and representatives reported dissatisfaction with the skills and knowledge of management and some staff.

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


The home does inform care recipients, representatives and other interested parties about the internal complaints mechanisms. Care recipients and representatives are provided with information regarding the internal and external complaints mechanisms via the resident information booklet. The home displays information regarding the external complaints process on noticeboards and near the activity room and there is a locked box for anonymity. The home does not analyse or trend complaints or identify opportunities for improvement.

Care recipients/representatives reported they are not aware of the external complaints and advocacy processes and that internal complaints are not responded to by management in a timely manner.


1.5 Planning and leadership

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

Team’s findings


The organisation displays its mission, vision and values statements and these are consistently documented in the resident and staff information booklets. These statements incorporate the home’s commitment to provide excellence in care, accommodation and support to enhance the quality of life for care recipients. Staff reported the organisation’s mission, vision and values are discussed at orientation.

1.6 Human resource management

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

Team’s findings


The home was unable to demonstrate there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the Accreditation Standards. The home does not monitor staff performance as per the home’s policies and procedures. Limited training and education has been provided to staff. Staff are not consistently replaced when absent from work. Staff without appropriate skills or qualifications give medications and deliver care after hours and weekends. Staff performance is not monitored annually as per the home’s policies and procedures. Eight of 14 care recipients and representatives reported there are not always enough staff.

1.7 Inventory and equipment

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

Team’s findings


The home has processes to facilitate the purchase, use, storage, maintenance, and management of goods and equipment required for quality service delivery. Reporting of maintenance issues ensures equipment is checked and serviced when required by external contractors. However, regular audits and environmental inspections are not undertaken to ensure that goods and equipment are maintained at sufficient levels, correctly maintained, stored, or used safely and effectively. Stock items are rotated. Chemicals are not stored with relevant safety information. Staff, care recipients and representatives reported dissatisfaction with the availability and suitability of goods and equipment.


1.8 Information systems

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

Team’s findings


The home does have information management systems in place. However, these are not effective. The home’s current information system does not assist the home to identify and use key information and measures required to ensure quality care for care recipients.

Systems have not been maintained to collect, record, analyse or action information on the home’s performance. Staff do not have access to accurate and up-to-date information to help them perform their roles. Care recipients and representatives reported they are generally satisfied with the information provided.

1.9 External services

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

Team’s findings


The home has processes to ensure the provision of externally sourced services meets the home’s quality needs and service requirements. The organisation identifies externally sourced services in response to regulatory requirements, licensing and specified care services, and the home accesses preferred suppliers. Management and relevant staff monitor the level of performance with external services, and stakeholders use feedback mechanisms to raise issues about the quality of external services provided as appropriate. The organisation’s management reviews the services required, and the quality goals for external service providers in response to changes. Care recipients, representatives and staff reported satisfaction with 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


See Continuous improvement in Standard 1 – Management systems, staffing and organisational development for an overview of the home’s continuous improvement process.

An example of a continuous improvement that has recently been implemented in relation to Standard 2 – Health and personal care is described below.

Following the retirement of the previous executive manager of care services and a restructure of the executive management team, it was identified clinical support at the home could be improved. As a result, a clinical nurse consultant was employed approximately six weeks ago. The management team reported this will be evaluated at a later date.


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


The home has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines in relation to care recipients’ health and personal care. However, this system is not effective. Qualified staff oversee the initial and ongoing assessments of care recipients. Professional qualifications for nursing staff and other health professionals are monitored. The home monitors changes in legislation, but does not disseminate information to relevant staff.



Team’s findings


Refer to Education and staff development in Standard 1 – Management systems, staffing and organisational development for an overview of the home’s education and staff development.


