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Bupa Mosman RACS ID 0553

18-20 Bardwell Road MOSMAN NSW 2088

Approved provider: Bupa Care Services Pty Limited

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 28 March 2017.

We made our decision on 21 January 2014.

The audit was conducted on 17 December 2013 to 18 December 2013. The assessment team’s report is attached.

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

Home name: Bupa Mosman Date/s of audit: 17 December 2013 to 18 December 2013 RACS ID: 0553

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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.

Expected outcome Quality Agency 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


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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.


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

Principle:

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


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


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Audit Report

Bupa Mosman 0553


Introduction This is the report of a re-accreditation audit from 17 December 2013 to 18 December 2013 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 Accreditation 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


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 17 December 2013 to 18 December 2013. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. 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 1997. Assessment team

Team leader: Barbara Knight

Team member/s: Christine Logan

Approved provider details


Details of home

Name of home: Bupa Mosman

RACS ID: 0553

Total number of allocated places:

64

Number of residents during audit:

58

Number of high care residents during audit:

58

Special needs catered for:

N/A

Street/PO Box: 18-20 Bardwell Road State: NSW

City/Town: MOSMAN Postcode: 2088

Phone number: 02 9969 2500 Facsimile: 02 9270 0156

E-mail address: Nil


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Audit trail The assessment team spent two days on-site and gathered information from the following: Interviews

Number Number

General manager 1 Residents/representatives 14

Operations manager 1 Property manager 1

Care manager 1 Maintenance officer 1

Work health & safety consultant

1 Diversional therapist 1

Registered nurses 3 Recreational activities officer 3

Care staff 8 Dance movement therapist 1

Physiotherapy aide 1 Massage therapist 1

Dietician 1 Laundry staff 2

Chef 1 Cleaning supervisor 1

Catering staff 2 Cleaning staff 1

Sampled documents

Number Number

Residents’ files including assessments, care plans progress notes

8 Medication charts including nurse initiated medications

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Summary/quick reference care plans

8 Personnel files 6

Other documents reviewed The team also reviewed:

Activity program, attendance records, individual activity plans

Allied health logs

Behaviour charts

Catheter care plans

Clinical indicator data including analysis, trending and benchmarking

Compulsory reporting schedule for clinical documentation

Continuous improvement documentation including improvement/complaint logs, continuous improvement plans, audit schedule and audit results

Criminal record check register

Daily, weekly and periodical cleaning schedules, inspection reports

Dietician communication diary

Doctor’s request folder

Wound management folders


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Family conference records

Four weekly rotating menu, resident dietary requirements forms, resident change of dietary details forms

Handover sheets

Human resources manual, recruitment policies and procedures

Incident reports including medication, falls, aggression, skin tears

Induction and e-learning programs, education plan, attendance records, competency assessments

Mandatory reporting register and reportable incident guidelines

Master roster

Medication review documentation including collaborative resident medication management reviews, referral requests, medication review audit,

Meeting schedule and meeting minutes

Neuropsychiatric inventory

New employee pack

Newsletters, organisation wide and local level for residents/representatives and staff

NSW Food authority audit, food safety manual, cleaning, temperature and sanitising records consistent with hazard analysis critical control point (HACCP) requirements

Nurses communication diary

Physiotherapy aide schedule

Planned and preventative maintenance schedules, maintenance request log, hazard logs, risk assessments

Policies and procedures

Position descriptions and duty statements

Professional staff registration records

Resident and venue/location suitability checklist for bus trips

Resident pre entry and entry information including resident handbook, information packs, resident agreements

Self-medication assessments and agreements

Schedule eight drug register

Total care day schedule and forms Observations The team observed the following:

Activities in progress including Christmas barbecue well attended by residents, families and friends

Chemical storage and material safety data sheets appropriately located

Clean and dirty utility areas including personal protective equipment, sharps containers, spills kits and waste disposal bins

