decision to accredit flora mcdonald lodge nursing home · home name: flora mcdonald lodge nursing...

Decision to accredit

Flora McDonald Lodge Nursing Home

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Flora McDonald Lodge Nursing Home in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Flora McDonald Lodge Nursing Home is three years until 9 April 2014. The Agency has found the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. This is shown in the ‘Agency findings’ column appended to the following executive summary of the assessment team’s site audit report. The Agency is satisfied the home will undertake continuous improvement measured against the Accreditation Standards. The Agency will undertake support contacts to monitor progress with improvements and compliance with the Accreditation Standards. Information considered in making an accreditation decision The Agency has taken into account the following: the desk audit report and site audit report received from the assessment team; and information (if any) received from the Secretary of the Department of Health and Ageing;

and other information (if any) received from the approved provider including actions taken

since the audit; and whether the decision-maker is satisfied that the residential care home will undertake

continuous improvement measured against the Accreditation Standards, if it is accredited.

Home name: Flora McDonald Lodge Nursing Home Dates of audit: 7 February 2011 to 9 February 2011 RACS ID: 6816 AS_RP_00851 v2.5

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Home and approved provider details

Details of the home

Home’s name: Flora McDonald Lodge Nursing Home

RACS ID: 6816

Number of beds: 53 Number of high care residents: 11

Special needs group catered for: People with disabilities

People with dementia or related disorders

People with culturally and linguistically diverse backgrounds

Street: 206 Sir Donald Bradman Drive

City: COWANDILLA State: SA Postcode: 5033

Phone: 08 8443 6022 Facsimile: 08 8234 9404

Email address: [email protected]

Approved provider

Approved provider: Mary MacKillop Care SA Ltd

Assessment team

Team leader: Cherie Davy

Team member: Judy Aiello

Dates of audit: 7 February 2011 to 9 February 2011


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Executive summary of assessment team’s report Accreditation

decision

Standard 1: Management systems, staffing and organisational development

Expected outcome Assessment team recommendations

Agency findings

1.1 Continuous improvement Does comply Does comply

1.2 Regulatory compliance Does comply Does comply

1.3 Education and staff development Does comply Does comply

1.4 Comments and complaints Does comply Does comply

1.5 Planning and leadership Does comply Does comply

1.6 Human resource management Does comply Does comply

1.7 Inventory and equipment Does comply Does comply

1.8 Information systems Does comply Does comply

1.9 External services Does comply Does comply

Standard 2: Health and personal care


Agency findings




2.4 Clinical care Does comply Does comply

2.5 Specialised nursing care needs Does comply Does comply

2.6 Other health and related services Does comply Does comply

2.7 Medication management Does comply Does comply

2.8 Pain management Does comply Does comply

2.9 Palliative care Does comply Does comply

2.10 Nutrition and hydration Does comply Does comply

2.11 Skin care Does comply Does comply

2.12 Continence management Does comply Does comply

2.13 Behavioural management Does comply Does comply

2.14 Mobility, dexterity and rehabilitation Does comply Does comply

2.15 Oral and dental care Does comply Does comply

2.16 Sensory loss Does comply Does comply

2.17 Sleep Does comply Does comply


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Executive summary of assessment team’s report Accreditation

decision

Standard 3: Resident lifestyle


Agency findings




3.4 Emotional support Does comply Does comply

3.5 Independence Does comply Does comply

3.6 Privacy and dignity Does comply Does comply

3.7 Leisure interests and activities Does comply Does comply

3.8 Cultural and spiritual life Does comply Does comply

3.9 Choice and decision-making Does comply Does comply

3.10 Resident security of tenure and responsibilities

Does comply Does comply

Standard 4: Physical environment and safe systems


Agency findings




4.4 Living environment Does comply Does comply

4.5 Occupational health and safety Does comply Does comply

4.6 Fire, security and other emergencies Does comply Does comply

4.7 Infection control Does comply Does comply

4.8 Catering, cleaning and laundry services

Does comply Does comply

Assessment team’s reasons for recommendations to the Agency The assessment team’s recommendations about the home’s compliance with the Accreditation Standards are set out below. Please note the Agency may have findings different from these recommendations.


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SITE AUDIT REPORT

Name of home Flora McDonald Lodge Nursing Home

RACS ID 6816

Executive summary This is the report of a site audit of Flora McDonald Lodge Nursing Home 6816 206 Sir Donald Bradman Drive COWANDILLA SA from 7 February 2011 to 9 February 2011 submitted to the Aged Care Standards and Accreditation Agency Ltd. Assessment team’s recommendation regarding compliance The assessment team considers the information obtained through audit of the home indicates that the home complies with: 44 expected outcomes Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Flora McDonald Lodge Nursing Home. The assessment team recommends the period of accreditation be three years. Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation.


