decision to accredit wesley gardens nursing home · to the following executive summary of the...

Decision to accredit

Wesley Gardens Nursing Home

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Wesley Gardens Nursing Home in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Wesley Gardens Nursing Home is three years until 1 September 2012. 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: Wesley Gardens Nursing Home Date/s of audit: 15 June 2009 to 19 June 2009 RACS ID: 2629 AS_RP_00851 v2.3

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Home and Approved Provider details Details of the home Home’s name: Wesley Gardens Nursing Home

RACS ID: 2629

Number of beds: 140 Number of high care residents: 137

Special needs group catered for: • Dementia

Street/PO Box: 2B Morgan Road

City: BELROSE State: NSW Postcode: 2085

Phone: 02 9452 3022 Facsimile: 02 9975 9359

Email address: [email protected]

Approved provider Approved provider: The Uniting Church in Australia Property Trust NSW

Assessment team Team leader: Greg Foley

Team member/s: Lynda Walton

Allison Watson

Date/s of audit: 15 June 2009 to 19 June 2009


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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

2.1 Continuous improvement Does comply Does comply 2.2 Regulatory compliance Does comply Does comply 2.3 Education and staff development Does comply Does comply 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

3.1 Continuous improvement Does comply Does comply

3.2 Regulatory compliance Does comply Does comply

3.3 Education and staff development Does comply Does comply

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

4.1 Continuous improvement Does comply Does comply

4.2 Regulatory compliance Does comply Does comply

4.3 Education and staff development Does comply Does comply

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.

SITE AUDIT REPORT

Name of home Wesley Gardens Nursing Home

RACS ID 2629 Executive summary This is the report of a site audit of Wesley Gardens Nursing Home 2629 2B Morgan Road BELROSE NSW from 15 June 2009 to 19 June 2009 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 Wesley Gardens Nursing Home. The assessment team recommends the period of accreditation be 3 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.

Name of home: Wesley Gardens Nursing Home RACS ID 2629 AS_RP_00857 v1.2 Dates of site audit: 15 June 2009 to 19 June 2009


Site audit report

Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 15 June 2009 to 19 June 2009 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of three 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: Greg Foley

Team member/s: Lynda Walton

Allison Watson Approved provider details Approved provider: The Uniting Church in Australia Property Trust NSW

Details of home Name of home: Wesley Gardens Nursing Home

RACS ID: 2629

Total number of allocated places:

140

Number of residents during site audit:

137

Number of high care residents during site audit:

137

Special needs catered for:

Dementia

Street/PO Box: 2B Morgan Road State: NSW

City/Town: BELROSE Postcode: 2085

Phone number: 02 9452 3022 Facsimile: 02 9975 9359

E-mail address: [email protected]


Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Wesley Gardens Nursing Home. The assessment team recommends the period of accreditation be 3 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 five days on-site and gathered information from the following: Interviews

Number Number

Regional director 1 Residents 18

Executive residential care manager 1 Representatives 15

Director of nursing 1 Volunteers 1

Human resources manager 1 Recreational activities officers 3

Admissions officer 1 Chaplaincy staff 3

Deputy director of nursing 1 Catering services manager 1

Education manager 1 Catering staff 1

Team leaders 2 Laundry supervisor 1

Registered nurses 6 Contract laundry staff 1

Care staff 12 Contract cleaning staff 4

Physiotherapist 1 Maintenance manager 1

Physiotherapist aid 1 Regional property manager 1

Occupational therapist 1 Fire safety officer 1

Regional occupational health and safety manager 1

Sampled documents

Number Number

Residents’ files 17 Medication charts 15

Residents’ files - lifestyle 25 Personnel files 10

Residency agreements 7


Other documents reviewed The team also reviewed: • Accident and incident reports • Audits – internal, external and summaries • Behaviour charts • Catering - suppliers service agreements, menu, dietician’s report, NSW Food Authority licence,

food safety program, daily resident menu order, diet preferences and special needs assessments, temperature records, delivery checks, cleaning worksheet, continuous improvement plan