2.4 Clinical care

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

Team’s findings


Management was unable to demonstrate care recipients receive care appropriate to their needs and preferences. Staff have limited access to policies and procedures to assist them to deliver care. The management team reported care recipients entering the home are admitted via a paper-based system, as the current electronic system is not in working order. The home’s policies and procedures state care plans should be reviewed six-monthly. Care plans are not reviewed in accordance with the home’s policies and procedures, or in response to care recipients’ changing needs. Information in care plans is not correct, which leads to staff not providing optimum care. Care recipient accidents and incidents are not consistently reported, or appropriate measures taken to prevent reoccurrence. Clinical data is collected but not trended or actioned. Care recipients and representatives reported dissatisfaction with the clinical care of care recipients.

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 is able to demonstrate care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. However, specialised nursing care need of care recipients requiring blood pressure and diabetes management do not have identified parameters set by the general practitioner. Staff reported and documentation showed, staff have limited opportunities for ongoing training and education. Care recipients and representatives reported they are dissatisfied with the knowledge and skills of the management and staff.

2.6 Other health and related services

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

Team’s findings


The physiotherapist and occupational therapist review all care recipients on moving into the home and on a regular basis thereafter. Staff refer care recipients to external allied health professionals such as a speech pathologist, mental health specialists or geriatrician as required. A podiatrist visits the home regularly. Access to audiologists, optometrists and a dental service are available either as annual visiting services or in the community. Staff enter specific information in care plans. Care recipients and representatives stated they are aware of the availability of allied health professionals.


2.7 Medication management

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

Team’s findings


Management does not ensure care recipients’ medication is administered correctly. Staff are not properly trained or assessed for competency to administer insulin in accordance with the home’s policies and procedures. The home is not monitoring the care recipients use of ‘as required’ (PRN) medications. Management does not provide sufficient care recipient identification to enable staff to administer medications safely. Care recipients are not being regularly assessed as being competent to self-administer their medications in accordance with the home’s policies and procedures. The home has systems to monitor for medication incidents. However, medication incidents are not consistently reported, actioned or followed up. Care recipients and staff interviewed stated care recipients medications are often administered later than prescribed.

2.8 Pain management

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

Team’s findings


Care recipients are not as free as possible from pain. Pain assessments are not consistently completed in a timely manner. Care staff do not have the knowledge and skills to identify pain, or do not take action and seek assistance to manage care recipients’ pain. The effectiveness of analgesia is not consistently recorded and PRN analgesia is not monitored to establish if regular pain relief medication is required. Prescribed non-analgesic strategies such as heat packs are not documented as being given or assessed for effectiveness. Care recipients and representatives reported care recipients experiencing pain that has not been identified during pain assessments.

2.9 Palliative care

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

Team’s findings


Whilst the home currently has no care recipients in the end stage of life, staff were able to describe processes to consult with care recipients and representatives to plan care reflecting individual wishes and cultural beliefs to ensure the maintenance of comfort and dignity of terminally ill care recipients. Nurses reassess the care recipient’s needs when they enter the palliative phase of care, in collaboration with the family, attending general practitioner and, if requested, palliative care specialists. A palliative care plan is implemented during the palliative phase and includes care recipient preferences such as meals and drinks, nursing care required and reference to the care recipient’s final wishes. External assistance is sought to manage equipment for continuous medication delivery. Chaplaincy/pastoral care and external counselling services are available to enhance care recipient and relative support.



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

Team’s findings


The home does not ensure that care recipients’ nutrition and hydration needs are maintained effectively. An external catering company supplies the food, and the home frequently does not provide care recipients’ choice of meals and runs out of catering supplies. Whilst all care recipients are weighed regularly and reviewed by a dietician, the home could not demonstrate care recipients at risk of malnourishment and receiving prescribed nutritional supplements receive the supplements because correct dietary information is not provided to relevant staff. Monitoring processes do not identify care recipients’ nutritional and hydration needs are met. Care recipients and representatives were not satisfied care nutritional needs are being met.

