published_decision_(sa_and_ra) · web viewthis table outlines the details of the decision made....

Coffs Haven Residential Care ServiceRACS ID: 0545

Approved provider: The Churches of Christ Property Trust

Home address: 18 Sand Street NORTH BOAMBEE VALLEY NSW 2450

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 23 February 2021.

We made our decision on 03 January 2018.

The audit was conducted on 28 November 2017 to 30 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: Coffs Haven Residential Care Service Date/s of audit: 28 November 2017 to 30 November 2017RACS ID: 0545 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: Coffs Haven Residential Care Service Date/s of audit: 28 November 2017 to 30 November 2017RACS ID: 0545 3

Audit ReportName of home: Coffs Haven Residential Care Service

RACS ID: 0545

Approved provider: The Churches of Christ Property Trust

IntroductionThis is the report of a Re-accreditation Audit from 28 November 2017 to 30 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 28 November 2017 to 30 November 2017.

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

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

Details of homeTotal number of allocated places: 100

Number of care recipients during audit: 99

Number of care recipients receiving high care during audit: 99

Special needs catered for: 10 bed memory support unit (Opal House)


Audit trailThe assessment team spent three days on site and gathered information from the following:

Interviews

Position title Number

Director of Nursing (DON) 1

Deputy director of nursing (DDON) 1

General manager residential (organisation) 1

Clinical nurse educator 1

Registered nurses 3

Team leaders 3

Care staff 5

Physiotherapists 2

Activities staff 3

Business services officers 2

Kitchen staff (including hotel services coordinator, cook and catering staff)

5

Care recipients 24

Representatives 8

Volunteers 1

Laundry staff 2

Cleaning contractors (staff, supervisor and leading hand)

3

Maintenance staff 1

Chaplain 1

Sampled documents

Document type Number

Care recipients’ files 17

Medication charts 10

External contractors agreements 5


Document type Number

Incident reports 10

Personnel files 7

Other documents reviewedThe team also reviewed:

Activities calendar and planning materials

Approved suppliers list

Audits

Care recipient records: admission details, advance care directive, assessments, care plans and directives, case conference, consent forms, dietary requirements, monitoring records, progress notes, reports

Care recipients’ agreements

Care recipients’ information (welcome) pack and surveys

Cleaners folders and work instructions, daily cleaning schedule and records

Clinical resources, policies, procedures and guidelines, clinical indicators and line listing

Coffs Haven business plan

Comments and complaints register and logs

Consolidated register

Continuous improvement logs and plan

Education records, training matrix (mandatory education) and 2018 education plan

Falls analysis (monthly records)

Fire and emergency documentation including annual fire safety statement, plans, procedures and resources, equipment testing records, education records

Food safety advice for relatives

Hazards log

Human resources: job descriptions, orientation records, appraisals

Infection control: monitoring records, vaccination registers, outbreak management documentation, cleaning schedules and records, resources

Laundry checklists, procedures, missing clothing report

Maintenance logs, preventative matrix and schedules, pest control records, call bell and water testing records

Meeting minutes

Memos

Menu, food requirements and preference lists, food safety documentation, NSW Food Authority licences and audit reports

Newsletters


Organisational chart and home staff chart

Police certificates and registrations

Policies and procedures

Register of hazardous substances

Rosters

Self-assessment for reaccreditation

Staff handbook

Work health safety risk assessments, Work, health and safety plan, hazard reports, communication book, safe work method statements

ObservationsThe team observed the following:

Activities in progress including church, singing (choir) and visiting children, men’s group and exercise program

Activities posters including Montessori programs, ladies pampering and pet therapy

Australian Aged Care Quality Agency Re-accreditation audit notices displayed

Bird aviaries, chook house, raised gardens and children’s play area

Brochures and pamphlets including internal/external complaints information, advocacy, aged care resources (in range of different languages)

Care recipients utilising pressure relieving and limb protection equipment

Charter of Care Recipients’ Rights and Responsibilities

Clinical and medical supplies and storage areas

Clinical handover

Contractors repairing electrical equipment

Different coloured doors in Opal

Dining environment during meal service and morning and afternoon teas including staff serving meals, supervision and assisting care recipients

Education room

Emergency equipment: fire panel, fire-fighting equipment, emergency exits, emergency evacuation bag, emergency egress route diagrams

Equipment and supply storage areas

Equipment in use including mobility aids, assistive devices for meals and hoists

Feedback mechanisms internal and external

Flow chart for reporting

Front of house (reception area) with sign in books and staff interactions with care recipients, families and contractors