Computers for residents use


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Displayed notices including accreditation notices, activity programs, Charter of Residents Right and Responsibilities, vision and values, complaints scheme information, comments/suggestions forms, menus

Equipment and supply storage areas and equipment in use

Fire panel, fire equipment, evacuation plans, emergency instructions in residents’ rooms, annual fire safety statement

Hand sanitisers and hand washing facilities located throughout the home

Interactions between staff, residents, representatives

Key pad security at front and car park doors and in lift

Living environment internal and external, including upgrading of rooftop areas

Locked drawers in residents’ rooms for medication storage

Medication storage and administration

Outbreak kits with equipment, associated documentation and signage

Residents’ garden boxes

Storage of medications including schedule eight drugs, emergency supplies, refrigerator temperature and cleaning records

The dining experience and other hospitality services in progress


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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 residents, 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 Interviews, observations and document review demonstrate that Bupa Mosman has systems and processes that underpin the active pursuit of continuous improvement across the four Accreditation Standards. Information is obtained through improvement/complaint logs, results of audits and surveys, incident/accident reports, meetings, observation and informal feedback from staff, residents and representatives. Continuous improvement plans identify the issue, actions, timeframes, progress, evaluation and closure of all identified opportunities for improvement. Improvements relevant to Accreditation Standard One include:

Review of the organisation wide complaints management system to improve the complaints handling processes. Training was provided for staff at all levels with appropriate resources such as tip sheets, quick guides and letter templates. At Bupa Mosman complaints management was discussed with residents and representatives and the appropriate avenues for making a complaint were reinforced. This has resulted in a more open process and reduced the number of complaints escalated to head office.

Implementation of an electronic criminal history check program. The program maintains the register, monitors timeframes and alerts the home when renewals are due. This has reduced paperwork and administration time for managing the process.

Introduction of a Graduate Nurse Program to attract more graduate nurses into aged care and to improve retention rates of registered nurses. The program is based on a person centred model and is designed to develop clinical leadership capabilities. This provides opportunities for up-skilling and career progression within the organisation.

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 home meets this expected outcome There are systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Information is disseminated throughout the organisation regarding legislative changes and any impact they may have at a local level. Information is obtained through peak industry bodies, circulars and bulletins from government and non government departments and professional organisations. Regulatory issues and updates are communicated to staff through memoranda, meetings and educations sessions. Staff state they are made aware of regulatory issues and that they have access to information regarding legislative and regulatory requirements. Management


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monitors compliance through a review of policies and procedures, audits, observation of staff practices and feedback. Examples of the monitoring and compliance with regulatory requirements relevant to Accreditation Standard One are:

A system to ensure criminal history checks for all staff remain current and the maintenance of a criminal history check register

A system to ensure compliance with legislation regarding the compulsory reporting of allegations of assault.

Notification to residents/representatives of the accreditation site audit and their right to speak with the assessment team.

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 meets this expected outcome Bupa Mosman demonstrates that systems and processes ensure both management and staff have appropriate knowledge and skills to perform their roles effectively. There is a flexible education program which includes needs identified through performance appraisals, complaints, mandatory requirements, results of audits and surveys, in response to resident care needs and staff requests. There is a comprehensive e-learning program including core modules, face to face training, and the opportunity to attend external education. There is an extensive induction program and discussions with staff demonstrate they receive education at this time and on an ongoing basis to enable them to perform their roles. Education relevant to Accreditation Standard One includes:

Workplace conduct

Reportable incident training 1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome There are systems to ensure that residents, their representatives and other interested parties have access to internal and external complaints mechanisms. Internal mechanisms include meetings, internal improvement/complaint logs, and discussions with management. Information on external complaints mechanisms is displayed and detailed in the resident handbook and resident agreement. Review of the improvements and complaints register demonstrates that complaints are documented, actioned and closed off within appropriate timeframes. Interviews with residents/representatives confirm that they are aware of internal and external complaints mechanisms.


