published_decision_(sa_and_ra) - aged care quality · web viewthis table outlines the details of...

Warrina HostelRACS ID: 3277

Approved provider: Yarrawonga Health

Home address: Piper St/ Hume St YARRAWONGA VIC 3730

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 06 March 2021.

We made our decision on 02 January 2018.

The audit was conducted on 21 November 2017 to 23 November 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: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 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 carePrinciple: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.




2.4 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 MetHome name: Warrina Hostel Dates of audit: 21 November 2017 to 23 November 2017RACS ID: 3277 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services 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 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, 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

Home name: Warrina Hostel Dates of audit: 21 November 2017 to 23 November 2017RACS ID: 3277 3

Audit ReportName of home: Warrina Hostel

RACS ID: 3277

Approved provider: Yarrawonga Health

IntroductionThis is the report of a Re-accreditation Audit from 21 November 2017 to 23 November 2017 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 21 November 2017 to 23 November 2017.

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.

Details of homeTotal number of allocated places: 28

Number of care recipients during audit: 27

Number of care recipients receiving high care during15

Special needs catered for: N/A


Audit trailThe assessment team spent two and a half days on site and gathered information from the following:

Interviews

Position title Number

Chief executive officer 1

Director of clinical services 1

Quality manager 1

Manager people and culture 1

Corporate business manager 1

Community engagement manager 1

Facilities manager 1

Quality assistant 1

Health information manager 1

Nurse unit manager 1

Care staff 2

Administration assistant 1

Domestic services supervisor 1

Executive chef 1

Hospitality services 3

Care recipients 13

Lifestyle staff 2

Enrolled nurses 2

Work health and safety representatives 1

Continence lead nurse/acfi documentation 1

Stores coordinator 1

Healthcare coaching group mentor 1

Allied Health 2


Operational Director of Community Services 1

Infection control and prevention co-ordinator 1

Sampled documents

Document type Number

Care recipients’ clinical files 3

Care recipients’ lifestyle files 3

Medication charts 4

Personnel files 5

Other documents reviewedThe team also reviewed:

Audit tools and schedule

Bleach bath instructions

Care recipient agreement samples

Care recipient and representative satisfaction survey results 2017

Care recipient information booklet

Certification folder

Clinical and functional assessments, charts and records

Compulsory reporting/notifiable events register

Continuous quality improvement plan

Contractors’ handbook 2017-2018

Electronic contract register, services and supplier list

Electronic nursing credentialing system

Emergency evacuation checklist

Environmental inspection checklists

External services- task list

Financial information pack

Fire safety and emergency management booklet

Food safety plan and certificate of compliance

Handover sheet

Incident reports

Maintenance requests log

Mandatory training register 2016-2017

Manuals - fire safety, emergency management, housekeeping

Meeting minutes


Organisational ‘Quality improvement plan’

Organisational feedback report

Organisational risk register and high risk register

Police certification and statutory declaration documentation

Policies and procedures

Monitoring records-kitchen cleaning, refrigerator temperature, general services

Regulatory compliance action plan

Reports -pest control, clinical training, maintenance training, hotel services training,

Risk assessment and management form sample

Safety data sheets (SDS) –kitchen, laundry, cleaning

Staff employment pack

Staff orientation documentation

Staff satisfaction survey results 2017

Strategic plan 2016-2019

Volunteer education program

Yarrawonga Health Victorian Quality Account 2016-2017

ObservationsThe team observed the following:

Activities in progress

Activities program on display

Chemical storage

Cleaning and laundry service in progress

Emergency evacuation diagrams

Emergency exits

Equipment and supply storage areas

Evacuation pack

Infection control supplies, equipment and waste disposal

Interactions between staff and care recipients

Inventory and equipment stores

Living environment

Lunch and beverage services

Main kitchen and Warrina kitchenette

Medication administration and storage

Notice of reaccreditation audit on display

Short group observation

Smoking area.


