published decision (sa and ra) - quality agency · following an audit we decided that this home met...

Reconsideration Decision

Rosstown Community RACS ID: 3031

Approved Provider: City of Glen Eira

Reconsideration of decision regarding the period of accreditation of an accredited service under section 2.19(1)(a) of the Quality Agency Principles 2013.

Reconsideration Decision made on 22 November 2017

Reconsideration Decision An authorised delegate of the CEO of the Australian Aged Care Quality Agency has decided to vary the decision made on 29 April 2015 regarding the period of accreditation. The period of accreditation of the accredited service will now be 20 June 2015 to 20 January 2019.

Reason for decision Under section 2.69 of the Quality Agency Principles 2013, the decision was reconsidered under ‘CEO’s own initiative’.

The Quality Agency is seeking to redistribute the dates for site audits for a number of services that have demonstrated consistent and sustained compliance with the Accreditation Standards to achieve a more level distribution of the timing of accreditation site audits over a three year period. More information is available on our website at http://www.aacqa.gov.au/publications/news-and-resources/redistribution-of-aged-care-accreditation-program.

The Australian Aged Care Quality Agency will continue to monitor the performance of the service including through unannounced visits.

This decision is effective from 22 November 2017

Accreditation expiry date 20 January 2019

http://www.aacqa.gov.au/publications/news-and-resources/redistribution-of-aged-care-accreditation-program



Rosstown Community RACS ID 3031 6 Ames Avenue

MURRUMBEENA VIC 3163

Approved provider: City of Glen Eira

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 20 June 2018.

We made our decision on 29 April 2015.

The audit was conducted on 24 March 2015 to 25 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: Rosstown Community Dates of audit: 24 March 2015 to 25 March 2015 RACS ID: 3031

3

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.


decision




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


4

Standard 3: Resident lifestyle

Principle:

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


decision




3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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


decision




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


1

Audit Report

Rosstown Community 3031


Introduction This is the report of a re-accreditation audit from 24 March 2015 to 25 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


2

Audit report

Scope of audit An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 24 March 2015 to 25 March 2015. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: Lesley Richardson

Team members: Andrew Duncan

Jennifer Thomas

Approved provider details


Details of home

Name of home: Rosstown Community

RACS ID: 3031

Total number of allocated places:

53

Number of care recipients during audit:

47

Number of care recipients receiving high care during audit:

Not applicable

Special needs catered for:

None

Street: 6 Ames Avenue State: Victoria

City: Murrumbeena Postcode: 3163

Phone number: 03 9568 0199 Facsimile: 03 9563 0174

E-mail address: [email protected]

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


3

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

Interviews

Number Number

Management 3 Care recipients/representatives 16

Clinical care/nursing staff 3 Lifestyle staff 2

Care staff 5 Environmental staff 6

Allied health professionals 2

Sampled documents

Number Number

Care recipients’ files 17 Medication charts 9

Care recipients’ agreements/ files

5 Personnel files 5

Other documents reviewed The team also reviewed:

Activity calendars, resources and evaluations

Audit schedule, summary data and audits

Business plan, budgetary and purchasing documentation

Cleaning schedules and temperature monitoring records

Complaints register and complaint tracker forms

Compliments and complaints forms and correspondence

Continuous improvement plan, improvement log and self-assessment

Contractor service agreements

Dangerous drug register

Education calendar, attendance records and competency test records

Food safety program, audits, dietary information and menu

Handover sheet and resident list

Incidents, infection and clinical monitoring folders including charts

Maintenance and essential services records

Mandatory reporting register

Meeting minutes, memoranda and agenda

Mission statement and statement of values

Newsletters for staff and residents

Police certificates, statutory declarations and professional registration databases

Policies and procedures

Referral information


4

Resident handbook and information pack

Rosters

Staff and volunteer handbooks, orientation information, position descriptions and duty lists

Surveys.

Observations The team observed the following:

‘Charter of care recipients’ rights and responsibilities’ on display

Activities in progress and equipment in use

Cleaning and laundry service in progress

Compliments and complaints forms, support statement poster, brochures and locked box

Document storage and administration in progress

Emergency and firefighting equipment, egress routes and pathways

Equipment and supply storage areas including signage

Evacuation information

Interactions between staff and residents

Internal and external living environment including smoking area

Maintenance in progress

Meal and refreshment service

Notice boards and information on display

Personal protective equipment, spill and outbreak kits

Resident cat

Short observation in dining area

Storage and administration of medications

Waste processing, storage and disposal.


