dp jones nursing home...dp jones nursing home racs id 4345 38 impey street murchison vic 3610...

DP Jones Nursing Home

RACS ID 4345 38 Impey Street

MURCHISON VIC 3610

Approved provider: Murchison Community Care Inc

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 22 May 2018.

We made our decision on 10 April 2015.

The audit was conducted on 03 March 2015 to 04 March 2015. The assessment team’s report is attached.

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

Home name: DP Jones Nursing Home RACS ID: 4345 2 Dates of audit: 03 March 2015 to 04 March 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

DP Jones Nursing Home 4345


Introduction

This is the report of a re-accreditation audit from 03 March 2015 to 04 March 2015 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 03 March 2015 to 04 March 2015.

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

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

Assessment team

Team leader: Jill Packham

Team member: Margaret Edgar

Approved provider details


Details of home

Name of home: DP Jones Nursing Home

RACS ID: 4345

Total number of allocated places:

40

Number of care recipients during audit:

39

Number of care recipients receiving high care during audit:

25

Special needs catered for: n/a

Street: 38 Impey Street

City: Murchison

State: Victoria

Postcode: 3610

Phone number: 03 5826 2551

Facsimile: 03 5826 2466

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Management/administration 5

Clinical/care/lifestyle 9

Allied health/external contractors 2

Care recipients/representatives 11

Hospitality/environment 5

Sampled documents

Category Number

Care recipients’ files 8

Summary care plans 9

Care recipients’ financial files 6

Medication charts 9

Personnel files 7

Other documents reviewed

The team also reviewed:

Activity program documents

Advanced care plans

Allied health referrals and reports

Audits

Catering and dietary management records

Clinical observation and care management documents

Comments and complaints forms and register

Consent forms

Continuous improvement forms and register

Education and competencies records


External services agreements

Fire, security and emergency documents

Food safety records

Handover and communication documents

Human resource management documentation

Incident reports, analysis and trending data

Inventory and equipment records

Laundry and cleaning schedules

Mandatory reporting register

Meeting minutes, memoranda and newsletter

Occupational health and safety documents

Police certificates and statutory declarations

Policies and procedures

Position descriptions

Preventative and corrective maintenance records

Professional registrations and qualifications

Re-accreditation self-assessment

Residents’ information package and handbook

Roster

Satisfaction survey

Specialised nursing care records

Staff employment pack and handbook.

Strategic plan

Vision and mission statement

Weight management records.

Observations

The team observed the following:

Activities in progress


Catering, cleaning and laundry equipment and practices

Charter of residents’ rights and responsibilities

Cleaning in progress

Equipment and supply storage areas

External complaints and advocacy brochures

Fire, security and emergency equipment and signage

Infection control equipment

Interactions between staff and residents

Internal and external living environment

Internal feedback forms and suggestion boxes

Medication administration, storage and disposal systems

Menu displays and meal services

Mission statement

Noticeboards and information displays

Nurses’ stations resources

Short group observation in the Brisbane dining room

Staff room resources

Storage of medications

Waste management systems.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The organisation’s quality systems effectively identify, action and evaluate continuous improvements across the Accreditation Standards. Management sources information through stakeholder feedback, analysis of audits and monthly clinical data collection, resident needs, legislative changes and strategic planning. Management logs, monitors and evaluates actions with input from relevant departments. Continuous improvement is an agenda item at all relevant meetings. Identified improvement opportunities may result in reviews of policies and procedures, equipment purchases, additional staff training and updates to the audit schedule. Residents, representatives and staff are aware of the various avenues to make comments, complaints and suggestions and are encouraged to be part of continuous improvement at the home.

Improvements over the last 12 months relating to Standard 1- Management systems, staffing and organisational development include:

Management identified the need for a comprehensive information booklet for new residents. They sought guidance from specialist consultants and researched handbooks available at other homes. The newly developed handbook provides clear, practical information on care and services at the home along with their mission statement and relevant policies relating to safety and residents’ rights.