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Site audit report Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 7 February 2011 to 9 February 2011 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team

Team leader: Cherie Davy

Team member: Judy Aiello

Approved provider details

Approved provider: Mary MacKillop Care SA Ltd

Details of home

Name of home: Flora McDonald Lodge Nursing Home

RACS ID: 6816

Total number of allocated places:

53

Number of residents during site audit:

53

Number of high care residents during site audit:

11

Special needs catered for:

People with disabilities

People with dementia or related disorder

People with culturally and linguistically diverse backgrounds

Street: 206 Sir Donald Bradman Drive State: SA

City: COWANDILLA Postcode: 5033

Phone number: 08 8443 6022 Facsimile: 08 8234 9404

E-mail address: [email protected]


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Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Flora McDonald Lodge Nursing Home. The assessment team recommends the period of accreditation be three years Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation. Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and the reasons for its recommendations are outlined below. Audit trail The assessment team spent three days on-site and gathered information from the following: Interviews

Number Number

Director of care 2 Residents/representatives 4

Hospitality manager 1 Representative 3

Registered nurses 2 Quality manager 1

Care staff 2 Laundry staff 1

Enrolled nurse 1 Pastoral care team 5

Site quality coordinator 1 Cleaning staff 1

Quality manager 1 Chef 1

Values mission and training coordinator

1 Maintenance officer 1

Lifestyle staff 3

Sampled documents

Number Number

Residents’ clinical files and electronically held progress notes

6 Medication charts 10

Wound care records 8 Residential care agreements 2

Residents’ care plans 6 Lifestyle care plans 6

Other documents reviewed The team also reviewed: Asbestos audit report and register Audit records Chemical register Cleaning schedules Clinical assessment tools Comment and complaint records


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Compliment forms Continuous improvement quality check audits Continuous improvement register Contractors/Preferred suppliers list Correspondence letter-attendance staff training Dietary change advice notices Documentation review schedule EN/RN registration Audit 2010 Food safety audit Food service requirement forms Incident reports, summaries and analysis reports Infection control guidelines Information on recalled lines/products Job descriptions Lifestyle plan review schedule 2010/2011 Material safety data sheets Minister’s Specification SA 76 Essential Safety Provisions Nursing and care staff appraisal schedule 2011 Observation charts Orientation package and programme for staff/agency Pest control records Police check report staff and volunteers Policies and procedures Preventative maintenance programme 2010/2011 Priority action plans Progress note entries/email correspondence regarding change of room RCD test register Resident and staff surveys and analysis Residents’ information handbook Residents’ information package S4 and S8 drug licence Safe operating procedures and instructions Staff information booklet Staff questionnaire evaluation 2010 Strategic planning documents Suggestion forms Testing and tagging records Training needs analysis Training/Education schedule 2011-02-11 Triennial safety fire clearance Dec 2009 Various activity evaluations 2010 Various contractor service agreements Various duty descriptions Various external contractors maintenance records Various leisure and lifestyle evidence records Various maintenance records Various meeting minutes 2010/2011 Various service reports Various staff rosters Various training records/evaluations Volunteers handbook and orientation checklist Workplace safety inspections checklists


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Observations The team observed the following: Activities in progress Archive room ‘Café’ in operation Chapel Chemical storage Closed circuit television system Equipment and supply storage areas Information for residents displayed Interactions between staff and residents Kitchen facilities Laundry in operation Living environment Meal service Medication round Medication storage Staff pigeon holes Storage of medications Suggestion boxes


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Assessment information This section covers information about 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 recommendation Does comply An organisation wide strategic plan outlines key goals and objectives for the home’s continuous improvement program which is managed by a site coordinator and corporate quality manager. A continuous improvement plan and service specific priority action plans, record continuous improvement initiatives identified from a variety of sources such as, comments and complaints, audits, incident reports, staff and resident suggestions, surveys and meetings. Progress on planned actions and evaluation processes are monitored at meetings. A staff continuous improvement training package is provided at induction and residents informed of processes for participating and contributing to continuous improvement during entry and through regular meetings, newsletters and their handbook. Staff and residents are aware of continuous improvement processes and confirm the home’s responsiveness to their feedback. Improvements initiated by the home relevant to management systems, staffing and organisational development include: To improve the capture of compliments provided by residents, representatives and

staff the home has introduced a compliments form. This change was initiated by management who recognised there was no specific document to record compliments distinct from the existing comment and complaint form. Residents and staff were informed of the new form which as available throughout the home. Management have noted an increase in the number of compliments since the form has been implemented and residents interviewed described using the form to provide positive feedback to the home.

To better inform staff of the home’s values, following the amalgamation of Flora McDonald Lodge under Mary MacKillop Aged Care Ltd the home has revised the staff code of conduct. This now includes the values of respect for each individual and a focus on customer service and has been incorporated in the staff induction program. Existing staff were informed via their electronic pay slips although this communication process was not effective as some staff chose not to print their pay slips which would have provided ongoing access to the code of conduct. To further improve staff communication processes staff pigeon holes were installed in the staff room and staff now receive printed copies of all relevant memos, training information, survey questionnaires. Staff interviewed said they appreciate the improved access to information.

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 recommendation Does comply


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The home has systems and processes to monitor and action changes to legislation, regulatory requirements, professional standards and guidelines. The home receives regular updates via emails and newsletters of changes to legislative requirements through associations with peak industry bodies, and attending Health Sector Forum and S.A Catholic Aged Care network meetings. Legislative changes are an agenda item at all meetings. Staff are notified of legislation relevant to their role via electronic messaging, memos, meetings and noticeboards. The home has systems and processes to monitor and record police clearances for staff, volunteers and external service providers and advising residents and representatives of the accreditation site audit. Staff are aware of the legislative requirements that affect their role and responsibilities.