• Cleaning – manual, duty statements, schedule and records, inspection reports • Clinical performance indicator report • Clinical procedures • Clinical skill assessments • Clinical supply list • Code of Ethical Behaviour • Comments and complaints log • Compliments folder’ • Contact action plan – The Luke centre • Continence charts • Continuous improvement plan • Document distribution folder • Education - action plan, diary, mandatory education records, regional training calendar • Elder abuse register • End of life issues folder • External service providers - service agreements, site inductions, service reports, contracts

register, list of approved providers, emergency contact numbers • Fire safety and emergencies - inspection records, annual fire safety certificate, emergency

procedures manual, fire alarm protocol, staff booklet, security memo, daily security checks, evacuation list of residents

• Infection control – manual, infection register, monthly infection reports, staff training records, staff vaccination records, resident consent for influenza vaccinations, memos, audits, clinical performance reports

• Job descriptions • Laundry – manual, duties list, cleaning schedule, labelling records, temperature records • Maintenance and asset management system (MEX) – maintenance requests, reports,

preventative maintenance schedule, asset register • Meeting Minutes – relatives and friends, recreational activities officers and chaplains,

occupational health and safety committee, staff, infection control committee, nursing care staff, registered nurses, recreational activity officers, catering committee

• Occupational health and safety – policies, environmental inspections, audits, incident reports and register, risk analysis register, staff education records, manual handling information, material safety data sheets

• Opportunities for improvement • Orientation – program, orientation review • Pain assessments • Pastoral care – Chaplaincy policy and guidelines, pastoral care awareness booklet and

welcome pack for residents • Police checks • Policy and procedures manual • Privacy policy and Privacy statement for residents and consent forms for use of personal

information • Professional registration • Records of reportable assault • Recreational activities records – including: programs, attendance records, evaluations, monthly

reports, newsletters, photographs, handover sheets, communication diaries


• Recruitment policies and procedures • Residential aged care facility handbook for resident relatives and carers • Residents’ information handbook • Residents’ information package and surveys • Rosters • Sleep charts • Staff employment pack • Staff Handbook • Staff review • Staff visas register • Summary of achievements • Vision, values, mission and commitment to quality statements • Wandering charts • Wound care charts Observations The team observed the following: • Activities in progress • Administering of S8 medication • Application of topical treatments • Charter of residents’ rights and responsibilities • Cleaning in progress and cleaning trolley • Daily menu board and menu (on display) • Equipment and supply storage areas and supply levels • External environment - gardens and courtyards • Fire safety plans and equipment • Infection control – notices, equipment, hand washing facilities, personal protective equipment • Interactions between staff and residents • Large clock in dining room • Living environment – residential accommodation and communal areas • Medical dictionary • Medication rounds • Medication storage areas • Murals • Noticeboards for residents and staff • Occupational health and safety notices and equipment • Oral and dental trolley • Photography activity board • Resident call system • Security of documents • Security system and security fencing/access • Staff education notice board and resources • Staff work areas – care stations, kitchen, cleaners room, utility rooms, offices, maintenance

room, treatment rooms, staff room • Staff work practices • Suggestion box • Telephone • Vision mission and values statement displayed in the home • Visitors sign in and out register


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 The home has a system to actively pursue continuous improvement that facilitates the identification of improvements opportunities, which incorporates a number of activities including the quality plan, continuous improvement plan and continuous improvement register. Improvements are identified through a number of avenues including: resident and relative meetings, staff meetings, audits, surveys, comments, complaints and compliments, accident and incident reports and staff performance appraisals. The quality improvement plan also includes ensuring compliance with the Accreditation Standards through undertaking the annual audit program which covers 44 expected outcomes. The home uses these indicators along with other input from residents/relatives/staff to identify opportunities for improvement and to develop improvement plans. Residents, representatives and staff reported that they have opportunities and are encouraged to participate in the home’s continuous improvement activities through providing feedback and making suggestions for improvement through the home’s continuous improvement feedback mechanisms. Examples of recent improvements in relation to Accreditation Standard One include: • The home has implemented a new continuous improvement plan to make tracking and logging

of Continuous improvement easier. • The home has established register for staff visa’s, ensuring existing and new staff have

appropriate working visas. • The home has adjusted staff lunch hours improving the time frame for delivering resident care

with improved outcomes for residents. • The home has distributed more comments and feedback flyers around the home, also flyers

reminding relatives of relatives meetings are displayed a month before the scheduled meeting. This system ensures residents and their families have easy access to the home’s complaints process and advance knowledge of the date for upcoming relatives meeting.