The home’s electronic care program became outdated and unsupported by the service developer. Management sourced other available programs and installed a new system in July 2014. The program includes care management, staff messaging and monitoring reports for analysis and trending of data collection. The new system provides ongoing service support and updating of the software program.


1.2 Regulatory compliance

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

Team’s findings


Management receives regular information and updates on professional guidelines and legislative requirements through membership to peak bodies and notifications from professional networks and government departments. Processes ensure the revision of relevant policies and procedures when required. Monitoring of compliance is through internal and external reviews and the auditing schedule. Dissemination of information to staff regarding changes to regulations and the home’s practices is through electronic alerts, meetings and education sessions. The home notifies residents and representatives of any relevant changes to legislation.

Regulatory compliance at the home relating to Standard 1 - Management systems, staffing and organisational development includes:

Staff, volunteers and external contractors have current police certificates and signed statutory declarations as needed.

Nursing staff have current professional registrations.

The home notifies staff, residents and representatives of re-accreditation site audits.

Staff receive a Fair Work statement on commencement of employment

Confidential documents are stored and destroyed securely.

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


1.3 Education and staff development

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

Team’s findings


The education and staff development program supports management and staff to maintain the required knowledge and skills to perform their roles effectively. Recruitment and orientation processes include identification of skills and the provision of education to ensure appropriate skills and knowledge. Management develops the annual education program based on the outcomes of performance reviews, quality activities, mandatory training requirements and the monitoring of residents’ care needs. Education systems include online learning and individual education opportunities for management and staff. Staff receive email notification of their education requirements, which includes a link to the corresponding online education site. Staff and management said they have opportunities to attend education and they receive support to participate in learning and development opportunities.

Recent education relating to Standard 1 - Management systems, staffing and organisational development includes:

computer skills

bullying and harassment

complaint management

funding tool.

1.4 Comments and complaints

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

Team’s findings


Management provides stakeholders with access to internal and external complaints handling mechanisms. Information on the complaints process is in the information handbook given to residents and representatives prior to entry and is documented in their agreements. The home displays external complaints and advocacy brochures and provides access to internal comments and complaints forms and secure suggestion boxes. The home has an open door policy and regularly consults with staff, residents and representatives providing group and individual forums to raise issues or concerns. Analysis of complaint data occurs and feeds into the continuous improvement system. Residents, representatives and staff are aware of the process and documentation shows matters are actioned appropriately and in a timely manner.


1.5 Planning and leadership

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

Team’s findings


The home’s mission statement is on display and published in stakeholder documents. The home’s plan for continuous improvement confirms a commitment to providing ongoing quality service reflective of their philosophy.

1.6 Human resource management

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

Team’s findings


Management systems ensure there are appropriately skilled and qualified staff sufficient to ensure delivery of care and services according to the home’s vision and residents’ needs. Recruitment processes include identification of necessary qualifications and skills, interview guidelines and reference checks. New staff complete a structured orientation process and work buddy shifts with experienced staff before commencing regular shifts. Roster and leave vacancies are managed using regular or casual bank staff. Appraisals, competencies and management observations monitor staff skills and practices and assess the effectiveness of the staffing roster. Staff said they have sufficient time to perform their roles and are satisfied with staffing levels. Residents and representatives are satisfied with the care provided and the availability of staff to meet the needs of residents.

1.7 Inventory and equipment

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

Team’s findings


Management demonstrates systems to ensure appropriate goods and equipment are available for quality service delivery. Key personnel monitor stock levels and re-ordering processes are through an approved suppliers list. Adherence to maintenance and cleaning programs occurs and electrical equipment is tested and tagged for safety. Reviewing and updating of goods and equipment reflects identified special needs of the current resident population. New equipment is trialled prior to purchase and staff receive training. Equipment, supplies and chemicals are securely stored with access restricted to authorised personnel.

Residents and staff stated adequate supplies of appropriate goods and equipment are available at all times.