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 recommendation Does comply The home has systems and process to monitor that management and staff have the appropriate knowledge and skills. A staff training needs analysis, legislative requirements, performance appraisals, competency assessments, resident and staff surveys, audits, incidents, observations and residents’ changing acuity assist the home to identify key areas for staff education and develop an in-house education planner. Information on training sessions is displayed on noticeboards, in the staff room and is conveyed through staff meetings. The values, mission and training coordinator monitors staff attendance at training sessions. Training packages are provided to staff when mandatory training sessions are missed. Examples of training completed in management systems, staffing and organisational development in the last 12 months include Aged Care Funding Instrument, Better Practice Conference, Continuous Improvement training package and documentation. Staff demonstrated the appropriate knowledge and skill required to perform their duties. Residents and representatives are satisfied that staff are adequately trained and have the necessary skills to complete their roles.

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 recommendation Does comply

Resident are satisfied they have access to complaint processes and feel comfortable providing feedback to the home. Entry discussions, an ‘open door’ management approach and access to information on both internal and external comment and complaint processes, assist residents to provide feedback to the home. Staff are aware of their responsibilities to advocate for residents. Complaints from any source are logged, categorised and actioned by the Director of Care. Confidentiality is maintained where relevant. A summary and evaluation report is tabled at management meetings and opportunities for improvement identified. No significant trends have been noted in the last twelve months. The home monitors the effectiveness of the comment and complaint system through audits and resident satisfaction surveys.


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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 recommendation Does comply The organisation has documented its core values, philosophy and commitment to provision of quality services which has been re-confirmed through strategic planning sessions conducted in 2010. This information is on display in the home and included in resident and staff information books.

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 recommendation Does comply Residents and representatives are satisfied with the care, lifestyle and hospitality services provided and with the responsiveness of staff. The home has systems to ensure staff have the appropriate knowledge and skills to perform their roles effectively. The director of care and/or the hospitality manager screen, select and interview staff who meet the requirements of advertised positions. Orientation processes include a six month probationary period, providing job description, duty lists, staff information booklet and supernumerary shifts. Staff are also introduced to policies and procedures, safety, manual handling and fire safety information and specific competencies related to designated positions. The director of care monitors the staff roster and skill mix and additional hours have been allocated to the roster due to residents’ changing acuity. The home has processes to cover sick and annual leave, and the roster allows for extra hours and shift changes between staff. Agency usage has declined over the last twelve months due to a recruitment drive and the employment of new staff. Registered nurses are available at all times. Staff are satisfied with their working environment and the support provided by management.

1.7 Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply The home has systems and processes to maintain adequate stocks of appropriate goods and equipment to meet residents’ individual needs and preferences. A preferred suppliers list, minimum stock levels, regular ordering and rotating processes assist designated staff to monitor and maintain adequate stocks of medical, catering and hospitability supplies. The director of care oversees the purchasing process and the chief executive officer signs off on purchases over a certain amount. The home has an asset register and equipment is replaced on an as needs basis. New equipment is trialled by staff to ensure it will meet their needs and those of the resident. Safe operating procedures are in place for equipment used by staff. The home has a corrective and preventative maintenance program to maintain equipment in safe


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working order. Electrical equipment is tested and tagged and damaged equipment is appropriately tagged and removed from circulation. External contractors are sourced when specific equipment maintenance is required. Residents, representatives and staff are satisfied the home maintains suitable supplies of the goods and equipment required for quality service delivery.

1.8 Information systems

This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply Information management systems provide management, staff and residents with access to information relevant to their needs. Entry processes include provision of resident advice on care and services, their rights and responsibilities and processes for consultation and feedback. Ongoing communication is supported by regular meetings, newsletters, family conferences, letters, notice boards and access to information brochures relevant to resident needs and interests. Management decisions are informed through the home’s various monitoring processes and regularly reported through scheduled management and staff meetings. Staff roles and responsibilities are supported by regularly reviewed policies and procedures, job descriptions and duty guidelines and required information provided through staff pigeon holes, memos, communication books and notice boards. Information is stored and archived relevant to legislative requirements and there are protection and backup procedures for electronically maintained information. Audit and feedback processes monitor the effectiveness of information management system and staff practice.

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 recommendation Does comply The home has systems and processes to monitor and evaluate externally sourced service providers. The home has a preferred list of approved external providers to provide a range of services including but not limited to allied health, pharmacy, hairdressing, pest control, fire safety and maintenance services. Service agreements and evaluations with external suppliers detail the home’s expectations with regard to service, occupational health safety and welfare requirements, licensing and police checks. Service agreements are reviewed regularly. Management and designated staff evaluate the effectiveness of the services provided through audits, observations and feedback. Where deficiencies have been identified, management will liaise directly with the service providers. Staff, residents and representatives are satisfied with the external services provided.