2.11 Skin care

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

Team’s findings


Care recipients undergo a review of their skin integrity when they move into the home. Nurses identify risks to skin integrity and the potential for pressure injury. Care recipients with diabetes, peripheral vascular disease, reduced mobility, receiving palliative care, post- surgery, or who are frail receive specialised care. Staff use appropriate dressing protocols to support wound care management. Nurses prescribe specialised pressure relieving practices and the physiotherapist prescribed equipment, and emollients and barrier creams are used. Care recipients and representatives reported care recipients’ satisfaction with the provision of skin care management.

2.12 Continence management

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

Team’s findings


Care recipients’ continence is not being managed effectively. The home does not have effective assessment processes for identifying care recipients’ continence management needs. Care recipients’ continence assessments do not lead to continence care plans. Care staff supply continence aids in an adhoc manner and care recipients receive continence aids that do not meet their needs. The home’s monitoring processes are not identifying gaps in the staff practices. Care recipients and representatives are not satisfied with how care recipients’ continence needs are met.


2.13 Behavioural management

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

Team’s findings


On moving into the home, care recipients undergo behaviour management assessments during the initial phase, six-monthly, and when behaviours change. Care plans are developed from assessment information, documented staff observations over a defined period of time, information from adult mental health professionals and family feedback. The home has protocols in place to manage the need for restraint. Care recipients who exhibit challenging behaviour are assisted using individualised diversionary tactics. When indicated, family conferences are conducted to assist families to understand their loved one’s behaviour and relieve anxieties. Therapy staff utilise individual diversional and reminiscing therapies moderate care recipients’ challenging behaviours. Staff stated their understanding of mandatory reporting requirements. Care recipients and representatives generally stated the behaviours of other care recipients do not impact on them.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


The home assesses care recipients’ mobility on moving into the home, but does not reassess in response to major incidents such as an increase in frequency of falls. A physiotherapist conducts a weekly exercise class. The physiotherapy assistant undertakes one-to-one exercises with care recipients. However, this is not as prescribed by the physiotherapist. The home’s monitoring processes do not identify gaps and incident reporting processes are not being used effectively. Care recipients and representatives interviewed were generally satisfied with the home’s approach to ensure care recipients’ mobility and dexterity is optimised.

2.15 Oral and dental care

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

Team’s findings


On moving into the home, nurses review the care recipients’ oral and dental care needs. Care plans document individual preferences for cleaning natural teeth, dentures and other care, and care recipients receive a seasonal change of toothbrush. Referrals to the general practitioner and speech pathologist occur if the care recipient has swallowing difficulties.

Care recipients’ oral care is specialised during palliation, and individualised when a care recipient receives inhaler/nebuliser therapy. Dentists visit the home, and staff support care recipients to attend dental services in the community. Care recipients and representatives stated their satisfaction with oral and dental care and assistance provided to care recipients.


2.16 Sensory loss

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

Team’s findings


The occupational therapist conducts a formal assessment of care recipients’ five senses when care recipients move into the home, and the care plan nominates individual strategies to manage needs. Care recipients are referred to allied health professionals in the community for optical and audiometry services when required. Resources such as large print and talking books are available through the local library. During palliation, additional care ensures the enhancement of sensory care. Care recipients and representatives stated their satisfaction with the identification and management of care recipients’ sensory losses.

2.17 Sleep

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

Team’s findings


On moving into the home, an assessment of the care recipient’s sleeping and rest patterns occurs, and a re-assessment occurs if sleep patterns are disturbed. In consultation with the care recipient and/or representative, care plans generally nominate individual rising and settling times and other specific rituals. The home promotes the use of alternatives to medication where possible. Staff consider life histories, pain management, continence care, immobility and behavioural management when assessing disturbed sleep patterns and planning individual strategies to enhance sleep. Care recipients and representatives reported care recipients sleep well.


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


Whilst the home has a framework for continuous improvement and encourages staff and care recipient participation, this process is ineffective. Management was unable to demonstrate that results show improvements across Standard 3 – Care recipient lifestyle. Information gathered from a variety of sources is not regularly transferred to the home’s plan for continuous improvement, acted on or evaluated. Progress and results of continuous improvement activities are not regularly relayed to the stakeholders via newsletters or meetings. Care recipients and representatives reported they complete feedback forms.