Assessment informationThis 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 developmentPrinciple:Within the philosophy and level of care offered in the residential care services, 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 improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The organisation actively pursues continuous improvement across the Accreditation Standards and shows improvements in management, staffing and organisational development. Management identifies opportunities for improvement from sources including feedback forms, verbal feedback from stakeholders, meetings, an organisational community advisory committee, audits and satisfaction surveys. Management maintains continuous improvement plans at local and organisational levels to achieve objectives. A range of key performance indicator data is analysed for trends and action occurs where indicated to improve quality outcomes. Management monitors and evaluates improvement processes and outcomes through stakeholder feedback, meetings, audits and data analysis. Care recipients, representatives and staff are satisfied ongoing improvements occur.

Recent examples of improvements in Standard 1 Management systems, staffing and organisational development include:

To improve the accountability of leadership across aged care, a new staff structure has been implemented. Roles and responsibilities of senior positions were reviewed, staff leadership education occurred and mentoring arrangements were initiated to ensure the implementation of accountable and consistent leadership strategies. Management shows increased staff satisfaction as reported in recent staff surveys and through feedback from the leadership team.

To effectively monitor professional registrations, management implemented an online credentialing system to monitor professional registrations and Australian Health Practitioner Regulation Agency notifications. The system interfaces with a national medical registration database, enabling timely verification of all clinicians’ registration status, qualifications and scope of practice.

To ensure effective volunteer coordination and training, volunteers were surveyed to determine their activity status. Volunteer education was provided to realign with current organisational orientation. Management reports additional education for volunteers has increased care recipient safety, while support for volunteers has increased with enhanced coordination through the community engagement officer role.

1.2 Regulatory complianceThis 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”.



The home has a system to identify relevant legislation, regulatory requirements and guidelines, implement regulatory changes and monitor compliance in relation to the Accreditation Standards. Identification of regulatory compliance obligations occurs at the organisational level through regular notifications from legislative update services, peak body information, government communications including health alerts, network meetings and conferences. Where changes occur, management maintains a regulatory compliance action plan, updates policies and procedures and communicates the changes to care recipients, representatives and staff as appropriate. Management informs staff of regulatory compliance requirements through meetings, education, ‘smart time’ staff expert presentations, emails to heads of departments and through project work as appropriate. The monitoring of regulatory compliance occurs through analysis of key performance indicator data, audits, competency tests, database reviews, observation of practice and stakeholder feedback. Staff are satisfied management informs them of regulatory requirements. Care recipients and representatives are satisfied management provided them with information about the re-accreditation audit.

Examples of responsiveness to regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

Management maintains a plan for continuous improvement across the Accreditation Standards.

Management has a system for maintaining current police certificates and applicable statutory declarations for staff, volunteers and external contractors as appropriate.

Management provided advice to care recipients and representatives about the re-accreditation audit within the required timeframe.

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


The home's processes support the recruitment of staff with the required knowledge and skills to perform their roles. New staff participate in an orientation program that provides them with information about the organisation, key policies and procedures and equips them with mandatory skills for their role. Training needs are identified through incidents, feedback and planned surveys. A range of education resources are available including online e-learning packages, external and internal sessions, practical and competency based assessments. Staff are scheduled to attend regular mandatory training; attendance is monitored and a process available to address non-attendance. The effectiveness of the education program is monitored through attendance records, evaluation records and performance appraisal and staff are satisfied with the education and training provided. All care recipients interviewed agreed or strongly agreed staff know what they are doing and the home is well run.

Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include:

bullying and harassment

feedback and complaints

incident reporting

information systems (accessing and documenting in electronic database).


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


Internal and external comments and complaints mechanisms are accessible to care recipients, representatives and other interested parties. The system includes ‘comment, complaint, suggestions’ forms, meetings and an ‘open door’ policy of access to key staff and management. Management ensures external complaint information is accessible and conveys information about ways to comment and complain in information booklets, information displays, meetings and informal contact. Comments and complaints are addressed in a timely manner according to organisational processes and reported to the board of management as appropriate. Analysis of complaint data occurs to inform the continuous improvement system and complaint trends are reported to the wider community through the organisation’s published quality report. Care recipients and representatives said while they did not need to complain, they would be comfortable to discuss any concerns that may arise.

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


The organisation has a documented vision and objectives, together with ‘six pillars’ statements that describe the philosophy and platform to achieve the objectives. Leadership statements convey organisational values of respect, excellence, integrity, compassion and teamwork and there is a documented program that describes the way the values are to be practiced. Management demonstrates its commitment to quality in documentation throughout the service.