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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 recommendation Does comply An organisation wide strategic plan outlines key goals and objectives for the home’s continuous improvement program which is managed by a site coordinator and corporate quality manager. A continuous improvement plan and a nursing priority action plan, record continuous improvement initiatives identified from a variety of sources such as, care reviews, family conferences, clinical care audits, incident reports, staff and resident suggestions, surveys and meetings. A continuous improvement register documents small day-to-day improvements by staff and management. Progress on planned actions and evaluation processes are monitored at meetings. Staff and residents are aware of continuous improvement processes and confirm the home’s responsiveness to their feedback. Improvements implemented by the home relevant to health and personal care include: To improve processes for planning and documenting residents’ advanced

directives, the home has implemented ‘Respecting Patient Choices’ a project initiated by SA Health. Following the attendance of selected staff at an external training session the home reviewed all resident documentation in relation to advanced directives in October/ November 2010. This information is now filed in a green sleeve in residents’ clinical notes, briefly outlined on the first page of the electronic care plan and palliative care preferences documented in the hard copy care plan accessible in each resident’s room. This information is included in resident transfer documents and regularly reviewed during care review processes.

Following resident feedback on care, provided during a resident survey, the home has implemented regular ‘activities of daily living’ audits to ensure that staff practices are appropriate and that quality care is being provided to residents. An audit tool was developed and includes questions for staff on their understanding of care requirements for specific residents. While a further survey of resident satisfaction has yet to be conducted, resident feedback about care during the site audit was positive and residents observed to be well groomed.


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 recommendation Does comply The home has systems to monitor and respond to relevant legislation, regulatory requirements, professional standards and guidelines in relation to health and personal care. The home receives regular updates via emails and newsletters of changes to legislative requirements through associations with peak industry bodies and attending Health Sector Forum meetings and S.A Catholic Aged Care network meetings. Legislative changes are an agenda item at all meetings. Staff are notified of relevant legislation relevant to their role via electronic notification, memo, meetings and


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noticeboards. The home has systems and processes to monitor the provision of prescribed care and services, medication management, nursing and allied health professional registration and renewals. Staff are aware of their regulatory responsibilities relating to health and personal care.

2.3 Education and staff development

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


The home has systems and processes to monitor and update staff knowledge and skills in relation to health and personal care. Processes include legislative requirements, training needs analysis, performance appraisals, competency assessments, resident and staff surveys, audits, incidents, observations and residents’ changing acuity. Education and training related to clinical care includes medication management and administration, wound care, pain management, percutaneous endoscopic gastrostomy (PEG) feeding and Better Oral Health in Residential Care. Staff have access to a range of internal and external training and educational opportunities consistent with their role and responsibilities. Staff demonstrated the appropriate knowledge and skill required to perform their duties. Residents and representatives are satisfied that staff are adequately trained and have the necessary skills to complete their roles.

2.4 Clinical care

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


Residents are satisfied with the care they receive. Entry processes identify and document initial care needs and in consultation with the resident, subsequent assessments and observations assist the home to plan resident care. Most assessment tools are electronically based and on-line care plan templates are populated accordingly with additional information added to reflect resident individual preferences. A hard copy plan is accessible in each resident’s room. Allied health services and general practitioners contribute to resident assessment and care planning and regular care reviews include consultation with the resident or their family. Staff are informed about resident care needs through handovers, on- line message alerts, communication books and on-line progress notes. Staff practice and care standards are monitored through incident reporting, clinical care and ‘activities of daily living’, spot checks, audits and resident surveys.

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 recommendation Does comply


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Residents confirm their satisfaction with specialised nursing care provided. Registered nurses assess residents, plan their care and conduct regular reviews. A complex health care needs plan or problem sheets outline specialised care needs and guidelines for care are generally provided. Clinical procedure manuals are accessible to staff who have been provided with training in specialised care such as wound care, oxygen therapy, PEG feeding, and use of infusion pumps. External services may be accessed for some aspects of specialised care. Monitoring processes for specialised care include specialised care audits, incident reporting, resident observations, and resident surveys.

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 recommendation Does comply Residents are satisfied they have access to and are informed of health services available. Assessment processes identify resident requirements for referral and screening services. A physiotherapist and podiatrist assess and regularly review all residents. A referral form and transfer document is used for externally provided services and enables documentation of required changes to treatment. Visiting services document consultation outcomes in residents’ progress notes. A consolidated report on resident reviews by sight, hearing and dental services can be generated through the electronic care management system. Health and related services audits, and staff practice audits monitor the home’s processes

2.7 Medication management

This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply Resident are satisfied their medications are managed safely and correctly. Medications are administered by competency assessed registered and enrolled nurses, according to documented procedures. Medication management and supply audits are conducted, in addition to incident reporting and signature omission checks to monitor staff practice and medication management processes. Medications are supplied in pre-packed dose aids by contracted pharmacy services and are appropriately stored. Medication charts include relevant administration guidelines and resident identification, although indications for ‘as required’ medication use is not consistently documented. Medications are regularly reviewed and there are processes for the assessment and authorisation of self-administration. A medication advisory committee which includes resident representation advises on medication management practices.

