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Vietnam Veterans Keith Payne VC HostelRACS ID: 0309

Approved provider: Vietnam Veterans Keith Payne VC Hostel Ltd

Home address: 1 Evans Road NORAVILLE NSW 2263

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 10 February 2021.

We made our decision on 21 December 2017.

The audit was conducted on 14 November 2017 to 15 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: Vietnam Veterans Keith Payne VC Hostel Date/s of audit: 14 November 2017 to 15 November 2017RACS ID: 0309 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: Vietnam Veterans Keith Payne VC Hostel Date/s of audit: 14 November 2017 to 15 November 2017RACS ID: 0309 3

Audit ReportName of home: Vietnam Veterans Keith Payne VC Hostel

RACS ID: 0309

Approved provider: Vietnam Veterans Keith Payne VC Hostel Ltd

IntroductionThis is the report of a Re-accreditation Audit from 14 November 2017 to 15 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 14 November 2017 to 15 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: 76

Number of care recipients during audit: 74

Number of care recipients receiving high care during audit: 51

Special needs catered for: N/A


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

Interviews

Position title Number

Chief Executive officer 1

Clinical manager 1

Marketing manager 1

Registered nurse 3

Care staff 13

Safety co-ordinator 1

Quality assurance assessor 1

Work health and safety officer 1

Human resource officer 1

Catering staff 3

Care recipients and/or representatives 21

Volunteers 2

Administration assistant 1

Laundry staff 1

Cleaning staff 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files 10

Incidents and accident forms 7

Medication charts 22

Personnel files 6

Other documents reviewedThe team also reviewed:


Advocacy information

Behaviour management: behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, bed rail risk assessments

Care recipient agreement

Care recipient outing register, visitor and contractor sign in and out register

Care recipient room listing

Chemical register

Chemical stock folder

Cleaning and laundry records, schedules, instructions

Cleaning communication book

Comments and complaints documentation

Continuous improvement plan

Education documentation: education calendars, education training attendance records, educational resource information, staff mandatory training requirements, staff competency assessment information, education and training reports

Environment and safety audit

Fire safety and emergencies documentation: inspection records, annual fire safety statement, emergency evacuation diagrams, emergency management plan, evacuation details of care recipients, emergency evacuation signage, emergency procedures guide flipcharts

Food safety: food safety program, food safety monitoring records, care recipients’ dietary requirements and food preference information and menu, Food Authority licence and audit report

Human resource management documentation: staff roster, staff daily allocation sheets, employee orientation checklist, facility induction checklist, staff performance review documentation, staff code of conduct documentation, staff handbook, job descriptions and duty statements, employment agreement and contract, competency assessments, staff absentee list

Incident and accident reports

Infection control: surveillance data, infection control guidelines, vaccination registers for care recipients and staff, outbreak management report and line listing data

Information system documentation: policies and procedures, flowcharts, meeting minutes including: care recipient and relative; work, health and safety committee, handover record, admission and information pack including client information handbook, communication diaries, memoranda, notices, survey results, contact lists, organisational information, shift handover report forms, procedure for resident post fall management, use of restraint policy, feedback forms, computer based information systems

Inventory records

Maintenance documentation: preventative maintenance schedules, maintenance and approved supplier documentation, maintenance service reports and warm water temperature check records, pest control reports, legionella species reports, maintenance request logs, contractor review documentation

Medication management: medication advisory committee terms of reference and meeting minutes, ward registers of drugs of addiction, refrigerated medication storage,


medication management - principles of safe medication management, medication policies and procedures, PRN medications

Newsletters

Nutrition and hydration: food preference lists, specialised dietary requirements, seasonal menus, dietician reviews, nutritional supplement charts

Organisation chart

Quality management system: Mission, Philosophy, Purpose, Values, Goal statements, clinical governance framework, audit schedules, audit results and reports, clinical indicator results,

Regulatory compliance documentation: contractor auditing process, contractor induction procedures, incident management reporting system includes reportable incidents, staff and volunteer criminal record check reporting system, NSW Food Authority Licence, professional registration records, electrical equipment inspection register and consent forms for the collection and handling of private information

Safety data sheets

Security of tenure information

Self-assessment report for re-accreditation and associated documentation

Strategic plan

Vision, values and mission statement

Visitor sign in/out books

Work Health and Safety records including policies and procedures; safety and assessment checklists; risk assessment form, safety guidebook; hazard and incident reports; fire safety, infection control and manual handling training records

ObservationsThe team observed the following:

Activities in progress including card games, drumming activity and associated resources and notices