Infection control resources including hand cleansing facilities, colour coded, personal protective equipment, sharps containers, spills kits, outbreak supplies

Interactions between staff and care recipients in all areas of the home

Kitchen and laundry areas


Large colour photographs taken of the local area and placed throughout the home

Living environment - Internal and external

Maintenance area/workshop

Manual handling equipment: hoist and stand lifters, shower chairs, shower bed bath, slide sheets, walk belts, walking frames and wheel chairs

Meal services and ‘tea’ rounds

Medication system: administration and storage; controlled drugs locked cupboard, drug disposal system; after-hours emergency stock box, and oxygen

Mission statement, vision and values on display

Noticeboards including photographs

Rummage boxes (in Opal)

Staff knocking and identifying themselves before entering rooms

Staff room

Waste disposal area including contaminated waste bins and general waste bins/skips


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 home demonstrated it actively pursues continuous improvement. There is a comprehensive and robust continuous improvement system in place showing a range of continuous activities across all the Accreditation Standards. Living Care, the organisation, and Coffs Haven Residential Care Service (the home) have quality systems drawing on qualitative and quantitative data to identify areas for improvement in its delivery of care and services. These include audits, surveys, clinical indictors, incident reports, feedback, complaints and suggestions, care recipient changes and staffing. Staff, care recipients, representatives and other stake holders were seen to be actively encouraged to contribute to continuous improvement. Improvements are evaluated for effectiveness. Care recipients, representatives and staff were able to describe a range of recent improvements and their satisfaction and pleasure with these.

Continuous improvements related to Standard One include the following:

The organisation identified it would benefit from the introduction of a central point of contact about Living Care for potential care recipients and their representatives and to create a service to deal with ongoing business enquiries. In 2017, Living Care launched its customer hub with a centralised 1800 number, emails and website. This has led to an increase in contact and better informed care recipients/representatives regarding all aspects of Living Care’s services, including issues such as billing. It is also providing a further venue for feedback and the lodging of complaints. At the home it supports the roles of the business services officers who demonstrated competence and knowledge in line with the customer hub service.

Living Care aims to be an employer of choice, with key components of its people and culture focus being to attract and retain top quality staff. To drive this it is promoting four signature behaviours in line with its core values and mission statement. These are: to TREAT others the way you want to be treated; WORK together, achieve together, celebrate together; DO what we say we will do; DELIVER our services with JOY. Key to this is valuing staff and role modelling signature behaviours and recognising those who display them. This has led to a different way of engaging and surveying staff including encouraging staff to rate each other on the positive demonstration of these core values. This has led to a downward trend in staff turnover and an improved working environment. A large number of staff told us they enjoyed coming to work and were committed to working as a team to improve the quality of care and services as this improved care recipients experiences of daily living.


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 organisation and home’s management has a range of policies, systems and processes in place to identify and ensure compliance with all relevant legislation, regulation, professional standards and guidelines. The organisation monitors industry standards and guidelines and subscribes to a range of organisations and agencies that provide current and updated regulatory information. This includes its peak body the Aged & Community Services, Department of Health, local authorities and Australian Aged Care and Quality Agency. An external company audits Living Care’s compliance with legislative requirements. Homes are provided with information, training and education to ensure compliance is maintained across all Standards. Regulatory compliance under Standard One includes maintaining privacy requirements and ensuring currency of police certificates.

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


Staff and management were able to demonstrate they have the appropriate knowledge and skills to effectively perform their roles. The organisation has a consistent structure of education which includes both mandatory training and professional development. The organisation has an extensive e-learning capacity and staff were able to speak to how they utilise this to support their education. The annual staff survey and performance reviews identify further educational and training opportunities. Annual competencies are completed in areas where appropriate to maintain work skills. The home has an on-site educator and they use a comprehensive training matrix to track ongoing staff education. Staff said they are satisfied with the learning opportunities available and this supports them in the delivery of care and services. Management said they see improvement in practices where learning is directed. Care recipients said staff are competent in their work roles. Education provided under Standard One includes: client services, documentation, accreditation, orientation, professional development and use of the aged care funding instrument. The home is also forming better practice partnerships with a range of external services and providers including Joanna Briggs, Bug Control, Dementia Australia, Choice Aged Care and taking part in caring for carers trial research.

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".