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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 home meets this expected outcome The vision and values of the organisation are documented and displayed in the home and include the commitment to continuous improvement through ongoing review of all service aspects. The “Bupa Way” details the organisation’s promise to its customers. Policies and procedures guide staff practice and the home’s established improvement program monitors and evaluates the ongoing commitment to quality. Management and staff are aware of and understand the philosophy of the organisation and their commitment can be observed in the practices and attitudes and interactions between management, staff and residents/representatives. 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 meets this expected outcome Bupa Mosman has systems and processes to ensure there are sufficient staff with the appropriate knowledge and skills to provide care and services to the residents. There are recruitment and selection processes, an induction program including buddy shifts, ongoing education and a performance management system. Performance appraisals (Personal Best program) are conducted after a probationary period and then annually. Personal Best includes opportunities for the recognition and reward of achievements. There is access to an employee assistance program. Staff interviewed advise that they work together as a team to ensure care and service delivery and have the opportunity to provide feedback on staffing levels and increased care needs. There is ongoing education relevant to their roles and they are encouraged to undertake further training. Residents/representatives are satisfied that there are sufficient, appropriately qualified staff to meet care and service needs and commented favourably on accessibility and openness of management and the skills and empathy of the 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 meets this expected outcome The team observed and staff confirmed there are appropriate levels of stock and equipment including medical supplies and equipment, food, chemicals, furniture and linen, to provide quality care and services to residents. An approved supplier list is maintained by the organisation and there are local purchasing processes. A stock rotation and replacement system is in place. There is a preventative maintenance schedule and reactive maintenance is requested through the maintenance log and noted to be actioned in a timely manner. External contracts are in place for the maintenance of specialised equipment. Staff advised


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that they receive training on the use of newly purchased equipment, which may be trialled before use. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome Bupa Mosman has systems both electronic and manual to manage the collection, management and dissemination of information that supports care and service delivery. Electronic data is password protected, accessible at varying levels to authorised staff and regularly backed up. Confidential hard copy files are securely stored and there is a system for their archiving and disposal. Staff have access via the organisation’s intranet to policies and procedures, e-learning and other resources. Information is also disseminated to staff and residents via email, newsletters, family conferences, memoranda, at meetings and education sessions. Discussions with staff and residents/representatives indicate there is an efficient two way flow of information. 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 meets this expected outcome External service provision is managed at organisational and local levels to ensure that externally sourced services meet the organisation’s commitment to the delivery of quality care and service. The organisation identifies preferred service providers and contractor/ service agreements are managed at that level. At local level the general manager and maintenance staff monitor services and ensure that goods supplied meet quality objectives. There is ongoing evaluation of the goods and services provided with feedback from management, staff and residents.


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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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For details of the continuous improvement system refer to expected outcome 1.1 Continuous improvement in this report. Examples of continuous improvement activities relevant to Accreditation Standard Two include:

Implementation of Clinical Leadership Forums as an organisational initiative to support the learning and development of nursing staff. They provide the opportunity for registered nurses and care managers to increase clinical skills using an evidence based approach to care, and to develop as clinical leaders. Feedback from registered nurses is very positive.

Identification that there was a lack of relevant information in clinical documentation. A compulsory reporting schedule has been developed that determines the areas for documentation each day including assessments and care plan evaluation. Documentation has improved and provides a clear picture of resident care over the three shifts. Registered nurses advise that care needs are better reported and there is more accountability for care provided.

To reduce the risk of falls and improve resident safety, floor mats, seat alarms and bed pads have been purchased. Incident statistics demonstrate reduced numbers of falls.

Upgrading of the pad supply room and purchase of shelving and a trolley to improve ease of access and distribution of continence products.