1.8 Information systems

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

Team’s findings


The organisation has a range of strategies to ensure staff have access to current information necessary for the effective delivery of services and to inform residents and representatives of activities and care management. Newsletters, care consultations, meetings and informal discussions provide ongoing information. Policies and procedures, education, meetings, handover, communication books, daily diaries and position descriptions inform staff. Key data is routinely collected, analysed and is available for relevant staff to review. Electronic records are password protected with restricted levels of access. Resident and staff files are stored, archived and destroyed securely according to regulations. Staff, residents and representatives are satisfied with their level of access to relevant information provided at the home.

1.9 External services

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

Team’s findings


The organisation has systems to ensure the ongoing quality and responsiveness of externally sourced services. Management annually monitors contractors’ insurance cover, police certificates and qualifications and ensures services meet relevant regulations.

Contractors undertake an orientation to the home prior to commencing. The organisation regularly reviews satisfaction with externally sourced services through feedback from management, staff, residents and representatives, audits, surveys and observations. A list of preferred service providers is available and staff have access to after hours’ emergency assistance. Staff and residents are satisfied with the quality of currently sourced external suppliers.


Standard 2 – Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team.



Team’s findings


The home actively pursues continuous improvement in relation to residents’ health and personal care. The audit schedule includes monitoring of clinical outcomes and monthly incident/infection data is collated and analysed. Identified issues result in corrective actions through the quality system. Refer to expected outcome 1.1 Continuous improvement for more information about the home’s systems and processes.

Improvements over the last 12 months relating to Standard 2 – Health and personal care include:

Staff suggested an alternative pain patch chart to track treatments and outcomes. The new sheets contain more precise information and clear documentation of daily applications. Staff feedback is positive to the new strategy for managing residents’ pain.

The home introduced an electronic program for wound monitoring to replace the previous paper based system. The program generates daily alerts and instructions for staff and produces monthly reports for trending and analysis. The new system provides improved, consistent wound management with better outcomes for residents.



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

Team’s findings


Management ensures compliance with regulations and guidelines regarding health and personal care through their policies and procedures, regular auditing, staff education and clinical competencies. Refer to expected outcome 1.2 Regulatory compliance for more information about the home’s systems and processes.

Regulatory compliance at the home relating to Standard 2 – Health and personal care includes:

Appropriately qualified staff provides medication management and specialised nursing care.

Medication is stored securely.

The home has a current policy for missing residents with appropriate incident reporting and notification processes



Team’s findings


Management and staff demonstrate appropriate knowledge and skills to perform their roles effectively in relation to the provision of health and personal care. The education plan is responsive to changing resident care needs, incident trends, staff performance and audit results. Staff responsible for medication complete competencies annually or more frequently if required. Refer to expected outcome 1.3 Education and staff development for more information about the home’s systems and processes.

Recent education relating to Standard 2 - Health and personal care includes:

palliative care

medication management

movement disorders

promoting healthy skin.


2.4 Clinical care

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

Team’s findings


Care recipients receive clinical care according to their needs and preferences. Initial identification of clinical and care needs occurs when the resident enters the home, providing the basis for care until the assessment and care planning process is complete. Nursing staff review care plans three monthly, consulting with the resident and/or representative. Care plans describe needs and preferences and are consistent with handover information and staff feedback. External health specialists provide reports and contribute to care plan development and review. Communication systems inform staff and other health professionals of changes in residents’ care. Staff report on clinical indicators such as skin tears, falls, behavioural and medications incidents. Management monitor clinical care through clinical data analysis, care plan reviews and stakeholder consultation. Residents and representatives are satisfied with the clinical care residents receive.

2.5 Specialised nursing care needs

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

Team’s findings


Appropriately skilled registered and enrolled nurses identify, manage and attend to residents’ specialised nursing care needs. Referrals and consultation with other health professionals occurs with outcomes documented and reviewed. Care plans detail residents’ assessed need, nursing interventions and preferences. Resources available to staff include clinical policies and procedures, specialist equipment and staff have access to specialised care education. Management monitor specialised nursing care using audits, clinical data analysis and stakeholder feedback. Residents and representatives are satisfied with the specialised care provided to residents.