The organisation and home actively support care recipients and their representatives to access internal and external complaints processes. There are systems for formal and informal issues/feedback and complaints to be raised including a process for the lodgement of confidential complaints. The home maintains a register which shows how complaints are managed including actions taken to address the concerns raised. This also includes compliments. The home reports on this to its organisation, which actively supports the


home’s management to progress matters constructively and in a timely and effective manner. Case conferencing allows concerns to be addressed and solutions developed as part of ongoing care and services delivery. Comments and complaints were seen to be discussed at care recipient, representative and staff meetings. The DON has an open door policy and this was seen in practice during this visit. Care recipients and their representatives were familiar with the complaints processes available in the home. They said they do raise concerns as and when necessary and on the whole were confident there is a system in place to address these.

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".


Coffs Haven demonstrated it both documents and displays the organisation’s vision, values and philosophy throughout the service and in relevant documentation. These underpin the delivery of care and services. Staff sign a code of conduct which includes the values and mission statement. The home’s leadership team received many compliments from care recipients, representatives and staff for demonstrating the Living Care core values in their actions.

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".


Living Care has a comprehensive human resources framework supported through its head office and resulting in systems to ensure there are appropriately skilled and qualified staff who deliver care and services to care recipients. Reference checks and police certificate clearance are attended prior to employment. New staff receive comprehensive organisational and workplace orientation and complete ‘buddy’ shifts and a period of probation. Position descriptions and work schedules support delivery of care and services. Management regularly review rosters and staff numbers to ensure care and service needs are being met. The home rarely uses agency staff but has a pool of staff to draw on for sudden absences or leave requirements. Staff are appraised annually and the organisation has a strong commitment to professional development. Staff said they have sufficient time and skills to complete their duties. The majority of care recipients and representatives interviewed said there are sufficient and appropriately skilled staff available to meet care recipient requirements.

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


The home demonstrated there is a system in place for ordering all appropriate goods and equipment. This is monitored at both organisational and home level. Auditing processes by key staff with designated authority to do so ensure all ordered stock is appropriate for use in


the home, is useable and matches what was ordered. Systems were seen to be used to return goods which were unsuitable, faulty or below the required standard (such as fresh food supply). A review of inventory and equipment showed adequate supplies and appropriate storage including a system, where required, of stock rotation and when goods needed to be replenished or replaced. An assets register is maintained. The DON and organisation monitor inventory and equipment to ensure sufficiency is maintained. Care recipients expressed their satisfaction with the sufficiency of and access to appropriate goods and equipment.

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


The organisation has a comprehensive and effective information management system in place. This is both electronic and hard copy and supports a consistent approach to use of documentation and procedures. Policy and procedure is part of the organisation’s intranet system. Staff and management in the home demonstrated they apply these systems in the delivery of care and services. Management and staff have access to accurate and controlled information sufficient to help them perform their roles. These include care plans, clinical documentation, work schedules, position descriptions, the intranet and web site. Care recipients and representatives have access to information appropriate to their needs. This includes agreements, welcome packs, newsletters, brochures, meeting minutes, and noticeboard information. Information was seen to be stored in a way which was secure, such as password protected and accessible to only those with authority to do so. The computer system is backed up. Staff and care recipients said they are satisfied with the information available to them.

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".


The organisation has preferred contractors used by the home to ensure external services are provided in a way which meets the needs of the service and care recipients. Contractors are used to support maintenance, catering, clinical supplies and services and chemical supplies. The organisation and senior managers monitor contracts to ensure currency and that they meet required legislative requirements such as police certificates, insurances, indemnities, qualifications and registrations. Key staff in the home provide feedback around satisfaction with the quality and standard of the contracted services provided. The home demonstrated there is a system to monitor contractors when they are on site and to evaluate completed work. Recent changes in contractors to the home include cleaning. Staff and care recipients said they are confident in raising any concerns regarding the quality of the 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.



Refer to expected outcome 1.1 Continuous improvement for further information regarding the home’s system of continuous improvement.

Continuous improvements related to Standard Two include the following:

Following analysis of clinical data on falls it was decided in mid-2017 to introduce a falls prevention initiative using a traffic light system to enable identification of care recipients most at risk of falls. Those identified have been supported with the increase of aids such as non-slip socks, sensor beams, and lo-lo beds. There is also a multi layered discreet identification of care recipients at risk of falls. Such as a colour added to their door plate or wheelie walker. The home has also employed two on site physiotherapists who between the two of them provide seven days physiotherapy cover. The focus of the program is holistic person centred care and this was seen to be in use during this visit with care recipients praising the interventions and approach taken by the physiotherapist on site. Likewise a review of September/October 2017 clinical falls data showed a reduction in falls across the home. Staff were able to speak to the results of the falls prevention initiative. For example, in interview care staff and registered nurses in Diamond wing said they were confident they were identifying and reporting all falls. Staff also said that if they saw any unexplained bruises this would be reported immediately to the registered nurse and part of the investigation would be to identify if there had been an unwitnessed fall.