1.6 Human resource managementThis 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".


There are appropriately skilled and qualified staff sufficient to ensure services are delivered in accordance with these standards and the home’s philosophy and objectives. The recruitment, selection and induction of new staff is guided by an established organisational system. New staff are supported by management and staff and participate in supernumerary shifts while they gain familiarity with the home. Management monitors staff rosters, replaces unplanned staff leave and seeks feedback from stakeholders to ensure the maintenance of appropriate staff numbers and skill mix. Staff said while there are less staff available on the afternoon and night shifts there were no adverse impacts on care recipients. Care recipients and representatives expressed satisfaction with staff skills and were complimentary about the responsive care provided.


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


Established procurement systems ensure appropriate goods and equipment are available for quality service provision. Designated staff organise the purchase of inventory and equipment through established ordering and supply processes, compliance with instruments of delegation and the use of preferred suppliers and contractors. Management and staff identify equipment needs through mechanisms such as standardised lists of approved products and frequently ordered items, outcomes of procurement committee meetings, identification of care recipient need, observation, data analysis processes, audits and stakeholder feedback. Staff within the organisation trial and evaluate new equipment prior to purchase as appropriate. Goods are secured in clean areas and stock checking and rotation processes are established. Goods are stored safely and there are cleaning and maintenance programs to ensure equipment remains in good repair. Staff, care recipients and representatives were satisfied with the availability of goods and equipment.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The organisation has systems to ensure the safe management, storage and maintenance of information. Management, staff and volunteers have access to information to help them perform their roles including policies, procedures and position descriptions. Care recipients, representatives, staff and volunteers receive information as appropriate through mechanisms including meeting, minutes, notices and newsletters. The organisation is a member of a regional health alliance that provides the service with governance, management and operational support including security, maintenance and back up for information management systems. The organisation’s corporate reporting, risk management and data management processes support effective information systems. Sensitive information is securely stored and disposed of according to defined procedures. Management monitor the information management system through audits, reports and feedback from stakeholders. Care recipients, representatives and staff were satisfied with access to information and with communication processes.

1.9 External servicesThis 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".


Management ensures externally sourced services meet service needs and quality goals. External services include allied health services, pharmacy, nurse call systems, linen services and fire services. A procurement committee is responsible for the selection and monitoring of external services and suppliers through the use of established processes including contract reports. External service arrangements and credential checks apply External service providers receive and are required to acknowledge receipt of a contractors’ handbook with documented site induction information. Management monitor the quality of services provided


through consideration of service outcomes, stakeholder feedback and observation of quality and timeliness. Care recipients, representatives and staff are satisfied with external services.


Standard 2 – Health and personal carePrinciple: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.



The organisation actively pursues continuous improvement in care recipients’ health and personal care. A range of clinical indicator data is collated and analysed for trends. Care recipients and staff are satisfied the home is improving in Standard 2 Health and personal care. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 2 Health and personal care include:

In response to care recipient need, management implemented increased allied health services. Physiotherapy hours have increased from 1.5 hours per week to a full time position, with a pain management service now offered. Podiatry services have increased from one day a fortnight to one day a week across the three homes within the organisational group. The dietitian hours have increased to eight hours a fortnight to provide increased oversight of nutrition and hydration. Management report increased stakeholder satisfaction with the increased accessibility of allied health services.

Following an external audit identifying unplanned weight loss, management and staff have strengthened processes in relation to the reporting and actioning of weight loss. Indicators now result in early intervention in weight loss. Dietitians now regularly monitor the menu to ensure optimum nutrition and hydration and a nutrition committee meets regularly. Management and staff said strengthened processes promote enhanced results for individual care recipients in relation to nutrition and hydration.

To strengthen medication management, a review of self-medication assessment processes, including improved cognitive assessments and increased general practitioner involvement, was implemented. Management reports the system for monitoring the safety of care recipients who self-administer medications is more effective.

2.2 Regulatory complianceThis 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”.


Management has systems to identify and promote compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care. Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements.

Examples of responsiveness to regulatory compliance relating to Standard 2 Health and personal care include:


Appropriately qualified staff carry out specific care planning activities and care tasks.

Scheduled medications are stored appropriately.