5

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 home with support of the organisation actively pursues continuous improvement across the Accreditation Standards and shows improvements in management systems, staffing and organisational development. The system includes feedback forms, surveys, audits and meetings and management promotes formal and informal feedback. The continuous improvement plan identifies opportunities for improvement with goals set, strategies developed and outcomes monitored. Regular review of a range of data occurs with feedback of results provided to stakeholders. Management and the organisational continuous improvement committee monitor the effectiveness of improvement strategies using a range of mechanisms such as observation, audits, data analysis and feedback. Residents, representatives and staff are satisfied the home actively pursues continuous improvement. Examples of recent improvements in relation to Standard 1 Management systems, staffing and organisational development include:

Management identified the need to improve communication between staff across the facility, between facilities and externally. Management researched possible options and upgraded the system to cordless phones. Nursing staff received training and the system receives support from the organisation. Staff are satisfied the new phones have improved communication in the home and between facilities and other parties.

Following feedback from staff requesting more flexible training opportunities management decided to source a new online education resource for mandatory training. Management support staff to complete this training at work or in their own time and specify an expected completion period. Management said staff say they are able to attend the face to face training available and attendance levels have been higher. Monitoring of mandatory training completion is also improved.

The finance department identified an improvement to the pay system and has introduced an automated vein identification system to replace the manual work attendance system. Management said the system has significantly reduced administration work with staff time now allocated to quality initiatives. Management said staff are satisfied as pay is able to be calculated accurately and queries have reduced.


6

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The organisation has systems to identify and promote compliance with relevant legislation, regulatory requirements, professional standards and guidelines across the Accreditation Standards. Management remain informed through legislative update services, peak bodies and government bulletins. They interpret this information and discuss at staff meetings, ensuring compliance and taking action when required. Management communicates relevant information to staff and stakeholders. Compliance with relevant legislation is monitored through the continuous improvement system, the organisation’s risk committee and compliance manager. Staff said they receive information regarding regulatory compliance relevant to their roles and demonstrate knowledge of regulatory requirements. Examples of responsiveness to regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

There is a system to ensure all staff, volunteers and appropriate service providers have current police certificates, statutory declarations as applicable and appropriate credentials.

Management ensured the notification of all stakeholders about the re-accreditation audit within the required time frame.

Confidential documentation is stored securely.

Policies, procedures and documents are reviewed and updated in line with changes in legislation.

1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The organisation has a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. Monitoring of staff skills occurs and specialised training is provided as required. Annual education days and access to online education sessions provide all staff with a variety of topics, ensuring management and staff remains up to date on contemporary practice. Staff development is encouraged within the organisation including care, housekeeping and lifestyle staff and the management team. Management and staff are satisfied with the type, frequency and availability of education provided. Residents and representatives are satisfied staff have appropriate knowledge and skills. Examples of education and staff development relating to Standard 1 Management systems, staffing and organisational development include:

documentation – information systems

mandatory reporting

incident reporting.


7

1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Internal and external complaints mechanisms are available to care recipients, representatives and stakeholders. Feedback is encouraged on noticeboards, in meetings and newsletters. Feedback is provided directly to staff and management, via forms, annual survey or a suggestion box. Assistance to complete forms or raise issues is available. Management maintains confidentiality and operates an open door approach. Identified issues inform the continuous improvement process and management provides feedback on outcomes. Staff are aware of complaints processes and encourage residents to raise their concerns. Residents and representatives said they are encouraged to provide feedback and satisfied with the responsiveness of staff and management. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome Information displays and documentation including resident and staff handbooks articulate the home’s mission statement and statement of values. These statements articulate the home’s commitment to providing high quality care and services responsive to the individual needs and well-being of residents. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome There are sufficient appropriately skilled and qualified staff to deliver care and services. The organisation supports local management in relation to staff recruitment and human resource management processes. Commencing staff complete an orientation program and a range of competency assessments. Staff information handbooks and access to the electronic resources guide them in their roles. Management regularly monitor staffing levels and skill mix through observation of staff practice, stakeholder feedback, ongoing competency testing, reviews of resident needs and data trend analysis. Results of monitoring inform staff education programs and changes to staffing schedules. Staff are satisfied with staffing levels and residents and representatives are satisfied there are sufficient and appropriately skilled staff to meet resident needs.