2.2 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 about health and personal care”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.2 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to Accreditation Standard Two include:

A system to ensure the currency of professional staff registrations

A system to ensure compliance with legislation regarding medication management practices

A system to manage unexplained absence of residents in accordance with regulatory requirements


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2.3 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 meets this expected outcome Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to Accreditation Standard Two include:

Person first, Dementia second training

Behaviour management

Incontinence and dementia

Continence management

Pain in the elderly

Falls prevention 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Residents/representatives believe they receive excellent clinical care and can give examples of residents’ health improving as a result of the care received. Management ensure care plans are reviewed and documentation confirmed residents are assessed on entry to the home and care plans routinely reviewed three monthly or when changes are identified. Individual needs and preferences regarding care and medical treatment are sought and respected. Regular family conferences involving the resident, family, care staff, allied health, medical practitioners, and other interested parties identify changes and evaluate care plans. Care staff said they enjoy the team structure and feel supported by team leaders and management. They receive ongoing education and believe they have the skills and equipment to provide a high standard of care to residents. Clinical care audits and the analysis of incidents ensure trends are determined generally and individually. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Bupa Mosman has a system for ensuring residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. The home is able to care for residents with specialised nursing care needs such as complex pain and wound management, palliative care, indwelling and supra-pubic catheters, percutaneous endoscopic gastrostomy feeding, blood glucose monitoring and diabetic management. The home ensures registered nurses receive specific training to manage this specialised care. The home liaises with specialist aged care advisers, the Greenwich Hospital Palliative Care Team and other specialists when needed. Staff and residents/representatives interviewed


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and the review of documentation confirmed residents’ specialised nursing care needs are attended to according to residents’ needs and preferences. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome Interviews with residents/representatives and staff and a review of clinical documentation confirm the home has a prompt and responsive system for referral of residents to appropriate health specialists. A physiotherapist attends weekly and supervises a physical therapy aide who works five days per week. The services of an occupational therapist, podiatrist, dietician, optometrist, audiologist, dentist, speech pathologist, wound specialist, geriatrician and psycho-geriatrician are available when required or requested by residents/representatives. Staff and residents confirm the home arranges referrals and transport to appointments as necessary. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Bupa Mosman demonstrates the management of medication is safe and meets relevant legislative and regulatory requirements and professional standards and guidelines. Registered nurses administer medications. A pharmacy pre-packed medication system is used and internal audits and reviews of medication management are conducted regularly. There is a Medication Advisory Committee which discusses and guides all aspects of medication management and administration. An external clinical pharmacist reviews medications. Residents who self-medicate are regularly assessed by a medical practitioner and store medications in locked drawers in their rooms. We observed all medications to be safely stored. Residents/representatives reported they are satisfied their medication is managed safely and correctly. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome The home has an effective system to assess and manage residents’ pain. A physiotherapist completes a pain management history and assessment for all residents when they move into the home and is responsible for a comprehensive pain management program which is developed collaboratively between medical practitioners, staff, residents/representatives, pharmacist and other relevant health professionals. We observed these plans to be implemented, documented and regularly reviewed. Alternative strategies to medication interventions for the management of pain are encouraged such as repositioning of the resident, massage, heat packs and gentle exercise. A massage therapist attends weekly and a full time physical therapy aide attends all residents routinely. Residents/representatives confirm they are as free as possible from pain. Several commented they enjoy the massages and heat packs and their pain relief has improved since moving to the home.