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 The home has systems to identify and ensure compliance with changes in relevant legislation, professional standards and guidelines. The organisation accesses relevant information through membership with a peak aged care industry organisation; subscription to legislative update services; from government departments, attendance at professional meetings and seminars; accessing the internet and other sources. The information is reviewed and regulatory and legislative changes are discussed at executive level, changes are made to policy and procedures, and changes are sent to the home in the form of information or policy/practice changes. Facility management communicate changes to staff by memoranda, staff meetings and staff education sessions. Compliance with regulatory requirements is monitored through audits, surveys, competency assessments, staff appraisals and observations by management. Specific examples of regulatory compliance relating to Accreditation Standard One include: • Procedures for police checks for staff, volunteers and contractors are in place. Interviews and

documentation confirm that these have been completed.


• The home has a system to ensure nurses’ registrations are current. • The home has a system whereby the home’s code of ethical behaviour is signed by all staff –

new and existing. 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 to enable staff to have appropriate knowledge and skills to perform their roles. An annual learning and development program and calendar of education sessions is developed. This calendar also includes mandatory training sessions and sessions considered of interest or important to various staff members. Various learning packages are provided that are competency based. Education and training requirements are identified through staff performance appraisals, internal audits and staff requests. Staff are supported by management to attend internal and external courses and conferences. Participation records are maintained and reviewed by management when planning future education program schedules. Staff interviews indicated that they were provided with training as part of the home’s orientation process and have access to on-going education. Specific examples of education and staff development relating to Accreditation Standard One include: • The home regularly undertakes orientation sessions for new staff and this occurs at facility and

at the organisation’s regional level. • A new teaching tool, skills package, questionnaire and competency for hand washing are part of

the home’s new education initiative. • Medical dictionaries have been purchased and are available in all areas of the home for staff

referral. • All staff have been given one-to-one education on the use of new software for documenting

residents’ care. • The home has provided staff training on the Aged Care Funding Instrument. 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 Information about internal and external complaints’ mechanisms is provided to residents and representatives on entry to the home through the resident handbook and their orientation to the home. Information is also communicated on a regular basis through resident and relative meetings and information displayed throughout the home. Staff are made aware of these mechanisms through the staff handbook, policies and procedures and staff meetings. Forms for suggestions and complaints are available in the home. Brochures about the external complaints’ mechanism are also available. Staff interviews demonstrated that they have knowledge and understanding of the complaint handling process and of their role in assisting residents in raising issues if they need help. Issues arising from complaints are communicated to staff via memoranda, staff meetings or by private discussion, as appropriate. Review of discussions and actions documented in the complaints register indicates that issues raised are responded to in an effective and timely manner. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".


Team’s recommendation Does comply The home embraces UnitingCare Ageing’s Inspire Strategy and the home’s vision, mission and values are well documented and on display in a variety of locations throughout the home. This information is also available in a number of documents including the resident handbooks and other publications by the home. The home’s vision, mission and values form a part of the staff orientation program and are discussed regularly at staff meetings. 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 The home has a system in place that aims to ensure there are enough staff with appropriate skills and qualifications to meet residents’ care and lifestyle needs. The staffing requirements of the home are reviewed by the facility manager to ensure the sufficiency of human resources. Management report that factors considered to ensure the adequacy of the home’s staffing levels and skill mix include, but are not limited to: residents’ care and lifestyle needs; quality performance indicators; feedback from staff; residents and representatives; the layout of the home and occupational health and safety requirements. There are systems for staff orientation, education and performance management. Recruitment policies and procedures ensure that the best possible match between candidates and roles are achieved. Job descriptions, selection criteria and reference checks are used by management to increase the effectiveness of the process. Staff are provided with position descriptions and duty lists for their roles. Performance appraisals are conducted and results are fed into the home’s human resource management system. 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 demonstrated that it has a system in place to ensure the availability of stocks of appropriate goods and equipment for quality service delivery. The home enters into service agreements with approved suppliers and has processes in place to identify the need to re-order goods, address concerns about poor quality goods, maintain equipment in safe working order and replace equipment. Maintenance records show that equipment is serviced in accordance with a regular schedule and reactive work is completed in a timely manner. The system is monitored through regular audits, surveys, meetings and the feedback mechanisms of the home. The team observed adequate supplies of goods and equipment available for the provision of care, to support residents’ lifestyle choices and for all hospitality services. Staff confirmed they have sufficient stocks of appropriate goods and equipment to care for residents and are aware of procedures to obtain additional supplies when needed. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply There are information management systems to provide management and staff with information to perform their roles and to keep residents and their representatives informed. The home has a staff information system which includes staff handbook, orientation and training sessions, staff meetings, communication book, shift handovers and memoranda, and management’s open door policy. The