8

1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The organisation supports the home’s system to ensure stocks of appropriate goods and equipment for quality care provision is available. Management and staff monitor stock levels and replace stock from existing stores and by reordering from regular organisational suppliers. Resident care needs and preferences, staff feedback, maintenance schedules, audits and contractor reports inform decision making in relation to purchases. Risk assessment and trial of equipment is undertaken where needed and quotes obtained and evaluated against standard criteria prior to approval. Staff receive training in the use of new and existing equipment. The home has adequate storage and equipment is accessible. Cleaning and maintenance schedules and reporting of maintenance issues ensures equipment is in good repair. Residents, representatives and staff said there is adequate and appropriate supply of goods and equipment to meet residents’ needs. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The organisation’s systems ensure management and staff effectively manage documented and electronic information in accordance with legislative requirements and the organisation’s policies and procedures. There are appropriate security levels to backup and protect data and maintain the privacy and confidentiality of resident and staff information. Scheduled information reviews ensure information remains relevant, current and complete. Management ensure information is circulated to residents, staff and other stakeholders through electronic messaging, meetings, informal discussions, letters, handover and memoranda. Staff said they have access to administrative, care and management information required to perform their roles. Residents and representatives are satisfied with access to information and communication in 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 home meets this expected outcome Management ensures the provision of all externally sourced services meet the needs of care recipients and stakeholders. The organisation supports the home in ensuring all personnel directly contracted by the home undergo police checks if their job role involves unsupervised access to residents. The organisation implements a tender process for large service contracts with the home contributing to the development of service expectations and participating in tender evaluation against weighted criteria. Contracts or service agreements inform the relevant party of their duty requirements and their responsibilities. There is a process to monitor attendance of external parties to the home and management review contractors’ performance to determine continuation of their service. Residents are supported


9

to access external services of their choice. Staff, residents and representatives are satisfied with the services provided by external contractors.


10

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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For a description of the home’s system of continuous improvement, refer to expected outcome 1.1 Continuous improvement. The home with support of the organisation actively pursues continuous improvement in residents’ health and personal care. Staff document incidents and designated staff analyse a range of clinical data for trends which are reported, overseen and actioned. Residents, representatives and staff are satisfied the home pursues continuous improvement. Examples of recent improvement initiatives in relation to Standard 2 Health and personal care include:

Following auditing of medication administration, management identified issues related to administration of ointments. Management discussed issues with staff and implemented a range of strategies with the support of residents’ medical practitioners. When review audit did not confirm an improvement, management revised processes to require staff to attend the home on the day of missed signing. Management said audit results have improved and medication administration practice remains consistent.

Management and staff discussed the low rate of return of advanced care planning information when a resident enters the home. Staff researched strategies to obtain relevant information to enable the commencement of discussion of end of life care at a more appropriate time. Management implemented an emergency information form and said residents and representatives are providing relevant information more readily.

Feedback from industry sources indicated a pain management program would be of benefit to residents. Management developed tender specifications and participated in the review of applications. The organisation implemented a pain management program and management and staff said residents are satisfied with the level of care and availability.

As a result of the increase in resident care needs management employed a registered nurse as a nurse advisor. Management and nursing staff increased care plan review from three monthly to monthly. Management said care staff are satisfied with the additional clinical support available and resident care is improved.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome Management has systems to identify and comply with all relevant legislation, regulatory requirements, professional standards and guidelines in the area of health and personal care.


11

Refer to expected outcome 1.2 Regulatory compliance for further information about the home’s regulatory compliance system. Examples of responsiveness to regulatory compliance relating to Standard 2 Health and personal care include:

Registered nurses plan and supervise the delivery of specialised nursing care.

Ongoing monitoring of registered nurse registrations.

Medications are stored and managed according to legislated processes.

A documented system guides staff actions in the event of an unexplained resident absence.

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has a system to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to care recipients’ health and personal care. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development. Examples of education and staff development in relation to Standard 2 Health and personal care include:

pain management

behaviour management

medication administration and drug competencies. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome Care recipients receive appropriate clinical care according to their needs and preferences. A collaborative clinical team completes the resident assessment and care planning. Staff use a summary care plan derived from initial assessments to provide care to residents. Staff report significant changes to individual care needs to the attending general practitioners. Handover information and staff feedback is consistent with care plan documentation and monthly review summaries. Management monitor clinical care through audits, clinical data analysis, monthly care plan reviews and consultation with the resident or their representative. Residents and representatives are satisfied with the clinical care provided to residents.