Professional registrations are maintained and monitored through an electronic credentialing system that alerts appropriate management to any new conditions of registration.

The home has a documented process to guide staff response in relation to any unexplained absences of a care recipient.



The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to health and personal care. Refer to Expected outcome 1.3 Education and staff development for more information.

Examples of education and training provided in relation to Standard 2 Health and personal care include:

basic life support

continence products

medication management

palliative care

wound management.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


Management and staff demonstrate there is a system to ensure care recipients receive appropriate clinical care. Staff complete a suite of assessments when care recipients enter the home and based on this information staff formulate an individualised care plan. Consultation during the admission occurs with the care recipient, representative, medical practitioner, physiotherapist and dietitian. Medical officers visit the home on a regular basis and in response to specific request and care recipients can choose to retain their own doctor if practical. There is access to allied health professionals from the adjacent hospital and surrounding towns for support and advice as required. Regular care plan review occurs to ensure documented clinical strategies and interventions remain effective. There is access to policies, procedures, training and equipment to assist staff in undertaking their clinical care duties. Care recipients and representatives are satisfied with the clinical care staff provide to care recipients.

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



There is appropriately qualified nursing staff available to identify, assess and manage care recipients’ specialised nursing care needs. Specialised nursing care occurs in the areas of diabetes management and stoma care. Consultation occurs with the care recipient, representative and medical practitioner as required. There is access to a registered nurse each shift with further support available from a range of health professionals at the adjacent hospital, if needed. Provision of relevant equipment assists the delivery of specialised nursing care. Care recipients and representatives are satisfied with the level of specialised nursing care staff provide.

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


Management and staff demonstrate care recipients are referred to appropriate health specialists and other health services as required and preferred. A physiotherapist assesses care recipients on entry to the home and reviews all care recipients according to schedule, following a change in health status and in response to a referral. A podiatrist and dietitian visit regularly. Further referrals occur based on identified need or specific request with support provided to care recipients to access external appointments. Access to additional allied health services at the adjacent hospital facilitates a timely response to referrals, as required. Care recipients and representatives are satisfied care recipients see specialists as required.

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


Management and staff demonstrate there is a system to ensure care recipients’ medication is managed safely and correctly. Nursing staff and competency tested carers administer medication based on prescribed orders written by the medical officer. Medication is appropriately stored, in accordance with legislative requirements. There is a medication imprest available at the adjacent hospital, if required, to ensure care recipients can receive prompt out-of-hours treatment if required, according to medical directive. Monitoring process of the medication system includes pharmacy review, incident reporting, signature omission checks and regular audits. There is access to a registered nurse on all shifts to assist with care recipients’ medication needs, with additional clinical support available at the adjacent hospital if needed. Care recipients and representatives are satisfied medication management occurs as required and in a timely manner.

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


Management and staff demonstrate there are processes to ensure all care recipients are as free as possible from pain. Staff assess care recipients for pain on entry to the home, regularly as part of the scheduled review process and as required. Corresponding care plans document identified strategies to reduce the incidence of pain, which may include the application of heat packs and massage. Referrals occur to the in-house pain management


program if more regular and intense treatment strategies are identified as being required. Provision of exercises and mobility equipment encourages movement and assists with the reduction of pain. Where medication is required outside of scheduled times, nursing review occurs to monitor effectiveness of pharmacological interventions and to determine if medical review is needed. Care recipients and representatives are satisfied staff assist them to be as free as possible from pain.

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


Management and staff demonstrate there is a system to ensure the comfort and dignity of terminally ill care recipients. During the admission process, care recipients and representatives are provided with the opportunity to discuss their end of life wishes, which includes any limitations of treatment. Staff have easy access to this information to ensure palliative care is delivered in conjunction with care recipients’ and representatives’ personal preferences. There is access within the organisation to trained palliative care link nurses who act as a liaison between the palliative care specialists and the care recipients as required. There is access to religious personnel if needed and additional support and counselling is available to families. A dedicated palliative care room provides a private space for families and loved ones to gather, if needed. Staff described the palliative care approach taken to ensure care recipients’ comfort and dignity is maintained, during the terminal phase of their life.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Management and relevant personnel demonstrate there is a process to provide care recipients with nourishment and hydration. The assessment of care recipients’ nutritional needs occurs on entry to the home, taking into consideration personal preferences, allergies, medical requirements and the level of assistance required. Dietary information guides staff in providing meals according to care recipients’ specific needs with updates occurring as required and in response to a dietary change. Staff weigh care recipients on entry to the home and monthly thereafter with scope to increase this frequency if required. Referrals to medical practitioners, speech pathologists and dietitians occur for additional support and advice. Nutritional supplements are available to enhance care recipients’ nutritional status when required. Staff supervise and assist care recipients with their meals and drinks, according to their needs. Care recipients and representatives are satisfied with the food provided and state they have enough to eat and drink.