home utilises these communication channels to disseminate information and to collect feedback. Information is also placed on notice boards and education sessions are used to keep staff informed of current work practices. Residents and their representatives are kept informed through the information provided on admission, resident and relatives meetings and verbally. Access to confidential information and records is controlled and limited to authorised personnel. Observations demonstrated that resident and staff files are stored securely. 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 There is a system in place to ensure all externally sourced services are provided in a way that meets the home’s needs and service quality goals. Service agreements are entered into with contractors for the provision of services and all external service providers are required to have current licences, insurance and comply with relevant legislation and regulatory requirements. There are schedules for all routine maintenance work to be undertaken by contractors and there is a list of approved service providers who are used on a needs basis. Residents are able to access external services such as hairdressing, podiatry, optometry and other allied health professionals. The services provided are monitored by management at a local and regional level through regular evaluations, audits and the feedback mechanisms of the home and there is a system for managing non-conformance of suppliers.


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 The home has a system to ensure that regular audits are undertaken to review clinical and personal care provision and to identify opportunities for improving the processes. Audit results are benchmarked; data is also obtained from clinical indicators including medication incidents and infection rates. Opportunities for improvements are also identified through: resident and relative meetings, staff meetings, comments, complaints and compliments, accident and incident reports and staff performance appraisals. Staff awareness and training in regard to quality improvement is evident from minutes of staff meetings and staff suggestions related to clinical and personal care as detailed in the continuous improvement plan and continuous improvement register. Examples of specific improvements relating to this Standard include: • The home has introduced a system whereby supplement forms are in the medication folders

with clear instruction and signing space for staff. • The home has introduced a system whereby all medication charts are computer generated with

information regarding allergies, and medications that can be ‘crushed’. Photographic identification is now shown on all medication blister packs.

• The home has updated all outbreak boxes ensuring all boxes in each nursing area contain standardised stock, and information regarding influenza and gastroenteritis, ensuring that appropriate care is provided to residents in the advent of an influenza or gastroenteritis outbreak.

• The home has purchased new wound management manuals for wound and registered nurses to use as resource material, ensuring that appropriate wound care is provided to residents.

• A deficit in oral care was noticed during the evening care rounds. A trolley with oral care equipment was developed to assist in the ease of implementing oral health care

• A recently refurbished “Dove Room” is in place for the comfort of residents in the end of life stage and who do not have a single room. The room includes sleeping space for relatives who wish to stay overnight.

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 recommendation Does comply Refer to expected outcome 1.2 Regulatory compliance for details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, and professional standards and guidelines. The team observed the home has information available for staff on legislation and guidelines relating to health and personal care. Specific examples of regulatory compliance relating to Accreditation Standard Two include: • The home monitors the currency of nurse registrations. • The home has reviewed restraint minimisation policies and procedures and also introduced an

auditing procedure to monitor restraint documentation. 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 recommendation Does comply Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Documentation reviews indicate that staff attended a variety of education sessions related to Accreditation Standard Two and these include but are not limited to: hand washing, oral hygiene, wound care and care dementia course. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply Residents clinical care needs are assessed upon entry to the home, annually and as care needs change with consultation from residents and their representatives. Identified issues are documented in the resident care plans and interventions are developed for individual care needs. Evaluation of care plans occur at least every three months but more frequently for the introduction of better practice or changes in care needs. Residents and their representatives reported being satisfied with clinical care received. 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 The home has systems in place to identify specialised nursing care needs. There is evidence in the resident files viewed of identified and met needs in this regard. Residents and their representatives expressed satisfaction with the care of specialised nursing care needs and also express confidence in the competence of the staff available to deliver this care. There are appropriately qualified staff to ensure specialised nursing care needs are met appropriately. Any deficiencies in staff skills are addressed with appropriate education. 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 Systems in place identify resident’s needs for referrals to other health and related services. Referrals occur and are consistent with the residents care needs. Referrals are documented in resident files and reminders of appointments are communicated to other staff through shift hand over and are also diarised. Information from specialists is added to residents’ files and where possible the specialist documents this in the relevant progress notes. Residents and representatives expressed satisfaction with the assistance provided in accessing other health services, and when those services are accessed outside the home, the staff ensure appropriate transportation. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply


There are systems in place in the home to ensure safe and correct administration of medications. Medications are administered by registered nurses. Medications are administered and stored in accordance with NSW health legislation. There is a pharmacist available for emergencies 24 hours per day who liaises with staff and medical practitioners to ensure appropriate medications are charted and available at all times. Medication audits are attended on a regular basis and there is a medication management committee in place with a consultant pharmacist who attends the home. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”.