Activities program on display

Archive storage

Cafe

Care recipients utilising limb protection equipment

Catering areas including the main kitchen

Charter of care recipients' rights and responsibilities on display

Chemical storage

Cleaner’s cupboards

Cleaning in progress

Clinical information noticeboards in treatment rooms

Colour coded equipment

Computer with Wi-Fi available for care recipients and visitors

Courteous interactions between staff, care recipients, and representatives'


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

Dining environments during lunch and beverage services with staff assistance

Electronic and hardcopy documentation systems

Equipment and supplies storage

Evacuation signs and diagrams

Feedback mechanisms - Internal and external

Fire safety systems and equipment

First aid kits

Infection control resources including hand washing facilities, hand sanitising gel, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, pest control and waste management systems

Information noticeboards: posters, notices, brochures and forms displayed for care recipients, representatives and staff

Key pad security

Leisure and lifestyle program displayed

Library

Living environment - internal and external (including private sitting and garden areas)

Medication administration and storage

Menu on display

Mission and values statement on display

Mobility equipment in use including mechanical lifters, walk belts, wheel chairs, shower chairs, low-low beds and hand rails in corridors

Museum of Vietnam war memorabilia

NSW Food Authority licence - current

Nurse call system and timely response by staff

Re-accreditation audit notices on display.

Secure storage of care recipients' clinical files

Short group observation in dining room

Staff handover

Staff work areas and work practices including administrative, cleaning, laundry, catering and maintenance

Storage of confidential care recipient and staff information - electronic and hardcopy

Suggestion box and feedback forms

Surveillance cameras in common areas

Work health and safety information displayed


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 continuous improvement program includes processes for identifying areas for improvement, implementing change, monitoring and evaluating the effectiveness of improvements. Feedback is sought from care recipients, representatives, staff and other stakeholders to direct improvement activities. Improvement activities are documented on the plan for continuous improvement. Management uses a range of monitoring processes such as audits and quality indicators to monitor the performance of the home's quality management systems. Outcomes are evaluated for effectiveness and ongoing monitoring of new processes occurs. Care recipients, representatives, staff and other personnel are provided with feedback about improvements. During this accreditation period the organisation has implemented initiatives to improve the quality of care and services it provides. Recent examples of improvements in Standard 1 Management systems, staffing and organisational development are:

The departure of the previous education officer presented an opportunity to improve the staff education system in addressing the increased needs of care recipients. Management decided to outsource education services and staff have found the training by the new educators to be very engaging. Staff are learning new solutions in handling different issues. Attendance has been very good. There are also self-directed learning packages which all staff throughout the home can complete.

The CEO identified that the clinical oversight system required reviewing as it was too reliant on the clinical care manager alone. The home, as part of a group of five aged care organisations on the Central Coast, utilised the group's shared in-house services in developing the clinical governance framework. Regular meetings are held to discuss and develop best practice making use of the group's expertise and knowledge.

As a management initiative, staff attended a series of training sessions in supporting staff to better understand their work environment, improve on care recipient experience and promote team building. The CEO said this has improved staff motivation and has promoted positive communication between staff and care recipients.

Night staff requested new phones for night shift as they had to charge dayshift phones during the shift. The home purchased 6 new walkie-talkie radios for staff to use. The CEO said the radios have been useful, easy to carry and less noisy when on vibrate mode.


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, and for monitoring these in relation to the Accreditation Standards. The organisation's management has established links with external organisations to ensure they are informed about changes to regulatory requirements. Where changes occur, the organisation takes action to update policies and procedures and communicate the changes to care recipients, their representatives and staff as appropriate. A range of systems and processes have been established by management to ensure compliance with regulatory requirements. Staff have an awareness of legislation, regulatory requirements, professional standards and guidelines relevant to their roles. Relevant to Standard 1, management are aware of the regulatory responsibilities in relation to police certificates and the requirement to provide advice to care recipients/representatives about re-accreditation site audits; there are processes to ensure these responsibilities are met.

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. 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 observation of staff practice. Care recipients and representatives interviewed are satisfied staff have the knowledge and skills to perform their roles and staff are satisfied with the education and training provided. Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include customer service, handling comments and complaints and information technology.

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".


There are processes to ensure care recipients, their representatives and others are provided with information about how to access complaint mechanisms. Care recipients and others are supported to access these mechanisms. Facilities are available to enable the submission of confidential complaints and ensure privacy of those using complaints mechanisms. The effectiveness of the comments and complaints system is monitored and evaluated. Management and staff have an understanding of the complaints process and how they can assist care recipients and representatives with access. Care recipients and other interested people interviewed have an awareness of the complaints mechanisms available to them and are satisfied they can access these without fear of reprisal.