However, feedback is not consistently provided to the originator.


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


The Charter of residents’ rights and responsibilities is displayed in the entry of the home and is documented in the resident handbook and resident agreement. Each care recipient or their representative is offered a resident agreement that outlines fees and tenure arrangements.

The home has a policy and procedure in place for the mandatory reporting of elder abuse. Documentation showed most staff have attended training in the reporting of elder abuse. Staff sign confidentiality agreements and those interviewed reported they are aware of the mandatory reporting process.




Team’s findings



An example of education and training undertaken by the home in the last twelve months in relation to Standard 3 – Care recipient lifestyle is given below.

Elder abuse.

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


Each care recipient receives support in adjusting to life in the new environment on moving into the home and on an ongoing basis. A handbook is supplied to all care recipients or their representative giving comprehensive information about care and services provided. Care recipients are orientated to the home and introduced to staff. A social history is undertaken which includes the care recipients’ background, significant life events, and previous and current social activity interests. Assessments are conducted by the occupational therapist and a care plan is developed from information gathered. Care recipients are encouraged to attend activities and social events. Care recipients and representatives stated representatives can visit the home at any time.

3.5 Independence

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

Team’s findings


The home has processes to ensure regular assessment of care recipients’ needs in achieving maximum independence. The occupational therapist and physiotherapist assess and review care recipients’ level of ability to participate in the activities of daily living. Care plans direct staff regarding the level of assistance required and, where appropriate, care recipients are prompted and encouraged to maintain their independence. Staff confirmed they support care recipients in accessing taxis so they can attend appointments and activities outside the home. Care recipients reported satisfaction with the assistance provided by the staff to assist them with their independence.


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


The home has processes in place to recognise and respect care recipients’ privacy and confidentiality. Care recipients’ information is stored appropriately and staff reported they are aware of the privacy policy of the home. We observed staff entering care recipients’ rooms without knocking during the visit. Strategies to support care recipients’ dignity are not reviewed or updated according to their needs. Information from audits is not actioned to improve care. Care recipients and representatives interviewed reported they are generally satisfied care

recipients’ privacy and dignity, and confidentiality is maintained.

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


Each care recipient’s current and past interests and activity preferences are identified when they move into the home. Care recipients have access to a range of activities with sensory and cognitive therapies and social activities. The program includes art and crafts, bingo, concerts and regular bus outings. Staff reported they provide individual therapy for care recipients who prefer not to attend group activities. Care recipients and representatives reported staff encourage care recipients to attend the range of activities conducted at the home.

3.8 Cultural and spiritual life

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

Team’s findings


Care recipients’ individual interests, customs, beliefs and cultural and ethical backgrounds are valued and fostered at the home. Church services are held fortnightly and culturally significant events and anniversaries are celebrated including Australia day, ANZAC day, Christmas and Easter. Staff described ways they support each care recipients’ interests, customs, beliefs and cultural and ethnic backgrounds. Care recipients and representatives reported they are satisfied with the way staff support care recipients’ cultural and spiritual needs.


3.9 Choice and decision-making

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

Team’s findings


The home has systems to enable care recipients and their representatives to participate in decisions about the services care recipients receive and to exercise choice and control over care recipients’ lifestyle. Care recipients and representatives have the opportunity to provide feedback through feedback forms and care recipient/representative meetings. Staff described some of the choices care recipients make including going to the shops, to attend or not attend activities and attending services outside the home. Care recipients and representatives reported their choices are respected by staff.

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


Systems are established to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Prior to moving into the home, care recipients and representatives are provided with a tour and information about the services and care available in the home. The resident handbook, residential agreement and associated documentation outline care recipients’ rights and responsibilities, fees and charges and security of tenure. Care recipients and representatives reported they have sufficient information regarding care recipients’ rights and responsibilities and secure tenure within the home.