Team’s recommendation Does comply There are systems in place at the home to ensure all residents are as free as possible from pain. Pain levels are evaluated on each resident on entry and assessments used to assist in identification in those who are unable to communicate pain relief needs. These assessments occur annually and when there are changes in the residents’ condition. Interventions for pain management are monitored for their effectiveness. Care needs including individual non verbal indicators of pain and interventions in relation to pain relief are documented in the progress notes and in the care plans. These interventions also include pain relief measures other than analgesia including repositioning, heat packs and physiotherapy. There is also evidence of consultation to relevant health care professionals in relation to unresolved pain. Residents and their representatives expressed satisfaction in staff commitment to the comfort of resident and interventions in relation to pain management. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply There are systems in place in the home to ensure the comfort and dignity of the terminally ill residents is maintained. There are advanced care directives in place and the staff go to great lengths to ensure that individual request and needs are met where possible. There is a quiet room for residents in the end stages of life to provide privacy for those in shared rooms. The quiet room also accommodates sleeping facilities for friends and/or relatives, and the management provide meals for those staying. Consultation is sought from the area palliative care team to ensure best practise for individual care needs and these needs are communicated to staff through the homes documentation processes. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply The residents at the home receive adequate nutrition and hydration. Residents are assessed for their needs in relation to nutrition and hydration on entry, annually and when care needs change. A dietician is consulted for menu planning and a varied diet is offered. Residents are monitored for deficits in nutrition and hydration. For example, residents’ weights are monitored each month and losses are identified and actioned with the addition of supplements and/or other interventions to encourage intake. Staff are aware of the need to encourage fluid intake and this is identified in individual care plans, in particular for those residents with recurrent urinary tract infections or those who are unable to access fluids independently 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”.


Team’s recommendation Does comply Residents’ skin integrity is monitored upon entry and care in relation to the residents’ skin integrity and care needs are documented from day one. Pressure area care is documented on the care plan as well as the individuals need for creams or emollients. Residents who are at high risk for skin break down such as pressure sores are given nutritional supplements. Various types of supplements are available depending on the individuals needs. For those residents with higher needs the supplements are documented in medication orders and administered by the registered nurse. Residents’ and their representatives’ report to be highly satisfied with the care received in relation to skin integrity. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Residents’ needs in relation to continence management are assessed upon entry to the home in consultation with the residents and their representatives. Residents identified with continence issues are monitored over several days to establish individual needs. These needs are documented in care plans and communicated to staff via progress notes and shift handover. Continence aids are provided and education is given to staff on a regular basis from the supplier of the continence aids on their most effective use, plus other issues related to continence management. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply There are systems in place to identify challenging behaviours on entry with consultation from residents and their representatives. Residents are then observed and regular documentations occurs to identify patterns of behaviour, identify triggers to challenging behaviours and effective individualised interventions. A care plan is then developed for individual management of residents with challenging behaviours. These interventions are reviewed annually plus when care needs change. Incident forms are completed when incidents of challenging behaviour occur. 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 The residents have a very thorough mobility assessment on entry to the home conducted by the homes physiotherapist, physiotherapist aide and occupational therapist. Mobility and dexterity programs are developed and individual range of motion exercises are implemented by care staff each morning. All individual mobility programs are documented in electronic care plans plus the quick reference care plans readily accessible to care staff. Group exercises also occur in all areas of the home. The home has a large pool of mobility aids in particular wheel chairs. Residents assessed as being suitable are assisted and educated in the use of motorised wheelchairs. There is a system of training and when deemed safe by the occupational therapist these residents are able to mobilise independently. Residents are also assessed by the occupational therapist and provision and instruction for use in other equipment such as railings, splints and specialised eating utensils.