12

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 The home meets this expected outcome Registered nurses in collaboration with other qualified staff assess, plan, manage and review specialised nursing care. Care plans detail residents’ assessed need, nursing interventions and preferences. Provision of specialised nursing care occurs in medication management, diabetic care, continence care including catheter care, wound and pain management. Referrals and consultation with other health professionals occurs with outcomes documented and reviewed. Care plans and the integrated progress notes record strategies resulting from such referrals or consults. Staff have access to policies, procedures and equipment for specialised care. 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 The home meets this expected outcome Referral to health specialists occurs according to care recipients’ needs and preferences. Medical review and assessments identify residents need for referral to other health professionals and specialists. Specialist mental health, wound consultant and palliative care services visit the home when required. Staff assist residents to access specialists who do not visit the home. Care plans include diagnosis, treatment and updates to care occurring as a result of referrals. 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 The home meets this expected outcome Enrolled nurses and competent personal care staff manage and administer care recipients’ medication safely and correctly according to legislative requirements and the home’s policies and procedures. The initial assessment, identifies medication requirements and preferences, allergies and any assistance needed. Medication charts are up to date and include clear medication orders, identification information and detail special considerations for administering medication. General and restricted medications are stored securely and there is a safe disposal system. Protocols exist for residents who wish to self-administer all or part of their medications. Medication advisory committee, medication reviews, audits and the incident reporting system contribute to the monitoring of safe medication management. Residents and representatives are satisfied with the management of residents’ medication


13

2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome Pain management strategies ensure all care recipients are as free as possible from pain. Initial assessments identify residents’ present and past pain history. Assessment and management plans include consideration of resident’s current physical condition, cultural and spiritual requirements and care choices. Pain management is reviewed if there is a change in residents’ clinical status, when there is a new episode of reported pain and when ‘as required’ pain relief is administered routinely over a period of time. Staff complete reassessment and charting for new or continuing pain. Pain relieving measures include a pain management program implemented by the physiotherapist, massage, heat treatment and medication. Management monitor the effectiveness of pain management strategies using care reviews, medication use, 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 The home meets this expected outcome Staff provide care to care recipients requiring palliative care that maintains their comfort, emotional support and dignity. Each resident’s end of life wishes are discussed and documented when they enter the home. Staff said that planned additional education and resources will ensure compassionate, contemporary palliative care can be provided to residents. An external palliative care service is available during the palliative phase of care as required. There are systems to ensure residents receive adequate nourishment and hydration. Care plans include symptom management, comfort measures and emotional support for residents. Management ensure specialised nursing care, pain management and additional emotional support is provided to residents and representatives. Staff said their approach is to maintain comfort and to respect the choices of residents and representatives when providing palliative care. 2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome There is a system to ensure care recipients receive adequate nourishment and hydration. Initial assessment of residents’ nutritional needs takes into consideration personal preferences, cultural, religious and medical requirements. Reassessment and review of nutrition and hydration care plans occurs monthly. If staff identify changes in a resident’s weight as per the weight management policy or food and fluid intake alters, the general practitioner, dietitian and speech therapist are consulted to ensure optimal nutritional intake. Menu choices are available and there are individual strategies for staff to ensure residents’ independence and dignity during meal times. Residents and representatives are satisfied with staff support and assistance in maintaining residents’ nutrition and hydration


14

2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Care recipients’ skin integrity is consistent with their general health. Initial and ongoing assessments and care plan reviews identify residents at risk of skin breakdown and staff implement skin care management strategies. If the resident has a compromised clinical status such as the presence of diabetes, peripheral vascular disease, reduced mobility, increased frailty or is post-surgery then specialised care occurs. Wound care includes appropriate wound dressings, documentation and evaluation of care and referral to wound care specialists as required. Staff confirm they have access to pressure relieving equipment; skin care products and other resources. Audits, incident and care plan reviews and resident consultation 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 home meets this expected outcome Management and staff demonstrate care recipients receive effective continence management that is appropriate to their individual needs and preferences. Staff assess each resident and determine the optimal continence aid they require and the level of assistance required to meet their continence needs. Staff discreetly maintain residents’ dignity while providing continence care. Education is provided to staff to assist residents with their continence requirements. Staff said they have access to adequate continence aids and showed knowledge of residents’ individual toileting preferences. Residents said their continence needs are met. 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome Staff provide effective care for care recipients with any challenging behaviours. Staff assess each resident on entry to the home and document if additional behaviour monitoring is required. Charting is undertaken if changes to behaviours are identified and care plans reviewed. Care plans include triggers, contributing factors and strategies to manage behavioural episodes. Staff document behavioural incidents which management review to identify and minimise recurrence. Specialist services and secure care are available within the organisation for residents who require additional review and management of challenging behaviours. Staff have access to education and resources and were observed to provide assistance to residents in a calm and respectful manner. Residents and representatives are satisfied staff effectively manage the needs of residents with behavioural issues.