Standard 4 – Physical environment and safe systems

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



Team’s findings


Whilst the home has a framework for continuous improvement and encourages staff and care recipient participation, this process is ineffective. Management was unable to demonstrate that results show improvements across Standard 4 – Physical environment and safe systems. Information gathered from a variety of sources is not regularly transferred to the home’s plan for continuous improvement, acted on or evaluated. Progress and results of continuous improvement activities are not regularly relayed to the stakeholders via newsletters or meetings. Care recipients and representatives reported they complete feedback forms. However, feedback is not consistently provided to the originator.


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


The home has processes in place to identify and ensure ongoing regulatory compliance in relation to the physical environment and safe systems. The home is advised of new legislation and changes to existing regulations through membership with peak bodies and government departments. Workplace and building, fire emergency preparedness, and the catering environment are inspected and audited by internal/external auditors. Safety data sheets are not all stored with chemicals. External contractors are not supervised at all times when onsite. The home has a food safety plan in place to provide guidance to staff.



Team’s findings





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 was unable to demonstrate a safe and comfortable environment consistent with care recipients’ care needs. Care recipients are accommodated in single rooms with ensuites and are encouraged to personalise their rooms with pictures and mementos. A cleaning program is in place and the home has a corrective maintenance program. However, we observed rooms that were dusty, toilets unclean and living areas and carpets dirty. The external environment was observed to have a large amount of dead leaves, weeds, cobwebs and outside furniture was dusty. Care recipients and representatives provided feedback that they were not satisfied with the homes living environment.

4.5 Occupational health and safety

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

Team’s findings


The home’s management is not actively working to provide a safe working environment that meets regulatory requirements. Environmental and safety audits have not been regularly undertaken. Staff meeting minutes do not demonstrate occupational health and safety (OHS) is actively discussed and the previous month’s hazards and incidents are not addressed to improve working conditions or practises. Up-to-date information is not available for staff. Staff reported, and documentation confirmed there is limited access to training and education.

4.6 Fire, security and other emergencies

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

Team’s findings


The home has systems and processes to maintain a safe environment that reduces the risk of emergencies, fire, and breaches of security. External providers complete regular checks on fire-fighting equipment including fire alarms, sprinkler system and fire panel. Evacuation maps and safety equipment is located throughout the home, and exits are clearly marked and unobstructed. A maintenance program ensures all electrical items are regularly tested and tagged. Care recipients and representatives receive information of what to do if they hear a fire alarm on moving into the home and stated they would follow the instructions from staff in the event of a fire or evacuation.


4.7 Infection control

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

Team’s findings


The home has processes to direct staff practice in minimising and managing actual or potential infection control risks. Personal protective equipment was observed to be readily available throughout the home. There is a process in place to report and record care recipients’ infections. However, this is not effective. Data is not analysed to identify trends. The food safety program at the home is being followed by staff. Staff reported, and documentation confirmed there are limited opportunities for infection control training. We observed, and staff reported they do not have access to appropriate equipment.

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


An off-site contractor provides a four-weekly rotating menu that allows for choice of meals and drinks and delivers pre-prepared cook/chill meals to the home. Catering staff reported that menus are seasonal and reviewed by a dietician. The home has a system in place which is ineffective in monitoring and ensuring care recipients’ individual dietary needs are met on an ongoing basis. The home has a food safety program in place. Care recipients’ personal laundry is undertaken at the home and there are informal processes for minimising lost laundry. A contractor launders flat linen. The home’s cleaning staff conduct cleaning duties and complete task checklists. However, feedback mechanisms such as audits are not analysed or actioned by management. Care recipients and representatives interviewed stated they are not satisfied the home’s hospitality services meet care recipients’ needs and preferences.

braemar village - aged care quality › ... › braemarvillage8.pdf · 2018-12-14 · braemar...

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