2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply Residents’ oral and dental health status is assessed on entry to the home, and continuously monitored on a daily basis. There is an oral health trolley that contains all the equipment for oral health care for individual needs during care rounds. The residents have access to a dentist and dentures are labelled. Oral care needs and interventions are documented in resident care plans and these are evaluated every three months or as needs change. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Residents sensory losses are identified on entry to the home and needs and individual interventions are documented in the care plans. This is reviewed annually or as changes in needs occur. Staff are aware of the care of hearing aids and glasses. Residents have access to specialised consultation to relevant health care professionals. There is a library which includes large print books and resources such as games with large print used in the activities program to enable participation for visually impaired residents. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply The home assesses individual sleep patterns and preferences, in consultation with residents and their representatives, upon entry to the home, on a yearly basis and when care needs change. The residents’ sleep patterns are observed over a period of time where needed. Individual interventions are documented in care plans and implemented these interventions include appropriate lighting, minimising noise, warm drinks, regular exercise programs and where possible observation of residents preferences in usual sleep patterns. Where sleep difficulties continue medical officers are consulted for the prescription of medications to assist with sleep.


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 Performance in relation to residents’ lifestyle and leisure is monitored through audits, surveys, resident feedback by way of compliments and complaints and through resident and relative meetings. Residents and relatives are advised of outcomes as appropriate. Improvements achieved in Standard Three include, but is not limited to: • In order to improve residents’ independence light weight wheelchairs have been purchased for

residents to go on outings. • The home has purchased an easy to read wall clock which is mounted in the residents’ dining

room where residents are able to view the time with greater ease. 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 recommendation Does comply Refer to expected outcome 1.2 Regulatory compliance for details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, and professional standards and guidelines. The home has information available on legislation and guidelines relating to resident lifestyle. Specific examples of regulatory compliance relating to Accreditation Standard Three include: • The director of nursing monitors residents movements to ensue security of tenure is maintained

and is based on applicable legislation. • Confidentiality agreement signed by all new and existing staff to protect privacy and dignity at

both regional and local level. 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 recommendation Does comply Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Interviews and documentation reviews demonstrate that staff have knowledge and skills relating to resident lifestyle. Documentation indicated that staff attended a variety of education sessions related to Accreditation Standard Three including: • Training sessions have been held on effectively dealing with grief and bereavement. • Dementia education for recreational activities officers. • Education on the new Recreation and lifestyle manual, and documentation.


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 The home has a system in place to ensure residents receive support in adjusting to life in the home and on an ongoing basis. When residents come to the home they are provided with information about the home, introduced to key staff and are given an orientation. Staff and particularly the chaplaincy team and recreational activities officers provide one to one support for new residents to help them settle into the new environment. They also maintain regular contact and are available at times of special need. The education program enables the staff to better understand the needs of residents and observations of staff interactions with residents showed warmth, respect, empathy and understanding. Family and friends are encouraged to visit and volunteers visit a number of residents who do not get regular family visits. Residents/representatives interviewed expressed satisfaction with the emotional support offered by management and staff. 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’ individual care needs are identified when they come to the home and strategies are implemented to assist them to maintain maximum independence. Residents are encouraged to participate in the recreational activities of the home and activities are designed to cater for individual abilities and needs. The program includes: outings; an exercise program, to help residents maintain their strength and dexterity; and a number of entertainers, volunteers and community groups who help the residents keep in touch with the wider community. A kiosk, run by volunteers, provides a place for residents to socialise and entertain their visitors and the home provides a service where residents can get cash advances from their personal accounts. The home facilitates the independence of individuals as special needs arise with initiatives such as an electric wheelchair, a personal computer and arranging for a resident to return to their family home for palliative care. Residents are able to personalise their living space and staff encourage them to maintain as much independence as possible in their personal care. The effectiveness of the assistance provided to residents in relation to their independence is monitored through regular review of care plans, audits and the feedback mechanisms of the home. Observations by the team and residents/representatives interviews confirmed that residents are encouraged to maintain their independence and participate in the life of the community within and outside the home. 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 The home has a policy to ensure each resident’s right to privacy, dignity and confidentiality is recognised and respected. Residents are provided with information relating to their right to privacy and written consent is sought from residents/representatives for the use of personal information when they come to the home. Staff are provided with training on privacy and residents’ rights during their orientation and are required to sign confidentiality agreements and a code of ethical behaviour on appointment to their positions. The team observation of interactions between staff and residents show that staff respect the privacy and dignity of residents, knocking and waiting for permission before entering residents’ rooms and referring to residents in a dignified manner. All personal information is collected and stored securely with access by authorised staff only and there are