2.8 Pain management

This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply


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Residents confirm they are satisfied with how their pain is managed. Residents’ pain management needs are identified through assessment, observation and consultation and regularly evaluated and reviewed. Pain management plans include strategy alternatives to medication such as heat packs, massage, support bandages and splints, advised by the physiotherapist. The use of pain management medication is monitored for effectiveness. A pain management procedure is available to staff who have also received training in identifying and managing resident pain. Pain management audits are conducted and indicate effective processes and resident satisfaction.

2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply Representative feedback confirms the home’s practices maintain the dignity of terminally ill residents. Entry processes include consultation with residents and their family about terminal wishes which are documented in residents’ file and care plan. A specific palliative care plan is developed when palliation is required. A palliative care resource trolley provides required equipment for resident comfort such as aromatherapy, music, and special bed linen. Staff have received training in the provision of palliative care and are supported by external services and the pastoral care team.

2.10 Nutrition and hydration

This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply Residents are satisfied with the home’s approach to meeting their nutrition and hydration needs. A risk based assessment process identifies residents’ nutrition and hydration needs and nutrition plans document dietary requirements, supplements, required utensils and support strategies although resident hydration needs are not consistently recorded. Plans are regularly reviewed and relevant information is communicated to catering services. Resident weights and food and fluid intake is monitored and referrals arranged as required. Between meal snacks and drinks are regularly provided and supplement intake recorded on medication charts. Staff have received training in nutrition and the safe assistance of residents with swallowing deficits and have access to nutrition and hydration protocols. Nutrition and hydration audits are conducted and a dietitian has reviewed the home’s menu.

2.11 Skin care

This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply


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Residents are satisfied with the care provided in relation to their skin integrity. Assessment processes identify residents at risk and skin care plans include strategies to maintain skin integrity such as position change, sheep skins, moisturisers and pressure relieving mattresses. These plans are regularly reviewed. The incidence of skin tears and wound healing rates are monitored and nutrition supplements may be used to promote wound healing. Wound management processes are coordinated and monitored by a registered nurse with a wound management policy and guidelines documented. Wound care training has been provided to the registered and enrolled nurses who attend to wounds.

2.12 Continence management

This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Residents confirm their continence management needs are met. Resident consultation and recorded observations of residents continence patterns and needs assist the home to develop toiletting plans and allocate required aids. Bowel management needs are also assessed and plans to achieve natural bowel patterns documented and regularly monitored. A continence link nurse assists staff and residents across the home to monitor, evaluate and modify continence plans to meet residents’ needs. Urinary tract infections are reported and logged to assess trends. Preventive strategies include a focus on perineal hygiene, cranberry juice and increased fluid intake. Frequent urinalysis is used to monitor at-risk residents and continence management processes are regularly audited.

2.13 Behavioural management

This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply Residents and their representatives are satisfied with the home’s approach to managing challenging behaviours. Initial entry processes included monitoring resident behaviour as they settle into the home. In consultation with the resident, their family, lifestyle staff and the general practitioner behaviour management and lifestyle plans are developed and regularly reviewed relevant to behaviour monitoring outcomes. Referral to external services and consultants has assisted the home to provide an environment conducive to resident behaviour needs. Residents with a tendency to wander are accommodated in a secure unit. No other form of restraint is used in the home. Incidents of aggression are reported and staff provided with accessible information, handover discussions and training to assist them to manage residents safely.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply


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Residents are satisfied that the home supports and encourages their mobility and provides opportunities to enhance their dexterity. A mobility and dexterity plan and a physiotherapy plan is established following assessment of residents’ functional abilities and risk of falling. These plans are regularly reviewed and modified relevant to resident progress and monitored slips and falls. Staff receive manual handling training to assist safe resident transfers and mobility support. A variety of ambulatory aids including electric wheel chairs are accessible to residents and regular exercise classes are conducted by lifestyle staff. Utensils to assist resident independence during meals are provided. Mobility and dexterity management processes are regularly audited.

2.15 Oral and dental care

This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply Residents are satisfied with the home’s approach to assisting them to maintain their oral and dental hygiene. Resident preferences for oral and dental care and dental services are documented and plans regularly reviewed. Care plans included strategies to support oral care in residents resistive to care and those with dentures. There is a toothbrush replacement program. Residents are supported to attend their dentist of choice or a visiting dental service is available. Oral and dental care processes and staff practices are audited and the home has commenced an oral and dental health project which has included staff training and assessment.

2.16 Sensory loss

This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Residents are satisfied with the home’s approach to managing and supporting their sensory deficits. Assessment processes include consultation between care and lifestyle staff and specific plans to enhance resident sensory experiences documented and regularly reviewed. Support for residents may include screen magnifiers, large print and talking books, a garden club, cooking sessions and an audio loop in the chapel. Individual aids are maintained by staff according to care plan instructions. Sensory loss management processes and staff practices are audited.

2.17 Sleep

This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Residents confirm they are able to achieve natural sleep patterns. A sleep flow chart assists the home to monitor residents’ sleep patterns and develop a settling plan and strategies to support adequate sleep and rest. Resident preferences for rising and settling are accommodated and their ongoing needs regularly reviewed. The use of sedation is monitored and reported as minimal. Sleep audits monitor the effectiveness of sleep management processes.