In January 2017 it was decided to introduce an initiative in partnership with Choice Aged Care to reduce the use of psychotropic medications in the home. Monthly reports from the pharmacy provided detailed breakdowns of usage. Medical officers were contacted by clinical pharmacists to discuss use of psychotropics, including where there was an identified higher use of medications to control behaviour. In partnership with the medical officers, psychotropic medication use was reviewed and in line with person centered care other options considered. This also resulted in education for staff to use non medication interventions to manage challenging behaviours. This initiative has resulted in a decrease in the use of psychotropic medications within the home.

A review of continence aid usage has led to a trial of a new product in the home. The DDON had attended continence management education in Denmark which changed the way in which the home managed continence care. In particular moving away from set ides such as changing three aids per day to reassessing all care recipients and identifying their needs on a daily basis. The new product in use is a better fit and more comfortable. This has led to better skin integrity outcomes and improvement in skin care and wound management.


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”.


Refer to expected outcome 1.2 Regulatory compliance for further information regarding the home’s system in this area.

The home demonstrated it has systems to ensure the currency of professional registrations. The home demonstrates it has safe systems for the administration of medications and delivery and storage of S8 medications.



Refer to expected outcome 1.3 Education and staff development for further information regarding the home’s system in this area.

Education provided under Standard Two includes: behavioural management, palliation, continence, pressure area care, use of psychotropic medications, advanced care planning, medication competency and pain management.

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

Team's findingsThe home meets this expected outcome

The home has mechanisms to ensure care recipients receive clinical care that is appropriate to their needs and preferences. Care needs are identified on entry and on an ongoing basis through a review and transfer of information, consultation with the care recipient and/or their representative and assessment processes. Individual care plans are developed by qualified staff and reviewed regularly. There are processes to ensure staff have access to current information to inform care delivery including care plans, progress notes and handovers. Care recipients' clinical care needs are monitored, evaluated and reassessed through incident analysis, reviews and feedback. The home regularly reviews and evaluates the effectiveness of the clinical care system and tools used. Changes in care needs are identified and documented; where appropriate, referrals are made to medical officers or health professionals. Staff provide care consistent with individual care plans. Care recipients and representatives interviewed stated they are satisfied with the clinical care being provided.

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”.


Care recipients' specialised nursing care needs are identified through assessment processes on entry to the home. Care is planned and managed by appropriately qualified staff. This information, together with instructions from medical officers and health professionals is


documented in the care plan. Specialised nursing care needs are reassessed when a change in care recipient needs occurs and on a regular basis. The home's monitoring processes identify opportunities for improvement in relation to specialised nursing care systems and processes. Staff have access to specialised equipment, information and other resources to ensure care recipients' needs are met. Specialised nursing care is delivered by appropriately qualified staff consistent with the care plan. The local hospitals nurse practitioner provides support for specialised nursing care. Care recipients and representatives interviewed are satisfied with how care recipients' specialised nursing care needs are managed.

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”.


The home has systems to ensure care recipients are referred to appropriate health specialists in accordance with their needs and preferences. Health specialist directives are communicated to staff and documented in the care plan and care is provided consistent with these instructions. Staff practices are monitored to ensure care is in accordance with the care recipients' needs and preferences. Staff support care recipients to attend external appointments with health specialists. Care recipients and representatives interviewed stated they are satisfied referrals are made to appropriate health specialists of their choice and staff carry out their instructions.

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


The home has systems to ensure care recipients' medication is managed safely and correctly. There are processes to ensure adequate supplies of medication are available and medication is stored securely and correctly. Medical officers prescribe and review medication orders and these are dispensed by the pharmacy service. Documented medication orders provide guidance to staff when administering or assisting with medications. Procedural guidelines provide clarification surrounding safe medication practices. The home's monitoring processes include reviews of the medication management system and analysis of medication incident data. Opportunities for improvement in relation to the medication management system are identified and addressed. Staff who administer or assist with medications receive education in relation to this. Care recipients and representatives interviewed are satisfied care recipients' medications are provided as prescribed and in a timely manner.