procedures for archiving and disposing of documents in accordance with privacy legislation. The system to maintain the privacy and dignity of residents is monitored by regular audits, meetings and the feedback mechanisms of the home. Residents/representatives interviewed are satisfied their privacy, dignity and confidentiality is recognised and respected. 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 The home has a policy of providing a recreation and lifestyle program to meet the interests, needs and capabilities of individual residents. The leisure interests and needs of residents are identified through the admission process and by the ongoing assessment and observations of the recreational activities officers. A person centred activity plan is developed to identify activities for residents with dementia. The home has three separate sections, including two secure units for residents with dementia, and each section has its own recreational activities officer who develops activities programs to cater for their residents. The programs have a range of activities that include, group activities, exercises, art therapy, music therapy, pet therapy, bus outings, church services and entertainers. One-to-one attention for the residents is provided for those residents who are less capable of active participation in the program or choose not to take part in group activities. The recreational activities officers keep records of resident attendance and evaluate the activities provided. The residents/representatives interviewed indicated that they are encouraged and supported to participate in the recreation and lifestyle program and are satisfied it is meeting their leisure interests and needs. 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 The home has a system for ensuring that residents’ individual interests, customs, beliefs and cultural and spiritual values are fostered. Information is gathered about residents’ interests, customs, beliefs and cultural and ethnic backgrounds through a social profile and assessments and this information is used to cater for residents needs. Support is arranged for residents from a culturally and linguistically diverse background as needed with such resources as the community carers with the same language, translating services and cultural advisors. Culturally specific meals are available and provision is made for the celebration of special cultural and religious days relevant to the residents. The home has a chapel and a chaplain and pastoral care team are available for all residents. They provide individual pastoral care, run ecumenical religious services and group discussions, and arrange for visits by clergy or representatives from different denominations. The residents/representatives interviewed are satisfied with the care the home provides for the support of their cultural and spiritual lives. 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 The home has processes in place to ensure residents participate in decisions about the services provided and are enabled to exercise choice and control in relation to their lifestyle. Residents/representatives are provided with information to assist them in making informed choices. Residents indicate their likes and preferences when they move to the home and these are


documented in resident notes and care plans. The team observed staff consult with residents about their wishes and preferences and the choices of residents are respected in relation to care activities (e.g. shower times), leisure activities, lifestyle and beliefs. The effectiveness of the system in place to ensure residents are able to exercise choice and control over their lives is monitored through audits, meetings and the feedback mechanisms of the home. Staff interviewed were able to describe ways they encourage and support residents to make choices and decisions and residents/representatives stated they are enabled to participate in decisions about the services they receive and are able to exercise choice and control over their lifestyle. 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 There is a system to ensure that residents understand their rights and responsibilities regarding their tenure at the home. The home’s admission’s officer advised that where possible residents or their representative are offered an opportunity to visit and view the facilities. Information on the admission process and paperwork required by relevant government departments such as Centrelink is discussed. An information package is available which includes a copy of the residential agreement as well as information on the internal and external complaints resolution mechanisms. Residents and their representatives are able to take the residential agreement away to read and are always advised to seek independent legal advice before signing. The team noted that the agreement covers fees, services provided and outlines the terms under which the agreement can be terminated.


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 The home has a system that enables it to actively pursue continuous improvement. For further information relating to the home’s continuous improvement system, please see expected outcome 1.1 Continuous improvement. Examples of recent improvements in relation to Accreditation Standard Four include: • New furniture has been purchased for dining and lounge rooms. Documentation regarding

capital expenditure and maintenance associated with the home is now kept on file in the home for easy reference by facility personnel.

• In order to improve the attractiveness of blank wall and door space, murals have been painted giving residents a more attractive environment.

• The home has developed plans to provide identification of emergency facilities, for example; gas, water and electricity. Plans have been laminated and displayed in all areas of the home.

• The home has purchased call bell extensions, enabling residents to use call bells at different locations within their rooms.

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 recommendation Does comply Refer to expected outcome 1.2 Regulatory compliance for details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home has a wide range of information available to staff on legislation and guidelines relating to the physical environment and safe systems. Specific examples of regulatory compliance relating to Accreditation Standard Four include: • An injury register has been established and the physiotherapist, physiotherapist-aide and

occupational therapist are trained in injury reporting, return to work programs and the legal obligations involved.