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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 recommendation Does comply An organisation wide strategic plan outlines key goals and objectives for the home’s continuous improvement program which is managed by a site coordinator and corporate quality manager. A continuous improvement plan and lifestyle and pastoral care specific priority action plans, record continuous improvement initiatives identified from a variety of sources such as, lifestyle reviews and evaluations, family conferences, comments and complaints, staff and resident suggestions, surveys and meetings. Progress on planned actions and evaluation processes are monitored at meetings. Staff and residents are aware of continuous improvement processes and confirm the home’s responsiveness to their feedback. Improvements implemented by the home relevant to resident lifestyle include: As a result of resident feedback that they often forgot about special activities and

outings, the home has introduced activity reminder cards. While residents receive a copy of the activity calendar in their room and it is posted on noticeboards, residents said they forgot about special occasions and outings unless they were reminded. Activity reminder cards are now delivered to residents’ rooms the day prior to the activity. This enables them to plan their activities of daily living with staff so they are ready to participate. Residents report this is very helpful enabling them to be better prepared, particularly for outings.

To better provide for residents’ emotional and spiritual care the home has established a pastoral care team. This team is provided by The Sisters of St Joseph as volunteers and is accessible to residents and their families 24 hours a day. Each member of the team has a job description, and an on call schedule is available to advise staff. A new admission form identifies resident preferences for support and requests for daily communion. All denominations are supported. The team is also available to provide support to families and residents during palliation. Residents interviewed indicated they appreciate access to the pastoral care team who provided them with company and a listening ear as well as spiritual support.


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 recommendation Does comply The home has systems to monitor and respond to relevant legislation, regulatory requirements, professional standards and guidelines in relation to resident lifestyle. The home receives regular updates via emails and newsletters of changes to legislative requirements through associations with peak industry bodies and attending Health Sector Forum and S.A Catholic Aged Care network meetings. Legislative changes are an agenda item at all meetings. Staff are notified of legislation relevant to their role via


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electronic messaging, memos, meetings and noticeboards. Residents and representatives are provided with a residential care agreement on entry to assist them to understand their rights and responsibilities, fees and charges and security of tenure. Processes to monitor compliance regarding security of tenure, privacy information and mandatory reporting of resident abuse include compliance audits, surveys and observations. Staff are aware of their regulatory responsibilities relating to resident lifestyle.


This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has systems and processes to monitor and update staff knowledge and skills in relation to resident lifestyle. Processes include legislative requirements, training needs analysis, performance appraisals, competency assessments, resident and staff surveys, audits, observations, residents’ changing acuity and evaluation of the lifestyle program. Education and training related to resident lifestyle issues includes elder abuse, spark of life, ‘colour my world’ workshop and activities for people with sensory loss. Lifestyle staff are satisfied that they have access to a broad range of training and educational opportunities consistent with their role and responsibilities. Staff demonstrated the appropriate knowledge and skills required to perform their duties. Residents and representatives are satisfied staff have the necessary skills to complete their roles.

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 recommendation Does comply Residents and representatives are satisfied with the level of emotional support given on entry to the home and on an ongoing basis. Residents and representatives are given a life history booklet to complete which identify residents’ emotional needs and wishes and these are recorded in the lifestyle care plans. Lifestyle care plans are reviewed by lifestyle staff and updated regularly or as required. Residents are welcomed to the home with a welcome card and flower placed in their room and are orientated to the home and introduced to other residents. Residents are encouraged to personalise their room with familiar items and representatives are kept informed during the settling in period. Residents with cognitive deficits are monitored through observations and verbal and non-verbal cues. Emotional support provided includes one-to-one visits from the Sisters of Saint Joseph, priest, the pastoral care team, pet therapy, community volunteers and hand massages. Resident satisfaction is monitored through emotional support audits, activity evaluations, complaints, feedback, observation and regular and lifestyle care reviews. Staff practices, knowledge and skills are monitored through observations, audits, complaints and performance appraisals.


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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 recommendation Does comply Residents and representatives are satisfied that the home assists them to achieve independence and maintain friendships and participate in the life of the community. The lifestyle and care assessment and review processes identify residents’ individual interests, preferences and family and community associations. Residents are assisted to achieve a level of independence both within the home and the outside community. Residents can maintain their voting rights, access specialised sensory, mobility and dexterity aids, social leave, access cabs, visiting medical and allied health providers, the hairdresser, maintain links to community and culturally specific clubs, weekly exercise classes and library resources. Resident satisfaction is monitored through audits, activity evaluations, complaints, feedback, observation and regular care reviews. Staff understand their responsibility in promoting residents’ independence whilst respecting their right to refuse participation.

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 recommendation Does comply Residents and representatives are satisfied that their right to privacy, dignity and confidentiality is recognised and respected. The home’s orientation process, policies and procedures and staff and resident handbooks outline residents’ rights for privacy, dignity and confidentiality, the Privacy Act and code of conduct. Staff are required to sign a confidentiality agreement. Resident information is stored securely with appropriate access. Staff assist residents in their activities of daily living by promoting and supporting their privacy, dignity and confidentiality needs. Specific strategies include using their preferred name, personal care preferences are respected, knocking on doors before entering, providing care in the privacy of the resident’s room, using privacy capes and screens and ensuring discretion during staff handovers. Resident satisfaction is monitored through audits, surveys, activity evaluations, complaints, feedback, observation and regular care reviews. Staff understand their responsibility in promoting residents’ rights and the importance of maintaining their privacy, dignity and confidentiality.