15

2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome Staff promote and optimise care recipients’ mobility and dexterity in conjunction with the physiotherapist resulting in an individual exercise and mobility plan being implemented. Staff document on care plans the number of staff and equipment required to safely transfer and mobilise each resident. Staff said they assist residents to mobilise and to undertake their individual exercise programs, go for walks and to attend activities that promote their mobility and dexterity. Staff said they have equipment to assist safe transfer of residents and have manual handling training and education. Residents said they attended exercises and appreciated the assistance given to them by staff to optimise their mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Management demonstrate there are systems to identify and maintain care recipients’ oral and dental health care needs. Oral and dental assessments are completed and care plans developed and implemented. Staff assist and facilitate residents to access their preferred dentist and dental technician services as required. Staff assist and encourage residents to brush their teeth, clean dentures and provide oral care as needed. Staff said they have a system for ‘seasonal’ changing of toothbrushes and adequate supplies to ensure all residents have the equipment needed for oral and dental care. Residents and representatives are satisfied with the management of residents’ 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 The home meets this expected outcome There are systems to identify and manage care recipients’ sensory losses. Assessments identify any sensory loss and staff develop strategies to manage residents’ needs and preferences. Staff review residents’ sensory loss monthly and update care plans to reflect current issues and requirements. Appointments to relevant specialists are arranged and staff assist residents with the fitting and cleaning of their sensory aids including hearing aids and glasses. Residents are satisfied staff effectively manage their sensory loss.


16

2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Assessment processes and care planning assists care recipients’ to get adequate sleep and rest. Staff identify residents’ sleep needs and preferences using assessments, observations, and resident feedback. Care plans detail individual strategies including comfort measures to promote sleep, waking and settling times and preferences. Past life histories, pain management, immobility, continence care and escalation of behaviours are defined precursors to disturbed sleep patterns and are integral to individual care planning. Staff described strategies to help resettle any resident who wakes during the night including offering comfort care initially instead of medications when appropriate. Residents said they are satisfied with staff assistance to help them get adequate rest and sleep.


17

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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For a description of the home’s system of continuous improvement, refer to expected outcome 1.1 Continuous improvement. The home’s continuous improvement system shows improvements in the area of care recipient lifestyle. Residents, representatives and staff are satisfied the home is actively improving resident lifestyle. Examples of recent improvement initiatives in relation to Standard 3 Care recipient lifestyle include:

Lifestyle staff identified the potential benefit of an animated dog to provide opportunities for individual support and group reminiscence. Staff said residents enjoy interacting with the dog and discussion is stimulated.

Following feedback from residents, lifestyle staff introduced podcast presentations played on the TV followed by group discussions. Management said this resource is also useful for staff education. Residents are satisfied this activity provides opportunity for discussion.

To improve resources to meet residents’ spiritual and cultural needs, lifestyle staff identified a musical resource which includes a variety of music including old hymns. Staff said residents enjoy the music and reminiscence and relaxation is improved.

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 care recipient lifestyle”. Team’s findings The home meets this expected outcome Management has systems to identify and monitor regulatory compliance obligations in relation to Standard 3 Care recipient lifestyle. Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system Examples of responsiveness to regulatory compliance related to Standard 3 Care recipient lifestyle include:

Residents receive information about their rights and responsibilities, privacy and consent issues in their information packs and residential agreements.

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

Management has processes to ensure it meets compulsory reporting requirements.