• Mandatory manual handling and fire safety training has been implemented for all staff. • The home has implemented a food safety program, which is monitored by the catering

manager. 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 recommendation Does comply Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Interviews and documentation reviews demonstrated staff have knowledge and skills relating to the physical environment and safe systems.


Education sessions and activities that relate to Accreditation Standard Four include, but are not limited to: manual handling, infection control, fire safety, and food safety training. The majority of this training is mandatory and staff attendance is monitored by management and is competency based. 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 The home consists of three separate sections, including two secure areas for residents with dementia, and is collocated with a low care home. Residents living in the two secure areas are accommodated in individual rooms with ensuite bathrooms and those in the nursing care section are accommodated in multiple and single bed rooms with shared toilet and bathroom facilities. There are a number of communal areas and lounge rooms as well as courtyards and gardens for each area. The living environment is clean, well furnished, and has a heating/cooling system to maintain a comfortable temperature. The buildings and grounds are well maintained with a program of preventative and routine maintenance. The safety and comfort of the living environment is monitored through environmental inspections, resident/ representative feedback, incident/accident reports, audits and observation by staff. Management is actively working to provide a safe and comfortable environment consistent with the residents’ care needs and the residents/representatives interviewed expressed their satisfaction with their living environment. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply Management has a system in place to provide a safe working environment that meets regulatory requirements. The organisation has an occupational health and safety policy and oversees the workplace safety of the home through its regional structure. An occupational health and safety committee has trained representatives from all departments of the home and has regular meetings to manage occupational health and safety within the home. All staff are trained in manual handling, occupational health and safety and emergency procedures during their orientation and on an on-going basis. Equipment is available for use by staff to assist with manual handling and personal protective equipment is available for staff safety. The home monitors the working environment and the occupational health and safety of staff through regular audits, risk and hazard assessments, incident and accident reporting and daily observations by management, occupational health and safety representatives and maintenance staff. The staff interviewed show they have a knowledge and understanding of safe work practices and were observed carrying them out. 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 There is a system in place to provide an environment and safe systems of work that minimise fire, security and emergency risks. A trained fire safety officer oversees fire safety at the home and all staff take part in mandatory training in fire awareness and evacuation procedures. Inspection of the external contractor records and equipment tagging confirms that the fire fighting equipment is regularly maintained and the current annual fire safety statement is on display. Emergency flipcharts and evacuation plans are displayed throughout the home and evacuation packs with current resident lists of all residents are located at the nurses’ stations in case of evacuation.


Security is maintained at night with a lock-up procedure, security lighting and monitoring by closed circuit television. The systems to minimise fire, security and emergency risks are monitored through occupational health and safety and staff meetings, internal audits and external inspections. Staff interviewed indicated that they know what to do in the event of an emergency and residents interviewed stated they feel safe in 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 ensures that its infection control program is effective through clear policies and procedures, education and an infection surveillance program. The director of nursing coordinates the program with the support and supervision of the organisation. The home has mandatory training in infection control and hand washing competencies are assessed. Hand washing facilities, personal protective equipment and other equipment is available to enable staff to carry out infection control procedures. The infection control program also includes an outbreak management policy and kits, a food safety program used in the kitchen, a vaccination program for residents and staff, pest control and waste management. The staff interviewed show they have a knowledge and understanding of infection control and were observed implementing the program. The program is monitored through reporting of all infections, trend analysis, audits, benchmarking and organisational review. 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 The hospitality services provided are meeting the needs of the residents and are enhancing their quality of life. All residents are assessed for their dietary preferences and needs when they move into the home. There is a six week menu that has been assessed by a dietician, caters for special diets and provides choices for residents. It is updated regularly with input from residents/representatives. The home is cleaned by full time contract cleaners. The cleaning is carried out according to a schedule and the quality of the cleaning is monitored by the management and staff of the home and the contractor supervisor. The team observed the home to be clean and residents/representatives state they are very satisfied with the results. Personal clothing is laundered at the home daily and linen is supplied by a contractor and laundered off site. The home has a labelling machine to clearly mark clothing and minimise losses and there is a system in place for the management of misplaced clothing. The hospitality services are monitored through audits, meetings and the feedback mechanisms of the home. Residents/representatives interviewed said they are satisfied with the hospitality services provided.

decision to accredit wesley gardens nursing home · to the following executive summary of the...

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