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


Management and staff demonstrate there is a system to maintain care recipients’ skin integrity in accordance with their general health and wellbeing. Review of skin integrity


occurs for all care recipients on entry to the home. This includes assessing for existing wounds or pressure areas and establishing strategies to maintain skin integrity in accordance with care recipients’ health status. Corresponding care plans document individual care recipient’s skin care needs which may include daily moisturising, use of pressure reliving mattresses or application of limb protectors. A designated staff member holds the portfolio of wound management to assist with a streamlined approach of reviewing and treating wounds. There are adequate supplies of wound dressings. Care recipients and representatives are satisfied staff utilise a range of strategies to promote and maintain skin integrity in accordance with the care recipient’s health.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


Management and staff demonstrate there are processes to ensure care recipients’ continence is managed effectively. There are ongoing review and evaluation systems for identifying and managing care recipients’ continence care requirements. Processes include initial assessments in consultation with care recipients and representatives, regular care plan reviews and reassessments in response to identified changing continence care requirements. Strategies to promote effective continence care include regular toileting times, increased hydration, provision of a high fibre diet and regular exercise. A designated staff member holds the portfolio of continence management to assist with a consistent approach of managing care recipients’ continence needs. There are sufficient supplies of continence aids that are allocated to individuals based on assessed need. Increased monitoring of urinary tract infections, using an evidence based identification tool ensures timely intervention. Care recipients are satisfied with the continence care staff provide.

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


Management and staff demonstrate there are processes to ensure the needs of care recipients with challenging behaviours are managed. These include the development of assessments, corresponding care plans that include individualised behavioural management interventions and strategies, based on care recipients’ life experiences. These processes occur in consultation with the care recipient, their representative and medical practitioner. The lifestyle program assists in enhancing the behavioural management system through the provision of varied activities to suit different needs. Referrals occur to advisory and specialist services for additional advice and support as required. Staff record behavioural incidents via the organisational incident reporting system with any identified trends prompting further review. Care recipients and representatives are satisfied with the home’s approach to behavioural management.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.



Management and staff demonstrate there is a system to promote care recipients’ mobility and dexterity. Assessment of each care recipient’s mobility and dexterity needs occurs on entry to the home with input from the care recipient, representative and physiotherapist. The corresponding care plan documents identified strategies to enhance care recipients’ mobility and dexterity and includes interventions to minimise falls risk. There is equipment available to aid transfer and mobility with staff required to participate in manual handling training. Provision of exercises and pain management strategies promotes movement, enhancing mobility and dexterity. Management monitors falls data to identify trends and implements strategies to minimise reoccurrence. Care recipients are satisfied staff provide adequate support to promote their mobility and dexterity.

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


Management and staff demonstrate there are ongoing review and evaluation systems for identifying and managing care recipients’ oral and dental requirements. All care recipients’ oral and dental needs are assessed as part of the entry process. Staff develop a care plan based on each care recipient’s oral health needs and personal preferences and consider the assistance required for daily care of teeth, mouth and dentures as appropriate. Referral to dental services occur in response to specific request or identified need and there are adequate supplies of toothpaste, toothbrushes and denture containers available. Care recipients and representatives are satisfied with the oral and dental care provided.

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


Management and staff demonstrate there is a system to identify and effectively manage care recipients’ sensory loss. Assessment for sensory deficits occurs upon entry to the home and dedicated sensory resources to identify the level of the five senses assist this process. Corresponding care plans detail care strategies to support care recipients including details of assistive devices such as glasses and hearing aids. Staff refer care recipients to specialist appointments in response to specific request and identified need. The environment is well lit and clutter free with handrails throughout the home to assist care recipients with sensory loss to easily navigate their way around the home. A range of resources of different textures are on display to enhance touch, with the varied lifestyle program offering activities to enhance the other senses. Care recipients and representatives are satisfied staff assist care recipients to minimise the impact of any sensory loss.