2.6 Other health and related services

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

Team’s findings


Referral to health specialists occurs according to residents’ needs and preferences. Management provides residents and representatives with information about health specialists assisting them to make informed choices. Medical review and care assessments identify residents requiring referral to other health specialists. A range of health specialists visit the home and staff assist residents to attend external appointments. Staff include specialist Instructions with the care plan and review process and care staff confirmed they receive information when residents’ care changes. Audits and care reviews monitor outcomes of referrals. Resident and representatives are satisfied with the assistance residents receive to access other health specialists.


2.7 Medication management

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

Team’s findings


Registered and enrolled nurses administer medications in accordance with legislative guidelines and the home’s medication policy and procedures. The initial assessment, completed when the resident enters the home, identifies medication requirements and preferences, allergies and any assistance needed. Medication charts and care plans include clear medication orders, identification information and detail residents’ preferences for taking medication. Processes include checking of medications not included in dose administration aids and for the administration of ‘as required’ medications. Medications are stored securely and there are procedures to maintain supply and to dispose of unnecessary medication. The medication advisory committee, medication reviews, audits and the incident reporting system contribute to the monitoring of medication systems. Residents and representatives are satisfied with the management of residents’ medication.

2.8 Pain management

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

Team’s findings


Pain management strategies ensure all care recipients are as free as possible from pain. Initial assessments identify residents’ present and past pain experiences and effective coping strategies. Assessment and management plans include consideration of disease progression, cultural and spiritual requirements and treatment choices. Assessment tools include a process for residents who cannot verbalise their pain. Staff complete reassessment and charting for new or continuing pain. Staff described a range of comfort measures they use to relieve residents’ pain including heat and massage therapy, keeping the resident company, repositioning and medication. Management monitor for effectiveness of care using care reviews, medication, audits and feedback. Residents and representatives are satisfied with the management of residents’ pain.

2.9 Palliative care

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

Team’s findings


Care management systems and staff practices ensure dignity and comfort for residents nearing the end of their life. Residents or representatives have the opportunity to discuss their preferences and wishes on entry and continue the discussion as required. Staff review care and develop an individual palliative care plan in consultation with resident, representatives and other health professionals to address end of life care. Medical practitioners and registered nurses regularly review care and staff have access to palliative care specialists if needed. There are sufficient goods and equipment to provide palliative care and staff complete relevant


education. Audits and feedback mechanisms monitor the effectiveness of palliative care processes. Staff described empathetic end of life care including consideration of the resident’s preferences and wishes, dignity, comfort and spiritual care.

2.10 Nutrition and hydration

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

Team’s findings


Care recipients receive adequate nourishment and hydration. Initial assessment and ongoing nutritional care plans identify allergies, special dietary requirements, details of any assistive devices, personal and cultural preferences and clinical needs. Processes include monitoring of residents’ weight and referral to dietitian and speech pathologist as necessary. Staff assist residents at mealtimes and provide adaptive cutlery and crockery to enable independence when eating. Dietary information in the kitchen reflects residents’ needs, preferences and any specialised dietary requirements. The care review includes monitoring of residents’ weight and nutritional status and the need for referral to other specialists. Residents and representatives are satisfied with the presentation and variety of food available to residents.

2.11 Skin care

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

Team’s findings


Care recipients’ skin integrity is consistent with their general health. Initial and ongoing assessments, including a risk assessment process, identify residents’ skin care needs and preferences and contribute to the development of the care plan. Skin care interventions include pressure relieving devices, specific hygiene and skin moisturising strategies, mobility reviews, position changes and nutritional strategies. Wound care includes appropriate wound dressings, documentation and evaluation of care and referral to wound care specialists as required. Audits, stakeholder consultation, incident and care plan reviews monitor the effectiveness of care. Residents and representatives are satisfied with the care residents receive to manage their skin integrity.