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 recommendation Does comply


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Residents and representatives are satisfied they are supported to participate in a wide range of interests and individual and group activities. The life history booklet and lifestyle interview identifies residents’ past and current leisure interests and preferred activities, these are recorded in the lifestyle care plans. Lifestyle care plans are reviewed by lifestyle staff and updated regularly or as required. A monthly lifestyle calendar is displayed in the home and each resident receives an individual copy along with a weekly lifestyle program and a coming events information sheet to inform them of the daily activities. Volunteers and staff help assist and support residents to attend individual and group activities, outings and appointments. These include beauty therapy, hand massage, cappuccino mornings, cooking, gardening, bingo, happy hour, movies, exercise to movement and puzzles/quizzes, local community clubs, bus trips and local theatre productions. Resident satisfaction with the lifestyle program is monitored through audits, surveys, activity evaluations, complaints, feedback, observation and regular care reviews. Staff encourage and support residents’ to participate in a wide range of interests and activities whilst respecting their right to refuse participation.

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 recommendation Does comply Residents and representatives are satisfied that their individual interests, customs, beliefs and cultural and spiritual needs are valued and fostered. Residents’ cultural, religious and local significant days and any practices that are of significance to them are identified on entry. Spiritual supports include an on-site chapel, mass service, rosary and communion and one-to-one support from Sisters of Saint Joseph, priests, the pastoral care team, lifestyle staff and volunteers. Cultural, religious and significant days celebrated include Christmas, Easter, Australia Day, Remembrance Day, Anzac Day, Mothers’ Day, Fathers’ Day, birthdays, Mary MacKillop’s Feastday, blessing of the sick, and no meat on Fridays. Resident satisfaction is monitored through audits, surveys, activity evaluations, complaints, feedback, observations and regular care reviews. Staff encourage and support residents’ to participate in a wide range of spiritual and cultural interests and activities whilst respecting their right to refuse participation.

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 recommendation Does comply Residents and representatives are satisfied with the consultation, choice and support provided to make decisions around issues that affect their daily life. Residents’ wishes, likes, dislike and personal care and preferences are identified on entry and these are recorded in the lifestyle care plans. Lifestyle care plans are reviewed by lifestyle staff and updated regularly or as required. The resident information booklet and residential care service agreement contains information on residents’ rights and responsibilities. Aged care advocacy and information is displayed in the home and available in several


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languages. Resident meeting forums, individual discussions with staff and case conferences with family and management and on-site medical and allied health services provide residents with choice over their care and lifestyle needs. Residents’ authorised representatives are identified in care plans and assist the home to make decisions when the resident is unable. Staff assist residents with choice and decision-making with activities of daily living by providing choice with clothing, lifestyle activities, meals and drinks.

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 recommendation Does comply Residents and representatives are satisfied with the information provided and the processes used to assist them to understand their rights and responsibilities and security of tenure. The director of nursing meets with residents and their families prior to entry to assist them to understand the residential service agreement including fees and charges, residents’ rights and responsibilities and security of tenure. Residents and their family are provided with the opportunity to ask questions and seek clarification. The resident information booklet also provides residents and representatives with information. Access to interpreters and appropriate cultural representation is available. The home has ageing in place, when residents and representatives request a change in room this is documented in progress notes.


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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 recommendation Does comply An organisation wide strategic plan outlines key goals and objectives for the home’s continuous improvement program which is managed by a site coordinator and corporate quality manager. A continuous improvement plan and hospitality priority action plans, record continuous improvement initiatives identified from a variety of sources such as, comments and complaints, infection surveillance, internal and external audits, incident, accident and hazard reports, staff and resident suggestions, surveys and meetings. Progress on planned actions and evaluation processes are monitored at meetings. Staff and residents are aware of continuous improvement processes and confirm the home’s responsiveness to their feedback. Improvements implemented by the home relevant to physical environment and safe systems include: Subsequent to the appointment of a new chef in August 2010 the home has

introduced new seasonal menus, special occasion menus and chef’s ‘surprise’ menu once a month. Prior to this appointment there was some dissatisfaction among residents about the meals provided. Residents have participated in the establishment of the new menus and have experienced special occasion meals at Christmas and Australia Day and the chef’s ‘surprise’ menu. The Chef has received compliments from residents about the meals and resident interviews confirmed they are happy with the changes to the menu and the standard of meals provided.

Following the creation of a new position to coordinate hospitality services and to improve the standard of cleaning, the hospitality manager has developed new cleaning routines and schedules for cleaning staff. A cleaning manual has been prepared and is available in each cleaner’s room. This includes a job description, procedures and cleaning schedules which are signed off by the manager each day. Cleaning audits are now regularly conducted and verbal feedback provided to the manager. The home was observed to be clean and tidy and residents confirmed that they are very happy with the standard of cleaning provided.