18

3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has a system to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to care recipient lifestyle. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development. Examples of education relating to Standard 3 Care recipient lifestyle include:

care and lifestyle integration

choice and decision making

privacy and dignity. 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 The home meets this expected outcome The home supports each care recipient in adjusting to life in a new environment and on an ongoing basis. An orientation process supports residents when first arriving at the home. Leisure and lifestyle staff provide welcome packs to each new resident, give a tour of the home and introduce them to staff and other residents. Residents can access a psychologist if they require additional support to settle into the home. Staff review residents’ emotional needs and update care plans regularly. In addition to one-on-one staff support, church services and visits from volunteers provide additional support for residents on an ongoing basis. Residents and representatives said that the home and its staff have established a supportive environment that meets residents’ 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 The home meets this expected outcome Care recipients are assisted to maximise their independence, maintain friendships and participate in life inside and outside the home. The home’s approach to care planning identifies, assesses and reviews residents’ various needs while recognising their independence. Strategies include regular exercise programs, the use of individual mobility aids and the provision of activities to promote social interaction within and outside the home. Car and bus outings are organised to assist residents to maintain these relationships. Staff consult with residents and representatives about their daily routines and how identified risks are managed. Residents and representatives are satisfied the home supports residents’ independence.


19

3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome The home respects and recognises each care recipient’s right to privacy, dignity and confidentiality through its physical environment, information management system and through positive staff interactions with residents. Residents are able to personalise their rooms and there are several areas for residents to meet with visitors or other residents. Resident information is stored in secure areas and computer records are password protected. Staff interactions with each other and with residents demonstrated an awareness of residents’ rights to privacy, dignity and confidentiality. Residents and representatives said staff respect their right to privacy, dignity and confidentiality. 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 The home meets this expected outcome Care recipients are encouraged and supported to participate in a range of interests and activities of interest to them. The home has an effective system for identifying, assessing and evaluating residents’ leisure and lifestyle interests which informs activity planning and delivery. Each resident has a social profile developed on entry into the home which identifies their particular needs and interests and informs their care plan. The home monitors the effectiveness of each resident’s activity program through informal feedback after activities, attendance and participation records, monthly activities review by lifestyle staff and annual resident lifestyle and satisfaction surveys. Staff provide a wide range of activities and take into account residents’ capabilities when planning and delivering activities. Residents are satisfied with the encouragement and support offered by staff and with the range of leisure interests and activities provided. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome The home values and fosters individual interests, customs, beliefs and care recipients’ cultural and ethnic backgrounds. Staff identify residents’ cultural, spiritual and dietary needs through the assessment process on entry to the home, with the results incorporated into activity planning. Church services and pastoral visits occur regularly at the home. A recent review has established a program to support the needs of residents who do not wish to attend formal religious services. A number of special days are commemorated throughout the year and residents’ families are invited to attend. Residents and representatives are satisfied with how residents’ cultural and spiritual needs are met by management and staff.


20

3.9 Choice and decision-making This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home has processes which allow care recipients and their representatives to participate in decision making about the care and services they receive. Residents are able to exercise choice about their food preferences, daily routines, activities and the management of identified risks. Staff document residents’ choices and consult with residents and representatives about residents’ needs and preferences, including with respect to palliative care. The home holds regular meetings for residents and representatives and offers opportunities for feedback through its compliments and complaints process. Residents and representatives said individual choices and decisions are encouraged, respected and supported by management and staff. 3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome The home has a system to ensure care recipients have secure tenure within the home and organisation and understand their rights and responsibilities. On entry, management provides information about security of tenure, privacy, confidentiality, complaints mechanisms and the available care and services through the information pack and residential agreement. The ‘Charter of residents’ rights and responsibilities’, statement of support, advocacy and independent complaints mechanism brochures are on display. Management ensures stakeholders are aware of residents’ rights and responsibilities through handbooks, newsletters, poster displays and policies and procedures. Management discusses care and service options with residents and representatives if service needs change and provides information to support decision making. The organisation budgets for improvements to support residents’ ageing in place. Residents and representatives said residents have secure tenure within the home and are aware of their rights and responsibilities.


21

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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For a description of the home’s system of continuous improvement, refer to expected outcome 1.1 Continuous improvement. The home with support of the organisation actively pursues improvements to ensure care recipients live in a safe and comfortable environment. Examples of activities that inform improvements related to the environment are environmental audits and inspections, third party reports and feedback from stakeholders. Staff, residents and representatives are satisfied management actively improves the home’s physical environment. Examples of recent improvement initiatives in relation to Standard 4 Physical environment and safe systems include:

Management decided to introduce a new manual handling program for all care and nursing staff. All staff completed a three hour practical workshop with an external professional. Management arranged for the establishment of an online component of this training package for staff supported by a manual. Management said staff are satisfied with this training and practical training will continue biannually and be extended to ancillary staff.