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2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome Bupa Mosman ensures the comfort and dignity of terminally ill residents and provides an opportunity for all residents/representatives to make choices about care when faced with a terminal illness. End of life discussions are held during the admission process and as required. A registered nurse is available to coordinate treatment, support families, educate staff and organise visits from religious representatives if requested. Relatives and friends may stay overnight and meals and snacks are provided. Staff interviewed demonstrated an awareness of the needs and requirements of terminally ill residents and described care provided to a resident who recently passed away. We spoke to a family member whose relative was receiving palliative care and they praised the attention and commitment of staff during this difficult time. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Interviews with staff and review of documentation indicated residents’ nutrition and hydration needs are assessed, documented and regularly reviewed. Meals are prepared on site and residents’ dietary needs and preferences are documented and the kitchen staff informed. A choice of meal is offered to residents and special and texture modified diets are available as required. Nutritional drinks are provided as a supplement when required. The changing needs and preferences of residents are closely monitored through observation, weight recording, resident meetings, regular surveys and discussions with residents/representatives. The resident is referred to their medical officer, dietician and speech pathologist if there are nutritional concerns. All residents/representatives interviewed stated the quality of food had improved recently with the appointment of a new chef. Their suggestions are actioned and they are given choices. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Bupa Mosman has a system to ensure residents’ skin integrity is consistent with their general health. Interviews with staff and review of documentation confirm residents have a skin assessment when they move into the home and any ongoing issues are managed by their medical officer and registered nurse. The occupational therapist advises on pressure care management and the appropriate equipment to be used such as specialised mattresses, cushions and boots. Residents’ skin integrity is monitored daily by care staff during activities of daily living who report any abrasions, rashes or abnormalities to the registered nurses. Wound management charts document dressings required, frequency of treatment and


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progress of healing. A wound care specialist oversees wound management at the home. Residents/representatives interviewed said they are satisfied with the care provided to maintain skin integrity and gave examples of wounds improving after arriving at the home. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome Bupa Mosman has a comprehensive system to ensure residents’ continence is managed effectively. Review of clinical documentation showed residents are assessed when they move into the home and a care plan is developed with a toileting program implemented when necessary. This is regularly reviewed and toileting regimes are maintained for as long as possible. Staff confirm there are always adequate supplies of continence aids of varying styles and sizes to suit individual needs. The continence aid provider is available for consultation, advice and the provision of education for staff. Staff demonstrate they have knowledge in the use of continence aids and the importance of regular fluids, a high fibre diet and the use of aperients when necessary to promote healthy bowel and urinary continence. Residents/representatives confirm continence is managed effectively. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome A review of documentation including care plans, the results of accidents/incidents audits and discussions with management and staff show residents with challenging behaviour are assessed, care plans reviewed and referrals made when necessary. The home consults with the local Dementia Behaviour Management Advisory Service (DBMAS) and referrals are made to a psycho-geriatrician when necessary. The home has recently installed an alarm system with key-padded security on the lift and exits. Residents attempting to leave the building who have been assessed as being at risk, wear alert bracelets. This has provided a safe environment where residents can optimise their independence. Individualised diversional therapy plans are used to manage challenging behaviours. Representatives appreciate the commitment and skills staff demonstrate in managing their family member and other residents. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome The home has a system in place to ensure the optimum levels of mobility and dexterity are achieved for all residents. All new residents are assessed by a physiotherapist and nursing staff to establish manual handling requirements, mobility, falls risk and their level of pain. They are reassessed three monthly or when changes are identified such as after falls or on return from hospital. Documentation review confirmed this and demonstrated the physiotherapist develops individual programs and delivers the program or oversees staff


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delivery of programs. Exercise classes are held regularly and residents are encouraged to attend. The introduction of a dance class has been popular and the care manager is monitoring residents to assess if there is any change in the frequency of falls. The home has adequate supplies of mobility aids and equipment. Residents/representatives interviewed state they are satisfied with the assistance given to maintain or improve residents’ mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Bupa Mosman has strategies in place to ensure residents’ oral and dental health is maintained. Care staff said they receive education in oral and dental care and assist residents to maintain daily dental and oral health. A dental technician visits the home regularly and residents are assisted to visit their dentist of choice. A review of clinical documentation indicates residents’ dental hygiene is assessed, documented, regularly reviewed and acted upon. Residents/representatives said the home provides appropriate diet, fluids, referrals and specialist equipment to ensure residents’’ dental and oral health is maintained. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Bupa Mosman has systems in place to effectively manage and identify residents’ sensory losses. Residents’ senses are assessed when they move into the home with an assessment that evaluates the senses of sight, hearing, smell, taste and touch. Residents who are identified as having sensory deficits have management strategies documented in their care plans and are assisted to access equipment or services to support them. Programs are developed with the activities officer to promote sensory stimulation. Staff said they receive training in sensory loss and specialist equipment is maintained in good working order. We observed the supply and use by residents of large print books and telephones with large number display. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Residents’ sleep patterns are assessed on moving into the home including any history of night sedation. Residents’ ongoing sleep patterns are reviewed and sleep disturbances monitored and appropriate interventions put in place to assist residents achieve natural sleep. Staff said residents who experience sleep disturbances are assessed, given emotional support, assisted with toileting, assessed for pain or provided with warm drinks and snacks as requested. Residents/representatives interviewed said they are satisfied with the way sleep is managed at the home and many residents said their personal preferences such as naps in the afternoon or early or late risers were respected by staff.