2.12 Continence management

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

Team’s findings


The continence program ensures residents receive care to manage their continence needs. Processes include assessments to identify conditions affecting continence, the need for specialist referral and effective management strategies. Following assessment and evaluation staff implement a plan for residents continence care. Care plans include consideration of dietary measures, indicators to identify infections, behavioural concerns and strategies to optimise bladder and bowel function. Staff confirm access to equipment and knowledge of


residents’ continence needs and preferences. Care plan review and program evaluation include audits, monitoring of aid use and obtaining feedback from residents and staff. Residents and representatives are satisfied with the assistance residents receive for continence care.

2.13 Behavioural management

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

Team’s findings


Care and nursing processes ensure staff identify care recipients presenting with challenging behaviours and develop effective management strategies. Staff commence the assessment of behaviour patterns when the resident enters the home and continue with additional monitoring and review as required. Care plans include behavioural triggers, strategies to manage and minimise identified behaviours and consideration of any impact for other residents. There is a minimum restraint policy which includes an assessment and trial of alternatives before any form of restraint is considered. Referrals to behavioural management specialists occur when necessary. Staff are aware of the home’s processes for managing incidents associated with behaviours. Management monitor behaviour management outcomes using incident data analysis, audits care plan reviews and feedback from residents, representatives and staff. Residents and representatives are satisfied with staff’s response to any challenging behavioural events.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


Care recipients have access to care and equipment to maintain optimum levels of mobility and dexterity. Assessment and care plans detail residents’ mobility and transfers, individual preferences, manual handling instructions and strategies to minimise the risk for falling.

Suitable mobility aids are available and assessments include the management and use of lifting devices. Staff complete incident reports following resident falls and a physiotherapist visits the home on a regular basis. The education program includes manual handling and education relating to transferring residents safely. Management monitor mobility and dexterity outcomes using audits and stakeholder feedback. Residents and representatives are satisfied with the care and opportunities provided to manage residents’ mobility.


2.15 Oral and dental care

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

Team’s findings


The maintenance of care recipients’ oral and dental health occurs effectively. Initial and ongoing assessment ensures staff identify residents’ oral and dental care needs and preferences. Care plans contain details of dental status, oral care preferences, level of staff assistance required and any specialised mouth care. Oral and dental health specialists visit the home or residents can attend outside specialists as needed. Care plan reviews include consultation with the resident or representative, replacement of dental care products and the need for referral to other specialists. Residents and representatives are satisfied with the assistance residents receive to maintain their oral and dental care.

2.16 Sensory loss

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

Team’s findings


Assessment and care planning processes ensure staff identify and manage care recipients’ sensory losses effectively. The initial and ongoing assessments identify resident sensory care needs for vision, hearing, communication, tactile experiences and sensation. Residents’ usual health care providers are identified and staff initiate referrals to specialists such as audiologists, optometrists and speech therapists in accordance with assessed needs Residents’ sensory care plans detail specific individual strategies including the level of assistance required, care of aids and strategies to optimise sensory function. Evaluation occurs through care plan reviews, audits and stakeholder consultation Residents and representatives are satisfied with the support residents with sensory loss receive.

2.17 Sleep

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

Team’s findings


Residents are able to achieve natural sleep patterns. Nursing staff identify resident sleep needs and preferences using entry and ongoing assessments. Staff consult with residents and representatives identifying preferred rising and retiring times and personal preferences such as use of night lights, pillows and previous routine to induce sleep. Care plans document individual preferences including comfort measures to promote sleep, individual rituals and preferences for day rest, retiring and waking. Management monitor residents’ sleep requirements by audits and stakeholder feedback. Residents said they sleep well, the home is quiet at night and staff respond to their needs.


Standard 3 – Care recipient lifestyle

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



Team’s findings


The home has a system for monitoring and improving outcomes relating to the residents’ lifestyle experiences. Feedback on the effectiveness of the program and ideas for improvement are from resident surveys, meetings and evaluation of activity participation levels. Refer to expected outcome 1.1 Continuous improvement for more information about the home’s systems and processes.