Management identified an opportunity to improve resident’s dining experience in a more relaxed environment and sought residents’ input into a trial of café style music. Staff undertook a survey and discussion following the trial. Residents and staff are satisfied the music has improved residents’ dining experience.

As part of the organisation’s heat wave strategy, management identified the need to purchase a generator available to the facility. The organisation purchased a generator and it is available in the event of an extended power failure.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome For a description of how the home identifies and promotes compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, refer to expected outcome 1.2 Regulatory compliance. Management has systems to identify and monitor regulatory compliance obligations in relation to Standard 4 Physical environment and safe systems. The home monitors compliance with legislation through audits, inspections, meetings, supervision of work practices and surveys. Staff said they are informed of regulatory requirements.


22

Examples of responsiveness to regulatory compliance relating to Standard 4 Physical environment and safe systems include:

The home has an audited food safety plan and certified kitchen.

There is an effective infection control system.

The home monitors and maintains the fire safety systems and the lift. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has a system to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to physical environment and safe systems. For details regarding the home’s system, refer to expected outcome 1.3 Education and staff development. Examples of education and staff development in relation to Standard 4 Physical environment and safe systems include:

infection control

no lift program

manual handling for ancillary staff. 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 The home meets this expected outcome The organisation and home actively work to ensure the living environment is safe and comfortable. Private and communal living areas are clean and of a comfortable temperature. External areas have a range of seating options, paving, shade and maintained gardens. Corrective and preventative maintenance systems and a cleaning program ensure equipment, fittings and fixtures are safe and functional. The organisation budgets for improvements to the residents’ living environment. Staff monitor the comfort and safety of the living environment through observation, risk assessments, audits and resident or representative feedback. Residents and representatives are satisfied with the safety and comfort of the living environment.


23

4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome Management and the organisation actively work to provide a safe working environment. Management inform staff of occupational health and safety requirements through orientation, documented processes, meetings and a manual handling training program. Management monitor and support occupational health and safety through mechanisms including regular discussion at meetings, visual observation, review of incident and hazard reports and review of maintenance and environmental audits. Occupational health and safety is a key criterion in organisational purchasing decision making. The organisation has access to consultants to support a safe work and living environment. Staff said they have equipment that promotes safe work practice, access to manual handling training and prompt maintenance support. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome The organisation, management and staff are working to maintain a safe environment that minimises fire, security and other emergency risks. Staff have access to documented emergency management procedures. Fire safety systems are in place including an evacuation kit, fire plans, fire detection and firefighting equipment. Contracted fire professionals regularly monitor and maintain safety equipment. The organisation has a generator in the event of power failure. The home is able to respond to other emergencies and monitors security. There is a lock up procedure in place at night. Staff said they are required to undertake regular fire and emergency training and are able to respond to fire or another emergency. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has implemented an effective infection control program. Personal protective equipment, hand washing facilities and a vaccination program for staff and residents are in place to minimise the risk of infection. Review of infection rates occurs, mandatory training includes infection control and management encourages staff, residents and representatives to practice hand hygiene. The home identifies residents at risk of infection and appropriate reviews undertaken with implementation of treatment as required. Kitchen, cleaning and laundry practices follow current infection control guidelines. There is a food safety program and the home undertakes pest control inspections. Appropriate waste disposal processes are in place. Staff said there are adequate supplies and equipment with policies and procedures to assist staff in minimising the risk of infection.


24

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 home meets this expected outcome The home and organisation provide hospitality services in a way that enhances care recipients’ quality of life and the staff’s working environment. Catering services meet residents’ individual dietary needs and preferences, offer variety with a four week seasonal menu and adhere to a food safety program. Staff provide cleaning and laundry services and follow schedules to ensure completion of tasks. Laundering of linen and furnishings is off site and slings and personal clothing are laundered onsite with replacement of linen as needed. Staff undertake labelling of clothing to minimise any loss and there is a system for returning any misplaced clothing items. Management and staff monitor environmental service performance through meetings for residents and representatives, surveys, stakeholder feedback, audits and observation of practice. Residents, representatives and staff are satisfied with the home’s catering, cleaning and laundry services.

published decision (sa and ra) - quality agency · following an audit we decided that this home met...

Documents