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Standard 3 – Resident lifestyle Principle: Residents 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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For details of the continuous improvement system, refer to expected outcome 1.1 Continuous improvement. Examples of continuous improvement activities relevant to Accreditation Standard Three include:

Introduction of Dance and Movement Therapy to encourage physical movement and group interaction initially for people living with dementia. This has been well received and participation has extended to other residents.

In response to resident feedback that the television in the activities room was too small, a larger screen television has been purchased and installed.

Following a suggestion from the resident/relative meeting, a regular monthly barbeque has been implemented and is much enjoyed by residents.

It was identified that there was need for easily accessible crockery for families particularly those who may be visiting palliating residents. A tea tray has been set up on each level and maintained for the use of families

3.2 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, about resident lifestyle”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.2 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to Accreditation Standard Three include:

Residents/representatives are provided with information on prudential arrangements and sign agreements on or before entry to the home.

Residents’ handbook and agreement detail tenure arrangements and the Charter of Residents’ Rights and Responsibilities, which is also displayed.


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3.3 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 meets this expected outcome Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to accreditation standard three include:

Privacy and confidentiality

Two recreational activities officers are enrolled in Certificate IV leisure and lifestyle

Lifestyle seminar for recreational activities officers 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The management and staff at Bupa Mosman have a welcoming procedure which includes an admission process involving the general manager, care manager, administration officer, registered nurse and staff who have ongoing communication with the resident and their family. Activities staff spend individual time with residents who don’t regularly participate in group activities. The massage therapist and physical therapy assistant observed the physical attention can help relieve residents’ distress or anxiety. Documentation and interviews confirmed residents’ emotional status and needs are identified and monitored consistent with the home’s philosophy. Residents/representatives praised staff and said their buoyant, happy approach to work created a positive atmosphere in the home. Staff said they feel the residents are like family and they really enjoyed working at the home. 3.5 Independence This expected outcome requires that "residents 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 meets this expected outcome Residents/representatives said they are encouraged to maintain their independence, friendships and participate in all aspects of community life within and outside the home. An occupational therapist assesses residents’ mobility aids which helps ensure residents’ mobility is maximised to assist their involvement in community life both inside and outside the home. A range of activities are available seven days a week and residents are encouraged and assisted to participate in activities. The home has access to a company bus and residents are regularly taken on outings of their choice. Private areas are available for residents to entertain guests.