Improvements over the last 12 months relating to Standard 3 – Care recipient lifestyle include:

Residents expressed interest in learning more about other cultures following an increase in staff from other countries and relatives sharing stories of recent overseas holidays. Lifestyle staff introduced cultural days into the activity program. The special days focus on food, music and costumes from other nations with staff or relatives sharing information on the chosen country. Residents have enjoyed the days already held and staff plan to continue with the activity.

To record residents’ involvement in the activity program, staff developed photographic folders. Each resident has their own folder with photographs to keep in their room. This stimulates conversations with visitors and informs families of the different activities offered. Residents are proud of their folders and enjoy sharing them with visitors, staff and other residents.



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

Team’s findings


The organisation’s policies and procedures, staff education and monitoring systems ensure staff are aware of and comply with relevant regulations relating to residents’ lifestyle. Refer to expected outcome 1.2 Regulatory compliance for more information about the home’s systems and processes.

Regulatory compliance at the home relating to Standard 3 – Care recipient lifestyle includes:

The home has appropriate documentation to record incidents of elder abuse and maintains a consolidated register for mandatory reporting matters.

Information for residents on their rights and responsibilities, security of tenure and privacy and consent issues are contained in their handbooks and service agreements.

Guardianship and powers of attorney information is on file.

The home displays posters of the Charter of care recipients’ rights and responsibilities.



Team’s findings


Management support staff with an education program to ensure they have the required knowledge and skills in relation to residents’ lifestyle. Lifestyle staff network with other homes and source educational resource material to continuously enhance their skills. Refer to expected outcome 1.3 Education and staff development for more information about the home’s systems and processes.

Recent education relating to Standard 3 - Care recipient lifestyle includes:

elder abuse and mandatory reporting

privacy and dignity.

certificate IV in leisure and lifestyle

cultural diversity and communication.


3.4 Emotional support

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

Team’s findings


Management and staff provide initial and ongoing emotional support to residents and representatives. New residents and representatives meet with management and receive an information pack and handbook explaining services and levels of care. They go on a tour of the facility and meet other residents and staff. After a settling-in period assessments capture past and current social and emotional histories. Care plans document preferences, triggers and strategies for the residents to enjoy life at the home. Residents are encouraged to personalise their rooms and staff invite representatives to join in activities and maintain close contact. The home has access to psycho-geriatric specialists and counselling services if required. Regularly reviewed care plans capture change and the activity program schedules individual time with residents. We observed staff interacting with residents in a caring and friendly manner and residents said the home meets their emotional needs.

3.5 Independence

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

Team’s findings


Management and staff demonstrate they support residents to achieve optimal independence, maintain friendships, family connections and community links. The home’s assessment and care planning process identifies residents’ cognitive, mobility and dexterity levels, any risk taking behaviours and preferences for social interaction. Exercise programs assist to maintain mobility and strength and lifestyle programs include sensory stimulation activities and community outings. The home assists residents to vote in elections, shop for personal items, attend community groups and entertain visitors. Supplied equipment aids and utensils encourage independence and audits ensure the environment is free of hazards. Residents stated they feel they are part of the local community and said staff assist them to be independent.

3.6 Privacy and dignity

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

Team’s findings


Management and staff respect each resident’s right to privacy, dignity and confidentiality. The organisation provides information to residents and staff on their privacy and confidentiality policies. Residents sign consent forms for the release of personal information and the display of photographs and names. The home accommodates residents predominantly in single rooms with ensuite bathrooms. There are effective strategies to maintain privacy and dignity


for residents in double rooms with shared bathrooms. The home has numerous internal and external areas to meet with visitors and provides separate rooms to hold private functions. Files are kept in secure areas, handover occurs discreetly and residents can lock their doors. Staff knock before entering rooms and address residents by their preferred name. Residents said staff treat them with respect and maintain their privacy.