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


Management demonstrate strategies that enable care recipients to achieve natural sleep patterns. An assessment process includes identification of sleep patterns and habits, and personal preferences to promote sleep. Development of care plans include consultation with care recipients and representatives and document the use of settling strategies such as the


provision of additional blankets, pillows and refreshments. Medical officer review occurs if pharmacological assistance is needed to promote sleep. Care recipients and representatives are satisfied with the way in which the home assists care recipients to achieve natural sleep patterns.


Standard 3 – Care recipient lifestylePrinciple: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.



The organisation actively pursues continuous improvement in care recipient lifestyle. Care recipients and staff are satisfied with improvements in care recipient lifestyle. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 3 Care recipient lifestyle include:

Following a change in lifestyle staffing, management organised an external review of care recipient lifestyle services. A new approach to lifestyle was developed with more program flexibility, relieving lifestyle staff and a new way of identifying care recipient lifestyle needs. Care recipient surveys indicate increased satisfaction with the new model of care recipient lifestyle.

To encourage individual art expression, a care recipient from Warrina now offers weekly art classes to other care recipients across the three homes within the organisation. Care recipients said they enjoy learning how to construct an artwork using medium including oil pastels and showed samples of their framed art. There are plans to hold an art exhibition and high tea at the end of the year to showcase care recipients’ work.

Care recipients preferred individual rather than group leisure pursuits and the lifestyle program has increased individual contact time in response to care recipients’ lifestyle needs. For example, staff changed a care recipient’s television so they could use new technology to follow their interest in horse racing.

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”.


Management has systems to identify and promote compliance with relevant legislation, regulatory requirements, professional standards and guidelines in the area of care recipient lifestyle. Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements.

Examples of responsiveness to regulatory compliance relating to Standard 3 Care recipient lifestyle include:

A consolidated compulsory reporting/notifiable event register is maintained.

Management ensure all staff, on induction and ongoing, complete training in recognising and responding appropriately to situations that may require compulsory reporting.


Care recipients or their representatives receive information on care recipients’ rights and responsibilities and security of tenure.

Staff position descriptions guide the maintenance of care recipients’ privacy and confidentiality.



The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to care recipient lifestyle. Refer to Expected outcome 1.3 Education and staff development for more information.

Examples of education and training provided in relation to Standard 3 Care recipient lifestyle include:

community engagement

cultural understanding

diversional therapy

elder abuse

‘Montessori’ model

understanding dementia.

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".


Care recipients' emotional needs are identified on entry and on an ongoing basis. Processes to assist care recipients include the provision of information prior to entering the home, support during the settling in period, involvement of family and significant others and a lifestyle plan to meet care recipient needs and preferences. Emotional support is provided to care recipients based on their identified need and concerns relating to emotional health are referred to appropriate support services. The home's monitoring processes, including feedback and care reviews, identify opportunities for improvement in relation to the emotional support provided. Staff engage with care recipients and support emotional wellbeing in accordance with care recipient preferences. Most care recipients interviewed agreed or strongly agreed there are staff to talk to if they are sad or worried.

3.5 IndependenceThis 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".


Care recipients' needs and preferences are assessed on entry and on an ongoing basis to ensure there are opportunities to maximise independence through engaging in meaningful activity, maintain relationships and participate fully in the life of the community. Strategies to


promote care recipients' independence are documented in the care plan and are evaluated and reviewed to ensure they remain current and effective. The living environment is monitored and equipment is available to ensure care recipients' independence is maximised. The home's monitoring processes, including feedback, and environmental and care reviews, identify opportunities for improvement in relation to care recipient independence. Staff are familiar with the individual needs of care recipients and actively promote community engagement. All care recipients and representatives interviewed agreed they are encouraged to do things for themselves.