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 recommendation Does comply The home has systems to monitor and respond to relevant legislation, regulatory requirements, and professional standards and guidelines in relation to the physical environment and safe systems. The home receives regular updates via emails and newsletters of changes to legislative requirements through associations with peak industry bodies and S.A Catholic Aged Care network meetings. Legislative changes are an agenda item at all meetings. Staff are notified of legislation relevant to their role


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via electronic messaging, memo, meetings and noticeboards. Occupational health safety and welfare policies and procedures are in line with professional standards and guidelines and assist the home in providing a safe physical environment. Internal and external audits include pest control, environmental audits, triennial fire safety clearance and food safety audit. Management and staff are aware of their legislated responsibilities for maintaining both personal and environmental safety.


This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has systems and processes to monitor and update staff knowledge and skills in relation to the physical environment and safe systems. Processes include legislative requirements, training needs analysis, performance appraisals, competency assessments, resident and staff surveys, audits, incidents, hazards, observations and residents’ changing acuity. Education and training related to the physical environment and safe systems includes fire and emergency, manual handling, occupational heath and safety, chemical safety, infection control and food hygiene and safe use of equipment. Staff demonstrated the appropriate knowledge and skill required to perform their duties. Residents and representatives are satisfied staff have the necessary skills to complete their roles.

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 recommendation Does comply Residents and representatives are satisfied with the comfort and safety of the living environment and the responsiveness of staff. Residents and representatives are provided with a tour of the living environment on entry to the home. Residents are accommodated in single and shared rooms, with privacy curtains used in shared rooms. Residents are encouraged to personalise their rooms within safety guidelines. Call bells are accessible to residents in their bedrooms and common areas. Alarm and wrist pendants are available for residents with specialised care needs. There are monitoring processes for maintaining a safe and comfortable environment. These include closed circuit television (CCTV), secure key pad entry/exit, sign in/out books for visitors and contractors, scheduled maintenance, testing and tagging of electrical equipment, pest control, cleaning schedules, surveys, feedback, incident and hazard data, various audits and an evening security round. Outside areas and the garden are maintained by the maintenance officer and gardener. Staff are familiar with recognising and reporting a hazard and are aware of their responsibility in reporting and maintaining a safe environment.


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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 recommendation Does comply Management and staff demonstrated they are actively working to provide a safe working environment that meets regulatory requirements. Staff are aware of their responsibilities for occupational health and safety according to the home’s policies and procedures and are aware of the homes incident and hazard reporting system. Risk assessments and safe operating procedures are in place for equipment used by staff. Management monitor the environment through maintenance programs, audits, surveys, workplace inspections, equipment evaluation and incident and hazard data. Occupational health, safety and welfare issues are a standard agenda item at all meetings. Staff receive training in manual handling, chemical use, infection control and fire safety and emergency training. Resident, representatives and staff interviews and review of audit documentation indicate the home is working to provide a safe environment.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s recommendation Does comply The home has safety systems and emergency procedures to minimise the risks associated with fire, security and other emergencies. Staff attend mandatory fire safety and emergency training and participate in evacuation drills. Staff are familiar with their responsibilities in the event of a fire or other emergency. There are evacuation plans, emergency exits, fire equipment and signage displayed through out the home. Emergency exits are free from obstruction. The home has a CCTV security system, key padded entry/exit on some doors and external lighting. There are security checklists in place including at night. Electrical equipment is tested and tagged according to a schedule. The home has a current triennial fire safety clearance. External service providers assist the home to maintain a safe and comfortable environment for example, the fire alarm system and equipment. Chemicals are labelled and stored appropriately. Resident, representatives and staff express their satisfaction with the safety of the home.

4.7 Infection control

This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply The home has an infection control system to identify, manage and monitor risks associated with the spread of infection. Infections are logged and monitored by the director of care. Trending and reporting occurs for all resident infections including urinary tract infections, wound and chest infections. The home has recently improved its reporting process, all infection control statistics are now discussed at the monthly occupational health, safety and welfare meetings. Other processes include sharps


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containers, use of protective equipment including single use items, sanitising hand gel located through out the home, colour coded cloths and mops, food labels, resident and staff vaccination programs and monitoring temperatures in the kitchen and laundry areas. Pest control programs and waste management are managed by external providers. Further monitoring occurs through internal and external checks, audits and surveys. The home has an audited food safety program. Staff receive training in hand washing techniques, infection control and food safety.

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 recommendation Does comply Residents and staff confirm that hospitality services are provided to their satisfaction and contribute to their comfort and enjoyment of living and working in the home. Hospitality services are coordinated by a hospitality manager. Residents are informed of the services provided and their preferences communicated to the manager. Dietary needs are documented on a ‘food service requirement’ form and advised to catering services. Meals are served according to resident choices in dining rooms or areas set aside for residents requiring staff support. On-site laundry services are available to manage residents’ personal items, while linen is laundered by contracted services. A naming system reduces the risk of losing residents’ clothing items and an ironing service is available. Cleaning services are provided according to regular and special cleaning schedules and responsive to residents’ privacy requests. Infection control guidelines are a component of hospitality service procedures and staff practices are monitored through regular audits. Resident satisfaction is confirmed through resident surveys, residents’ meetings and personal discussion with the hospitality manager.

decision to accredit flora mcdonald lodge nursing home · home name: flora mcdonald lodge nursing...

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