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 documented the home's vision, philosophy, objectives and commitment to quality. This information is communicated to care recipients, representatives, staff and others through a range of documents, and meetings. The organisation's strategic plan works towards achieving the organisation's vision, philosophy, objectives and commitment to quality through strategic planning processes.

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 systems and processes to ensure there are sufficient skilled and qualified staff to deliver services that meet the Accreditation Standards and the home's philosophy and objectives. Recruitment, selection and induction processes ensure staff have the required knowledge and skills to deliver services. Staffing levels and skill mix are reviewed in response to changes in care recipients' needs and there are processes to address planned and unplanned leave. The home's monitoring, human resource and feedback processes identify opportunities for improvement in relation to human resource management. Staff are satisfied they have sufficient time to complete their work and meet care recipients' needs. Care recipients and representatives interviewed are satisfied with the availability of skilled and qualified staff and the quality of care and services provided.

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


The home has processes to monitor stock levels, order goods and maintain equipment to ensure delivery of quality services. Goods and equipment are securely stored and, where appropriate, stock rotation occurs. Preventative maintenance and cleaning schedules ensure equipment is monitored for operation and safety. The home purchases equipment to meet care recipients' needs and maintains appropriate stocks of required supplies. Staff receive training in the safe use and storage of goods and equipment. Staff, care recipients and representatives interviewed stated they are satisfied with the supply and quality of goods and equipment available at the home.

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



The home has systems to provide all stakeholders with access to current and accurate information. Management and staff have access to information that assists them in providing care and services. Electronic information is stored securely and processes are in place for backup, archive and destruction of obsolete records. Key information is collected, analysed, revised and updated on an ongoing basis. Staff interviewed stated they are satisfied they have access to current and accurate information. Care recipients and representatives interviewed are satisfied the information provided is appropriate to their needs, and supports them in their decision-making.

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 home has mechanisms to identify external service needs and quality goals. The home's expectations in relation to service and quality is specified and communicated to the external providers. The home has agreements with external service providers. There are processes to review the quality of external services provided and, where appropriate, action is taken to ensure the needs of care recipients and the home are met. Staff are able to provide feedback on external service providers. Care recipients, representatives and staff interviewed stated they are satisfied with the quality of externally sourced 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 information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 2 Health and personal care are:

It was recognised that staff structures needed review due to some care recipients having higher care needs. A third registered nurse was employed by the home to cover more hours resulting in increased clinical oversight.

As an initiative from the home's quality assessment officer, a comprehensive program was developed in maintaining care recipients' hearing aids, glasses and dentures. The program also includes keeping care recipient representatives informed of upcoming sensory and oral clinics. Logs and checklists were developed, and information linked with care plans. Cleaning kits were created and used, replacement batteries made readily available. Staff are finding the forms easy to complete and the CEO reports that Australia Hearing have said it is a very good system of communication and is working well. The program has resulted in efficient care for care recipients.

A local hairdresser donated a foam head model which is used for hearing aid training. Certain holes have been placed in the ears to allow hearing aids to fit. Staff have been practising inserting the different types of hearing aids. There has been positive feedback from staff.

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 information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to Standard 2 Health and personal care, management are aware of the regulatory responsibilities in relation to specified care and services, professional registrations and medication management. There are systems to ensure these responsibilities are met.




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 clinical care, medication management, pain management, post-traumatic stress disorder, brain injury, delirium.

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


Vietnam Veterans Keith Payne VC Hostel provides care recipients with appropriate clinical care through initial assessments and care planning. The home has systems that enable care recipients/representatives to exercise control over the care they receive and to provide input into care recipients' care planning. The care manager and registered nurses review and evaluate care recipients’ individual plans of care. There is no system in place to identify when a care recipients’ care plan is to be reviewed. However, relevant staff are informed of any alterations/exceptions to the usual care required by the care recipient through electronically, handovers, progress notes, meetings, communication diaries and verbally. Care recipients’ weights, vital signs and urinalysis results are recorded monthly or as ordered by the medical officer. An incident and accident reporting system is in place for the reporting of incidents such as falls, skin tears and behaviours of concern. Staff demonstrate knowledge of care recipients’ care needs ensuring that care recipients’ clinical care is being met. All care recipients/representatives interviewed are satisfied with the timely and appropriate assistance given to care recipients by care staff.

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 and met by appropriately qualified nursing staff, with medical officer input when required. This includes registered nurse input into assessment, management and care planning for care recipients. The home currently provides specialised nursing care for care recipients requiring dementia care, diabetic management, catheter care, oxygen therapy, wound care and pain management. Staff are provided with education in specialised nursing procedures. Staff confirmed they have access to adequate supplies of equipment for the provision of care recipients’ specialised nursing care needs. Care recipients/representatives are satisfied with the level of specialised nursing care offered to care recipients by nursing, medical and/or other health professionals and related service teams.