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


Care recipients' preferences in relation to privacy, dignity and confidentiality are identified on entry and on an ongoing basis to ensure these needs are recognised and respected. Strategies for ensuring privacy and dignity are planned and implemented and this information is documented in the care plan. The living environment supports care recipients' need for personalised and familiar space and provides areas for receiving guests. The home's monitoring processes, including feedback, meetings and care reviews, identify opportunities for improvement in relation to the home's privacy, dignity and confidentiality systems and processes. Staff were observed to address care recipients in a respectful and courteous manner and they provided examples of ways they support care recipients’ privacy, dignity and confidentiality. All care recipients and representatives interviewed said staff treat them with respect most of the time or always and are satisfied with how privacy and dignity is managed at the home.

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


Care recipients' interests and activities of choice are identified on entry; barriers to participation, past history, and cultural and spiritual needs are recognised. This information is documented and regularly updated to inform staff of care recipients' current preferred leisure choices. A varied and flexible program of activities is available and is reviewed and evaluated to ensure it continues to meet the needs and preferences of care recipients. The activities program respects care recipients' varied needs and past history and includes both group and one-on-one activities as well as regular outings. Local community groups visit the home regularly and staff actively promote care recipients’ engagement in the local community. Care recipients’ participation in activities is encouraged but staff respect their choices if they choose not to participate. Care recipients are satisfied with activities and state they are supported to participate in activities of interest to them.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".



Individual care recipients' customs, beliefs and cultural and ethnic backgrounds are identified on entry through consultation with the care recipient and their representatives. Relevant information relating to care recipients' cultural and spiritual life is then documented in care plans which are regularly evaluated and reviewed. The home has access to support services, resources and community groups and provision is made for the observation of special days. Care recipients have access to a variety of religious services at the home in accordance with their stated preference. The home's monitoring processes identify opportunities for improvement in relation to the way care recipients' cultural and spiritual life is valued and fostered. Staff support care recipients to attend and participate in activities of their choice. Care recipients and representatives are satisfied care recipients' customs and beliefs are respected.

3.9 Choice and decision-makingThis 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".


The home has processes to ensure care recipients and their representatives are provided with information about their rights and responsibilities on entry to the home and on an ongoing basis. Staff are provided with information about care recipients' rights and responsibilities and provide opportunities for the care recipient to exercise choice and make decisions when providing care and services. Strategies to foster care recipient participation in decision making include care recipient/representative meetings, comments/complaints mechanisms, surveys, feedback from activities and reviews of lifestyle care plans in consultation with care recipients and representatives. Staff demonstrate their understanding of care recipients' rights to make choices and how to support them in their choices. All care recipients and representatives interviewed said staff explain things to them and are satisfied they can participate in decisions about the care and services they receive and that staff respect their choices.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


On entry, care recipients and representatives are provided with an agreement containing information about care recipients' rights and responsibilities, the terms and conditions of their tenure, any limitations to care provision within the home, fees and charges and information about complaints. Care recipients and representatives are assisted to understand their rights and responsibilities on an ongoing basis through meetings and one to one contact. Changes to care recipients’ security of tenure or rights and responsibilities are communicated to care recipients and representatives. If a change in care recipient health requires a room change or transfer to another home, this is discussed with the care recipient and representative. The home's monitoring processes, including stakeholder feedback, meetings and care consultations identify opportunities for improvement in relation to care recipient security of tenure and responsibilities.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



The organisation actively pursues continuous improvement in the physical environment and safe systems. Care recipients and staff are satisfied with improvements to the physical environment and safe systems. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 4 Physical environment and safe systems include:

To better respond to any fire emergencies that may occur, management upgraded the fire panel to integrate into the organisation’s whole service system. Staff said the fire panel is now easy to read and management is satisfied risk is reduced due to increased fire panel response times.

In consultation with care recipients, the catering service has implemented monthly carvery buffet lunches with two meat choices during the colder months when barbeques are not practical. Care recipients reported they enjoyed the new carvery meal.

Management has progressed plans to refurbish care recipients’ rooms, commencing in February 2018. Plans are in place to upgrade bathrooms, sinks and cupboards in bedrooms, to install picture rails for photographs and art displays and to replace carpets. In addition, the kitchenette will be reconfigured and a servery with shutter installed to reduce noise during meal services. The organisation is managing the project and care recipients are looking forward to the changes which will significantly improve comfort of the living environment.