3.7 Leisure interests and activities

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

Team’s findings


Management and staff support and encourage residents to participate in a range of activities and events both in groups and individually. Lifestyle profiles capture past and current interests, preferences for social interaction and community and family links. Care plans document these choices and regular reviews reflect changes in the individual needs of the residents. Activity evaluations, surveys, feedback from meetings and participation records monitor satisfaction and residents make suggestions for future planning. Community groups and volunteers are welcomed at the home and residents receive assistance to go on outings and to maintain individual hobbies. Friends and family are encouraged to be involved in their life at the home and to join in activities. Residents stated staff assist them to attend the daily events and they are satisfied with the variety of the activities program.

3.8 Cultural and spiritual life

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

Team’s findings


Management and staff demonstrate they foster and value residents’ cultural and spiritual lives. Initial assessments and care plans document preferences including celebratory days, beliefs, religious choices, cultural preferences and palliative care wishes. Staff access interpreters if needed. Local parishes provide group and individual religious services. Cultural and volunteer groups are welcome and staff assist residents to attend community clubs and events. Special events and significant days are celebrated and residents’ dietary preferences accommodated. Residents stated satisfaction with the support provided to meet their cultural and spiritual needs.


3.9 Choice and decision-making

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

Team’s findings


Management and staff are committed to promoting the residents’ right to participate in choices and decisions regarding their clinical care and lifestyle preferences. Authorised powers of attorney or guardianship information is available where required. Regular risk assessments and care plan reviews capture change. Displayed brochures, handbooks and agreements contain information on residents’ rights and responsibilities, the complaints process, external advocacy services and policies relating to clinical care and lifestyle choices. Audits, surveys and feedback from meetings monitor satisfaction and staff have access to policies and procedures on this outcome. Residents stated satisfaction with their ability to make independent choices and decisions.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Management ensures new residents understand their security of tenure, rights and responsibilities, financial obligations and services offered. An information handbook and formal agreement covers policies on termination of occupancy and strategies in place to deal with harassment and victimisation. Consultation occurs in the event of the need to move a resident to another room or to a more appropriate facility. Residents and representatives are encouraged to seek external legal and financial advice and power of attorney/guardianship information is on file. The home has an open door policy to discuss any concerns and the organisation forwards relevant correspondence to inform of changes. Residents and representatives feel secure in the residents’ tenancy and understand their rights and responsibilities.


Standard 4 – Physical environment and safe systems

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



Team’s findings


The home actively pursues continuous improvement to ensure residents live in a safe and comfortable environment. Confirmation of ongoing effective strategies and ideas for improvements are through feedback from residents, representatives and staff, maintenance requests, environmental audits and incident and infection data analysis. Refer to expected outcome 1.1 Continuous improvement for more information about the home’s systems and processes.

Improvements over the last 12 months relating to Standard 4 – Physical environment and safe systems include:

A recent gastroenteritis outbreak identified staff would benefit from additional training to reinforce infection management practices. Staff attended compulsory sessions run by two external specialist services. Management report staff now have a greater awareness and understanding of outbreak management practices including protective clothing and equipment storage systems and their expected actions in the event of any future outbreaks.

A recent audit identified gaps in the cleaning program including inconsistent documentation of completed tasks. Management introduced a new template for cleaning staff to sign off daily which captures all scheduled duties in residents’ rooms and common areas. Management report the new strategy has resulted in improved cleaning, infection control, communication and accountability.



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

Team’s findings


Management has systems to identify and ensure compliance with relevant regulations to provide a safe and comfortable environment for residents and staff. Refer to expected outcome 1.2 Regulatory compliance for more information about the home’s systems and processes.

Regulatory compliance at the home relating to Standard 4 – Physical environment and safe systems includes:

Staff receive ongoing education on fire and emergency procedures, safe food handling, infection control and manual handling.

Chemicals are stored appropriately with accompanying material safety data sheets.

The kitchen has a current food safety program and certifications by external authorities.

Effective monitoring and maintenance of fire and safety regulations occurs.