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


Care recipients' pain is identified through assessment processes on entry to the home and as needs change. Specific assessment tools are available for care recipients who are not able to verbalise their pain. Care plans are developed from the assessed information and are evaluated to ensure interventions remain effective. Medical officers and allied health professionals are involved in the management of care recipients' pain. The home's


monitoring processes identify opportunities for improvement in relation to pain management systems and processes. Staff assess care recipients' verbal and non-verbal indicators of pain and implement appropriate actions, including utilising a range of strategies to manage comfort levels. Care recipients and representatives interviewed are satisfied care recipients are 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”.


The home has processes for identifying and managing care recipients' individual palliative care needs and preferences. Assessments are completed with the care recipient and/or representative to identify end of life care wishes and this information is documented in an end of life plan. The home uses a multidisciplinary approach that addresses the physical, psychological, emotional, cultural and spiritual support required by care recipients and their representatives. There is a supportive environment which provides comfort and dignity to the care recipient and their representatives. Care recipients remain in the home whenever possible, in accordance with their preferences. A palliative care kit is located in a moveable bedside set of drawers. This provides easy access to equipment supportive to the delivery of palliation such as aromatherapy, music and oral hygiene resources. Referrals are made to medical officers, palliative care specialist teams and other health specialist services as required. Staff practices are monitored to ensure the delivery of palliative care is in accordance with the end of life plan. Staff follow end of life plans and respect any changes which may be requested. Care recipients and representatives interviewed are satisfied care recipients' comfort, dignity and palliative care needs are maintained.

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


Care recipients' nutrition and hydration requirements, preferences, allergies and special needs are identified and assessed on entry. Care recipients' ongoing needs and preferences are monitored, reassessed and care plans updated. There are processes to ensure catering and other staff have information about care recipient nutrition and hydration needs. Staff monitor care recipients' nutrition and hydration and identify those care recipients who are at risk. The home provides staff assistance, equipment, special diets and dietary supplements to support care recipients' nutrition and hydration. Staff have an understanding of care recipients' needs and preferences including the need for assistance, texture modified diet or specialised equipment. Staff practices are monitored to ensure nutrition and hydration needs are delivered in accordance with care recipients' needs and preferences. Care recipients and representatives interviewed are satisfied care recipients' nutrition and hydration requirements are met.

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



Care recipients' skin care requirements, preferences and special needs are assessed and identified, in consultation with care recipients and/or representatives. Care plans reflect strategies to maintain or improve care recipients' skin integrity and are reviewed regularly. Skin care needs are monitored, evaluated and reviewed as required. Referral processes to other health specialists are available if a need is identified. The home's monitoring processes identify opportunities for improvement in relation to skin care; this includes a process for documenting and analysing incidents relating to skin integrity. Staff promote skin integrity through the use of moisturisers, pressure relieving devices, pressure area care and safe manual handling techniques. Care recipients and representatives interviewed are satisfied with the assistance provided to maintain skin integrity.

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


Care recipients' continence needs and preferences are identified during the assessment process and reassessments occur as required. Strategies to manage care recipients' continence are documented in the care plan and regular evaluation occurs to ensure strategies remain effective. Care staff have an understanding of individual care recipients' continence needs and how to promote privacy when providing care. Changes in continence patterns are identified, reported and reassessed to identify alternative management strategies. Equipment and supplies such as continence aids are available to support continence management. The home's monitoring processes identify opportunities for improvement in relation to continence management; this includes the collection and analysis of data relating to infections. Staff are conscious of care recipients' dignity while assisting with continence needs. The majority of care recipients and representatives interviewed are very satisfied with the support provided to care recipients in relation to continence management.

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


The needs of care recipients with challenging behaviours are identified through assessment processes and in consultation with the care recipient, their representative and/or allied health professionals. Individual strategies to manage challenging behaviours are identified and documented in the care plan and are regularly evaluated to ensure they remain effective. The home practices a minimal restraint policy; where restraint is used it has been assessed, authorised and is monitored to ensure safe and appropriate use. Restraint authorisation is reviewed on a regular basis. The home's monitoring processes identify opportunities for improvement relating to behaviour management; this includes the collection and analysis of behavioural incident data. Staff have an understanding of how to manage individual care recipients' challenging behaviours, including those care recipients who are at risk of wandering. The team observed a calm environment and care staff providing individualised meaningful activities that engaged care recipients’ living with dementia. Care recipients and representatives interviewed said staff are responsive and support care recipients with behaviours which may impact on others.