Management introduced an anti-violence approach, including prevention and response to occupational violence and aggression. Staff education in relation to occupational violence is occurring and staff name tags now include ‘code grey’ instructions. Management and staff said the new training promotes workplace safety.

4.2 Regulatory complianceThis 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”.


Management has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines in relation to the physical environment and safe systems. Please refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system.

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


Staff participate in initial and ongoing training in fire and emergency management.

Chemicals are stored securely and chemical safety training occurs as appropriate.

The catering service follows a current, certified food safety program.

Management actively promotes work health and safety and staff have access to trained occupational health and safety representatives.



The home has a system to monitor the knowledge and skills of staff members and enable them to effectively perform their role in relation to physical environment and safe systems. Refer to Expected outcome 1.3 Education and staff development for more information.

Examples of education and training provided in relation to Standard 4 Physical environment and safe systems include:

fire training

hand hygiene

management of chemicals

manual handling.

4.4 Living environmentThis 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".


The home's environment reflects the safety and comfort needs of care recipients, including comfortable temperatures, noise and light levels, sufficient and appropriate furniture and safe, easy access to internal and external areas. Environmental strategies are employed to eliminate the need for care recipient restraint. Rooms are personalised with items from care recipients' homes and are fitted with call bells and secure storage areas. There are a range of communal and private areas for care recipient and visitor use. The safety and comfort of the living environment is monitored through feedback from meetings, surveys, maintenance reporting and inspections. There are appropriate preventative and routine maintenance programs for buildings, furniture, equipment and fittings. Staff support a safe and comfortable environment through hazard, incident and maintenance reporting processes. All care recipients interviewed said they feel safe in the home and are satisfied the living environment is comfortable.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Management actively work to provide a safe work environment that meets work health and safety regulatory requirements. The organisation provides trained occupational health and


safety representatives, an employee assistance program and resources that promote workplace health and safety. Management inform staff of their responsibilities in relation to safe work practices through induction programs, initial and ongoing manual handling training, risk assessments, policies, procedures and meetings. Health and safety meetings regularly occur and ‘no lift’ procedures are established. Processes to monitor work health and safety include audits and inspections, risk assessments, maintenance requests and incident and hazard reporting and analyses. Staff are satisfied management works to provide a safe environment.

4.6 Fire, security and other emergenciesThis 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".


Management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. Policies and procedures relating to fire, security and other emergencies are documented and accessible to staff; this includes an emergency evacuation plan. Staff are provided with education and training about fire, security and other emergencies when they commence work at the home and on an ongoing basis. Emergency equipment is inspected and maintained and the environment is monitored to minimise risks. Testing and tagging of electrical equipment and pest inspections occur. Staff have an understanding of their roles and responsibilities in the event of a fire and there are routine security measures. All care recipients interviewed said they feel safe in the home.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


Management and staff demonstrate there are processes to minimise the incidence and spread of infection. Access to ready supplies of personal protective equipment, hand washing facilities, a food safety program and pest control procedures are some of the measures in place to promote an effective infection control program. There is access to outbreak procedures to ensure timely implementation of management strategies and all staff undergo regular infection control training. Recording of infections, using an evidence based identification tool ensures timely intervention with review including data analysis. Care recipients and staff are all offered influenza vaccinations and there is access to an on-site infection prevention and control coordinator for additional support to ensure an effective infection control program. Relevant guidelines are incorporated into the catering, cleaning and laundry staff work practices. Care recipients and representatives are satisfied with the infection control measures demonstrated by management and staff.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


The home identifies care recipients' needs and preferences relating to hospitality services on entry to the home through assessment processes and consultation with the care recipient and their representatives. There are processes available that support care recipients to have input into the services provided and the manner of their provision. The home's monitoring


processes identify opportunities for improvement in relation to the hospitality services provided; this includes feedback from care recipients and representatives and monitoring of staff practice. Care recipients’ special dietary needs are assessed and reviewed by a dietitian and meals are prepared fresh on site, with a varied, seasonal menu and oversight by an executive chef. Care recipient menu choices, allergies and special dietary needs are taken into account. Staff clean according to a schedule and all laundry is processed on site with provisions for labelling and ironing of clothing. Staff are satisfied the hospitality services enhance the working environment. Most care recipients interviewed said they like the food most of the time or always and are satisfied with cleaning and laundry services.


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