The home adheres to occupational health and safety policies.



Team’s findings


Management has systems to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to physical environment and safe systems. Staff confirmed completion of mandatory education and demonstrated knowledge of their role and responsibilities. Refer to expected outcome 1.3 Education and staff development for more information about the home’s systems and processes.

Recent education relating to Standard 4 - Physical environment and safe systems includes:

infection control

emergency management

food safety

manual handling.


4.4 Living environment

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

Team’s findings


Management and staff are actively working to provide a safe and comfortable environment. The home provides generally well maintained internal and external environments with appropriate signage and security features. Furnishings and equipment are consistent with residents’ care and safety needs. Residents and visitors have access to a variety of private and communal areas to meet and refreshments are available. Monitoring of safety and satisfaction with the environment is through surveys, audits and a preventative and corrective maintenance program. Policies and procedures guide staff practices and meet regulatory requirements. Residents and representatives were complimentary of the comfort and safety of the environment.

4.5 Occupational health and safety

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

Team’s findings


The occupational, health and safety management program provides a safe working environment for staff that meets regulatory requirements. On-site trained representatives meet regularly with the quality committee to review safety related issues and improvement suggestions. Responsibilities include conducting environmental audits, trialling new equipment and monitoring and mentoring staff practices. Staff receive ongoing training for manual handling, fire and emergency, safe chemical management and infection control. They have access to policies and procedures to guide work practices. Incidents and infections data is analysed and hazards and maintenance requests dealt with in a timely manner. Identified opportunities for improvement feed into the continuous improvement plan. Staff stated they have access to appropriate equipment and aids to reduce the risk of injury.

4.6 Fire, security and other emergencies

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

Team’s findings


There are systems for the detection, prevention and management of fire, security and other emergencies. The home has fire detection and alarm systems installed and service records confirm external contractors undertake regular inspections and maintain equipment.

Evacuation kits are available including a current list of residents noting their mobility levels. Evacuation maps are on display, exits are clearly signed and free of obstruction and external assembly areas are marked. The home has keypad and closed circuit camera security


systems and provides effective after hours’ emergency measures. Visitors are required to sign a register on entry and exit. Education records confirm staff attend mandatory fire and emergency training at orientation and annually thereafter. Residents receive relevant information in their information handbook, written instructions on the back of their doors and at meetings. Staff are able to detail their actions in the event of an emergency evacuation and residents and representatives were satisfied with fire and security measures in the home.

4.7 Infection control

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

Team’s findings


The home has an infection control program to identify and manage infection risks and includes protocols for the management of infectious outbreaks. The program includes an infection surveillance program, data collection, actioning of identified trends, audits, staff orientation and ongoing education and competency programs. A staff and resident vaccination program is in place. There are supplies of protective clothing and equipment for the disposal of sharps and infectious waste. Food safety, pest control and environmental services comply with legislation and infection control guidelines. Management monitors infections and present monthly reports at relevant meetings. Staff demonstrated understanding of infection control practices. Residents and representatives said they are satisfied with the management of any residents’ infections.

4.8 Catering, cleaning and laundry services

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

Team’s findings


The provision of hospitality services enhances the quality of life for care recipients and the staff’s working environment. An external company provide meals to the site using cook chill technology according to a seasonal menu developed in consultation with residents and dietary services. Staff determine residents’ meal choices each day and alternative meals are readily available. Effective systems ensure catering staff have current information relating to residents’ nutrition and hydration requirements, food allergies, preferences and choices.

There is a registered food safety plan, current kitchen registration and annual food safety training for all staff. Cleaning systems and schedules guide staff to complete cleaning tasks. An external company provide laundry services for all linen and an onsite laundry provides for residents’ personal items. There are systems to minimise cross infection and ensure residents receive their correct laundry in a timely manner. Residents and representatives are satisfied with the catering, cleaning and laundry services.

dp jones nursing home...dp jones nursing home racs id 4345 38 impey street murchison vic 3610...

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