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



Care recipients' mobility, dexterity and rehabilitation needs are identified through assessment processes and in consultation with the care recipient and/or their representative. Where a need is identified, referrals are made to medical officers and other health specialists, including physiotherapists. Strategies to manage care recipients' mobility and dexterity are documented in the care plan and are regularly evaluated and reviewed to ensure care recipients' needs are met. The home's monitoring processes identify opportunities for improvement in relation to mobility, dexterity and rehabilitation, including the collection and analysis of data relating to accidents and incidents. Care recipients and staff have access to a variety of equipment to assist with care recipients' mobility, dexterity and rehabilitation needs. Associated programs are delivered by appropriately skilled staff, consistent with the care plan. Care staff and physiotherapy aide support individualised exercise programs developed by the physiotherapists. The majority of care recipients and representatives interviewed are very satisfied with the support provided for achieving optimum levels of mobility and dexterity.

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


Care recipients' oral and dental health needs are identified through assessment processes and in consultation with the care recipient and/or their representative. Care strategies are documented on the care plan and are regularly evaluated and reviewed to ensure care recipients' changing needs are met. The home's monitoring processes identify opportunities for improvement in relation to oral and dental management systems and processes, including clinical monitoring processes and consultation. Equipment to meet care recipients' oral hygiene needs is available. Staff provide assistance with oral and dental care and where necessary referrals are made to health specialists such as dentists. Care recipients and representatives interviewed are satisfied with the assistance given by staff to maintain care recipients' teeth, dentures and overall oral hygiene.

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


Sensory losses are identified through assessment processes and in consultation with care recipients and/or their representative. Care plans identify individual needs and preferences and are reviewed regularly. Care recipients are referred to health specialists, such as audiologists and optometrists, according to assessed need or request and are assisted to attend appointments as required. The home's monitoring processes identify opportunities for improvement in relation to how sensory loss is managed, including clinical monitoring processes and consultation with care recipients, representatives and health professionals. Staff receive instruction in the correct use and care of sensory aids and are aware of the assistance required to meet individual care recipients' needs. The majority of care recipients and representatives interviewed are satisfied with the support provided to manage care recipient sensory needs. The home is working with Vision Australia to further improve individualised programs for care recipients in relation to vision support.


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


Care recipients' sleep patterns, including settling routines and personal preferences, are identified through assessment processes on entry. Care plans are developed and reviewed to ensure strategies to support natural sleep remain effective and reflect care recipients' needs and preferences. Care recipients experiencing difficulty sleeping are offered a range of interventions to promote sleep; where appropriate medical officers are informed of sleep problems. The environment is optimised to ensure it supports natural sleep and minimises disruption. Environmental and clinical monitoring processes identify opportunities for improvement in relation to sleep management. Staff support care recipients when normal sleep patterns are not being achieved. Care recipients and representatives interviewed are satisfied with the peaceful environment and support provided to care recipients to assist them 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.




Continuous improvements related to Standard Three include the following:

Two staff undertook training in an educational model, Montessori to support and enrich activity programs and care recipient engagement. This is in line with Living Care’s person centered and mission focus. In particular the program focus on meaningful activities relevant to the care recipient’s life before coming to the home. This includes areas such as gardening or assisting with daily tasks around the home. It also draws on aids which stimulate reminiscing such as ‘read and chat’ books, such as ‘Victor’s lawnmower’, ‘Australian flowers and fauna’ and ‘Vegemite.’ Information from the reminiscing are added to the lifestyle and life story component of the care recipient’s care plan. Activity staff said this has been a positive initiative with a range of options to use in all aspects of care and services. They are currently encouraging other staff to use the Montessori tools and model. Another initiative as part of this has been an introduction in one area of the buffet breakfast. This allows care recipients to sleep in if they wish and have a choice of breakfasts when they choose to eat. Staff said there are instances of care recipients who previously required assistance with eating who are helping themselves to food and eating more and with appetite. Other care recipients said they enjoy assisting other care recipients with breakfast. Some care recipients and representatives said they prefer the old style set time breakfast sitting. The DON is aware of this and working to manage the concerns alongside the benefits of the new service. Care recipients have the option to have their meal served to them at the same time they previously received breakfast. Staff said they like this initiative as it allows them to concentrate on delivering care across the morning rather than at one time.