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3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Residents/representatives interviewed said their right to privacy, dignity and confidentiality is recognised and respected. They state staff knock on their doors before entering their room and they feel comfortable raising any concerns with management or staff. Staff sign confidentiality agreements and receive ongoing education concerning privacy, dignity and confidentiality. Staff handovers and confidential resident information is discussed in private and non-current medical and associated records are archived and stored securely. There are attractive communal and private areas for residents to spend time alone or with others. We observed staff interactions with residents showed warmth, respect, empathy and understanding. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome Residents/representatives said the activities offered were diverse, enjoyable and responsive to residents’ needs. New residents are welcomed by the recreational activities coordinator and information is gathered from the resident and family about their leisure interests and preferences. A weekly program of activities is displayed and activities are offered seven days a week. Activities include bus trips, concerts, art and craft classes, bingo, discussion groups, shopping trips, movies and special events such Anzac Day, Melbourne Cup and international days. Regular surveys and evaluations are conducted to ensure they reflect the ongoing and changing interests of residents. An activity officer visits and assesses all venues before residents’ outings to ensure the amenities are suitable. We observed colourful photographic displays and albums of residents enjoying outings, events and activities. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome Information about residents’ cultural background and religious preferences is collected and specific issues documented and acted upon. Residents with English as a second language are assisted with communication through specific language group activities, connection with staff who speak the same language and interpreter services when necessary. The home is visited by religious groups of various denominations to conduct church services and provide spiritual and emotional care to residents and their families. All residents/representatives interviewed believe their spiritual beliefs and cultural background are valued and fostered.


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3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident 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 meets this expected outcome Residents/representatives confirmed they are provided with information to enable them to exercise choice and decision-making without infringing on the rights of others. A review of documentation shows residents’ personal preferences are identified and a social profile is completed on moving to the home. Residents choose their own medical officer and case conferences and referrals are made in consultation with the resident and representatives. Residents said they choose whether they wish to participate in activities and other events at the home. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Bupa Mosman is able to demonstrate that residents have secure tenure within the home and understand their rights and responsibilities. A service agreement and handbook is provided for all residents. The agreement outlines information on security of tenure, charter of residents’ rights and responsibilities, fees/bonds, privacy matters and specified care and services. The resident handbook details the services available at the home. Information is provided and displayed in the home for residents/representatives and includes brochures on comments and complaints. Residents/ representatives interviewed state they are satisfied with the information that was provided pre entry and on entry to the home and on an ongoing basis.


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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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.1 Continuous improvement. The home’s continuous improvement activities include systems to check that the home provides a safe and comfortable environment consistent with residents’ care needs.

Examples of continuous improvement activities relevant to Accreditation Standard Four include:

As the result of a resident attempting to abscond, a wanderers alarm has been installed at the front entrance.

To maintain resident safety a key pad has been installed in the lift to limit access to inappropriate areas such as the basement service areas.

The rooftop area has been upgraded to provide additional garden space for residents. There are attractive murals, sitting areas, raised garden beds, catering equipment and barbecue. Residents were observed enjoying this area and attending a barbecue during the reaccreditation audit.

Following environmental audits and risk assessments new equipment has been purchased and installed in the laundry including a warning alarm for the laundry chute, a new dryer and air conditioner and spring loaded trolleys. Staff are very satisfied with improvements.

4.2 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, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.2 Regulatory compliance. There are systems to ensure compliance with regulations relevant to residents’ quality of life and provision of a safe environment. Examples of regulatory compliance relevant to Accreditation Standard Four include:

A system to ensure compliance with food safety requirements including a food safety program and NSW Food Authority license

A system to ensure compliance with fire safety regulations and building safety codes

A system to ensure compliance with infection control requirements and minimise the risk of infection for staff and residents.


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4.3 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 meets this expected outcome Refer also in this report to expected outcome 1.3 Education and staff development. The home demonstrates that staff have the knowledge and skills required for effective performance in relation to physical environment and safe systems. Examples of education and training programs relevant to Accreditation Standard Four include:

Infection control

Fire safety training

Manual handling and back care

Work Health and Safety responsibilities 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 residents’ care needs". Team’s findings The home meets this expected outcome Bupa Mosman provides a safe and comfortable environment consistent with residents’ current and future care needs. Attractively designed and furnished throughout, there are communal areas and smaller areas for private family functions. Facilities include a hairdressing salon, library with computer access, well equipped activities area and a roof top garden. Residents are accommodated in single rooms with ensuite bathrooms. Rooms and bathrooms are equipped with call bells and hand rails. Air conditioning in resident’s rooms can be programmed to suit individual preferences. Preventative and reactive maintenance programs are in place. The home presented a calm and peaceful environment during the two days of the audit and residents/representatives state that they are very happy with their home. 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 meets this expected outcome Bupa Mosman has systems and processes which enable it to demonstrate there is a safe working environment that meets regulatory requirements. The home is supported by specialist staff at an organisational level who are available for direction, guidance and education. Education provided at induction and on an ongoing basis includes manual handling, fire safety awareness, infection control, and hazard and accident/incident reporting. Lifting devices, personal protective and other equipment is available for the protection of both staff and residents. Equipment is risk assessed pre purchase and evaluated by the work health and safety team. A workplace health and safety committee meets regularly and reviews accident/incident and infection data, and results of audits and surveys. Hazards are reported through the maintenance log and risk assessments are undertaken when indicated.


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Preventative and reactive maintenance programs are in place and environmental audits are conducted regularly. Staff interviewed are aware of their responsibilities regarding work health and safety. 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 meets this expected outcome Bupa Mosman has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. Firefighting equipment, emergency flip charts and evacuation plans are located throughout the home. Emergency manuals detail procedures to be followed. There is controlled exit from the home, and key pad access to certain areas in the lift to ensure resident safety and security. All staff receive training at induction and on a regular basis thereafter. Fire and emergency instructions for residents/representatives are located in each resident’s room. A visit from the local fire brigade was well received by residents. Staff interviewed understand their role in an emergency situation and residents/representatives advise they feel safe and secure within the home. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome Bupa Mosman has policies and practices that support an effective infection control program. Staff receive training at induction and on an ongoing basis, and undertake regular hand washing competencies. Hand sanitisers and hand washing facilities are located throughout the home and personal protective equipment is available at point of use. The system includes auditing and reporting mechanisms, cleaning, maintenance and food safety programs, linen handling procedures, disposal of waste and use of spills kits. All equipment is appropriately colour coded. A vaccination program is in place for staff and residents. Outbreak kits with personal protective equipment, documentation and signage are easily accessible. Data on infections are collected, analysed, discussed with staff and reported at the work health and safety and other meetings. All staff interviewed are very aware of their responsibilities regarding infection control generally and extra precautions to be taken in the event of an outbreak. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome Bupa Mosman has policies and practices to enable them to demonstrate that hospitality services provided enhance residents’ quality of life and staff working arrangements. Residents/representatives interviewed are satisfied with the hospitality services provided and state they have the opportunity to provide feedback through resident/relative meetings, improvement logs and one to one meetings with the chef.


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Cleaning staff perform their duties guided by daily, weekly and periodic cleaning schedules and the results of inspections and audits. Staff receive training in the use of equipment, infection control and outbreak management procedures, manual handling and safe use of chemicals. Staff interviewed demonstrate a good knowledge of infection control practices and the safe use of equipment. The home presents as clean, fresh and well cared for. There is a well equipped commercial standard laundry with designated clean and dirty areas, operating seven days a week, and all linen and personal items are laundered on site. Laundry bags are delivered directly from the floor to the laundry via a laundry chute. Chemicals are dispensed automatically into washing machines which are programmed according to the load to be washed. Staff interviewed demonstrate a sound knowledge of infection control and manual handling practices and state that the laundry systems work well. The catering team is headed by a chef who consults regularly with residents regarding their wishes and preferences and attends resident/relative meetings. There is a four week rotating menu, which is reviewed by a dietician. All food is cooked fresh on site and resident choices can be easily accommodated. Meals are served from serveries in the attractive dining rooms and residents are encouraged to socialise, but may have tray service in their rooms if they wish. Residents’ individual requirements such as specialised or modified diets are forwarded to the kitchen and regularly updated, and catering staff are aware of any changes. Catering practices and documentation were observed to be consistent with HACCP requirements and the home achieved a B rating in the NSW food authority audit and the improvements required in documentation have been addressed.

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