The home through the initiative of a care recipient has provided LGBTI support and education across the home. The care recipient self-identified as transgender and wanted to apply their experience as a way of providing education to staff, other care recipients and representatives. In interview with us they acknowledged this has been a powerful and empowering experience for them. With the support of Living Care and key people at the home this was recorded and documented as a way of demonstrating strength through diversity. In response to the personalisation of this experience other people within the home community have felt able to self-identify their sexuality and this has resulted in more inclusiveness within the home for diversity.

Following an initiative with a local service to provide contact between the Coffs Harbour and the refugee/new migrant group communities, people from these communities were invited to the home to meet and socialise with care recipients and their representatives. The aim was to show although a difference in cultural backgrounds they would have many things in common such as dealing with adversity and war. Care recipients were able to help with language skills and enjoyed hearing about the wide array of places new migrants came from. They also enjoyed the baking and cooking ideas shared across


cultures. Some of the new migrants retained their contact with the home by volunteering with one person recently commencing a part time position within the home. As a result, there has been a breakdown in barriers and a getting to know people the care recipients may not have otherwise had contact with.

3.2 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 care recipient lifestyle”.



As an example of meeting regulatory compliance under this Standard the home maintains a consolidated record. This shows incidents where mandatory reporting has occurred or discretion not to report has been used. All incidents are reported up through the organisation and decisions on appropriate action are made by the designated key person only. Staff demonstrated an understanding of how they would report alleged assaults and said they had received mandatory education on reporting elder abuse. The home (through its organisation) has the link to the updated reporting form as is now required by the Department of Health for missing care recipients and the reporting of alleged assaults.




Education provided under Standard Three includes: Montessori programs and activities, pastoral care – grief and loss, privacy and confidentiality, LGBTS and compulsory reporting (reporting elder abuse).

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the Chaplain and recreational activities officers, care recipient/representatives meetings and involvement of family in the activity and Montessori program. Business support officers are trained in assisting care recipients and their families familiarise themselves with the service and entry to the home such as through showing them their room and layout of the home. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors are welcomed and encouraged to participate in the life of the home. Care recipients and representatives are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive.


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".


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Visitors, volunteers and entertainers are encouraged and arranged. The environment encourages care recipients, their representatives and their friends to participate in activities. Management actively support care recipients and representatives to speak openly and participate in the life of the home. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.

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


There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs, including the care recipient’s preferred name. For example, activity staff respect care recipient’s rights not to socialise by providing a range of one-on-one contact and engagement. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Confidential information is discussed in private and care recipients’ files securely stored. Staff practices were observed to respect privacy and dignity including consistently knocking on room doors before entering to provide care and services. Care recipients and representatives said staff are very respectful and they 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".


The lifestyle program offers an extensive range of activities seven days a week. There are individual activities programs for both the mainstream and memory support unit with many activities integrated. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. Lifestyle programs include concerts, bus outings, entertainers, happy hour, word games, pampering sessions and daily exercise classes. A number of Montessori activities and engagements have recently been introduced and were seen to be being enjoyed by care recipients. Care recipients are given the choice of whether or not to take part in activities. The results of interviews and document review confirm care recipients and representatives are highly satisfied with the activities provided to the care recipients. During the three days of


the re-accreditation site audit we observed meaningful engagement and obvious enjoyment of the lifestyle program.

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


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients/representatives are asked about end of life wishes and this information is documented in their file. The home has a Chaplain, who was observed interacting with care recipients and leading a care recipient focused choir. Religious services are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met. Staff care recipients and representatives spoke very highly of the pastoral care services provided by the chaplain.

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".


Management demonstrates each care recipient participates in decisions about the services the home provides and is able to exercise choice and control over their lifestyle through consultation around their individual needs and preferences. Management has an open door policy and this promotes continuous and timely interactions between the management team, care recipients and/or representatives. Observation of staff practices and staff interviews show care recipients have choices available to them including for example, meals, whether to attend activities, and waking and sleeping times. Care recipients/representatives meetings and surveys occur regularly to enable care recipients and representatives to discuss and provide feedback about the services provided and documentation showed this occurs. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

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".


The home was able to demonstrate care recipients and their representatives have been provided with information about security of tenure and understand care recipient rights and responsibilities. The care recipient welcome pack and care recipient agreement outlines security of tenure and potential care recipients are carefully taken talked through the contents of the agreement before signing and becoming a resident in the home. Any change of room is only done in consultation with the care recipient and/or their designated


representative and seeking their agreement to the change. The Charter of Care Recipients’ Rights and Responsibilities is on display around the home and included in documentation where relevant. Care recipients said they feel secure in the home and understand their rights 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.




Examples of continuous improvements under Standard Four include the following:

Following the winning of a grant the home has established a raised garden area and children’s playground. This is both to enhance the environment and encourage community involvement in the home. For example visitors with small children enjoy having a small playground in the central outdoor courtyard. Care recipients say they gain enjoyment by watching children use this area. Likewise the flower beds are a source of great enjoyment with care recipients saying they are amazed at how quickly it has taken shape with a range of herbs, vegetables and already tall sunflowers. This dovetails in with the effective use of garden and outdoor areas including a chook house and a range of bird aviaries. These provide meaningful engagement for care recipients who said they enjoy contact with the birds and some like to “potter” around the garden areas. It is planned to add a BBQ area and introduce outdoor games and sail cloth shades for summer.

In the memory support area (Opal) a number of environmental improvements have been added. This includes large, individually coloured doors to care recipient rooms for better identification and visual stimulation. The DON is aiming to add memory boxes for reminiscing items outside each room. Drawers for reminiscing materials were observed in this area and families are being encouraged to bring in things such as favourite small items or photographs. Across the home there are large colour photographs of the local Coffs Harbour area, these are beautiful land and sea scapes that enhance the environment. Many of the care recipients and representatives commented on how much they enjoy the beautiful and homely environment being created in the home.

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”.



The home has a current fire certificate and NSW Food authority certificate. The home has a work, health and safety committee. Catering staff have completed safe food handling training and nearly all staff have to completed their 2017 mandatory training under this Standard including fire and emergency and infection control.





Education provided under Standard Four includes: Work, Health & Safety, infection control, manual handling, fire and emergency and food safety.

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. The garden areas and a children’s playground area are accessible for care recipients and their families. Environmental strategies are employed to minimise care recipient restraint. The safety and comfort of the living environment is assessed and monitored through feedback from meetings, surveys, incident and hazard reporting, audits and inspections. There are appropriate preventative and routine maintenance programs for buildings, furniture, equipment and fittings. This includes electrical tagging and review for replacement of older furnishings and equipment. Staff support a safe and comfortable environment through hazard, incident and maintenance reporting processes. Care recipients and representatives interviewed are satisfied the living environment is safe and 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".


There are processes to support the provision of a safe working environment, including policies and procedures, staff training, routine and preventative maintenance and incident and hazard reporting mechanisms. Opportunities for improvement in the occupational health and safety program are identified through audits, inspections, supervision of staff practice, and analysis of incident and hazard data. Sufficient goods and equipment are available to support staff in their work and minimise health and safety risks. Staff have an understanding of safe work practices and are provided with opportunities to have input to the home's workplace health and safety program. Staff were observed to carry out their work safely and are satisfied management is actively working to provide a safe working 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".



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. Staff have an understanding of their roles and responsibilities in the event of a fire, security breach or other emergency and there are routine security measures. Care recipients and representatives interviewed are aware of what they should do on hearing an alarm and feel safe and secure in the home.

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


The home has processes to support an effective infection control program. The infection control program includes regular assessment of care recipients' clinical care needs in relation to current infections, susceptibility to infections and prevention of infections. Staff and management follow required guidelines for reporting and management of notifiable diseases. Care plans describe specific prevention and management strategies. The home's monitoring processes identify opportunities for improvement in relation to infection control; this includes observation of staff practices, analysis of clinical and infection data and evaluation of results. Preventative measures used to minimise infection include staff training, a food safety program, cleaning regimes, vaccination programs, a pest control program, waste management and laundry processes. Staff are provided with information about infections at the home and have access to policies and procedures and specific equipment to assist in the prevention and management of an infection or outbreak. Care recipients, representatives and staff interviewed are satisfied with the prevention and management of infections.

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. Hospitality staff interviewed said they readily have access to information about care recipient preferences and receive feedback about services provided. Staff are satisfied the hospitality services enhance the working environment. One care recipient stated that even though the food is of good quality they are not interested in food, another said sometimes the meat is tough and another said it is too soft. Care recipients and representatives interviewed are satisfied with cleaning and laundry services. The majority said that catering and hospitality services meet their needs and make their stay more enjoyable and many care recipients said that meals are a part of the day they look forward to.


published_decision_(sa_and_ra) · web viewthis table outlines the details of the decision made....

Documents