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”.


Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates timely referrals for care recipients are arranged with appropriate health specialists as required. The registered nurse has regular access to a


physiotherapist, podiatrist, speech pathologist, optometrist and community clinical nurse consultants. Regular review and evaluation of care recipients’ health and well-being and referrals are carried out by the registered nurse in collaboration with care staff and medical officers. Effective monitoring is achieved through the handover of key care recipient information to relevant staff. When required, care recipients’ medical officers are alerted and consulted. Care recipients/representatives stated referrals are made to the appropriate health specialists in accordance with care recipients’ needs and preferences.

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


Vietnam Veterans Keith Payne VC Hostel has processes to ensure care recipients’ medication is managed safely and correctly. These include policies and procedures, regular pharmacy deliveries, the secure storage of medications and internal/external audits. Staff administer medication using a prepacked system and the registered nurse oversees the home’s medication management system and processes. Review of care recipients’ medication profiles show current medical officers’ orders are recorded and information includes medication identification sheets, care recipients’ photographic identification and medication allergy status. All staff who administer medications are assessed according to the home’s medication policy through skills based assessments. Care recipients/representatives said they are satisfied with the home’s management of care recipients’ medication.

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


All care recipients are assessed to identify their pain history on entry to the home with medical officer input in determining the effectiveness of interventions. A multidisciplinary approach involving the care recipient’s medical officer, nursing staff, physiotherapist and recreational activity officers supports the care recipient’s pain management program. Staff are knowledgeable about the many ways of identifying care recipients who are experiencing pain. Pain management strategies include pharmacological reviews, various non-pharmacological interventions and treatment in liaison with care recipients’ medical officers. Care recipients are repositioned, assisted with movement and exercise, given gentle heat therapy, massage and are involved in distraction therapy. Care recipients said the care provided at the home relieves their pain or it is managed so they are comfortable.

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


The home has a suitable environment and culture to ensure the comfort and dignity of terminally ill care recipients is maintained. Where possible, care recipients' end of life wishes are identified and documented on entry to the home or at an appropriate time thereafter, through the assessment process. The home has specialised clinical and comfort devices to ensure and maintain care recipient palliation needs and preferences. The local clergy visit and are available to provide emotional and spiritual support. The home has a variety of


resources and equipment that families, friends and staff can use for the benefit of the care recipient. Staff receive ongoing education and describe practices appropriate to the effective provision of palliative care. Care recipients/representatives said the home’s practices maintain the comfort of terminally-ill care recipients.

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


The home has processes to provide care recipients with adequate nourishment and hydration. Care recipients are assessed for swallowing deficits and other medical disorders, allergies, intolerances, food likes and dislikes, as well as cultural or religious aspects relating to diet. Provision is made for care recipients who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information is recorded on a care recipient’s nutrition and hydration form and sent to the kitchen. Care recipients are provided with assistance at meal times and assistive cutlery and crockery are available. The home monitors nutrition and hydration status through staff observations and recording of care recipients’ weights with variations assessed, actioned and monitored. Care recipients are referred to a dietician and/or speech pathologist when problems arise with nutrition. Care recipients/representatives are satisfied they are able to have input into menus and care recipients’ meals.

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


The home has a system to ensure care recipients’ skin integrity is consistent with their general health. Initial assessment of the care recipient’s skin condition is carried out along with other assessments relating to and influencing skin integrity. Care recipients have access to nutritional support, podiatry, hairdressing and nail care according to their individual needs and choices. Maintenance of skin tears, skin breakdown and required treatments are documented, reviewed and noted on electronic wound care charts. The home’s reporting system for accidents and incidents affecting skin integrity is monitored monthly and is included in clinical indicator data collection. The home has a range of equipment in use to maintain care recipients’ skin integrity. Care staff help to maintain care recipients’ skin integrity by providing regular pressure care, by applying skin guards and by using correct manual handling practices. Care recipients/representatives are satisfied with the skin care provided to care recipients and report that staff are careful when assisting them with their personal care activities.

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


The home has a system for identifying, assessing, monitoring and evaluating care recipients’ continence needs to ensure their continence is managed effectively. Processes are in place for the distribution of care recipients’ continence aids and informing staff of care recipients’ continence aid needs. Care recipients are assisted and encouraged to maintain or improve


their continence level in a dignified and supportive manner. Care staff have access to adequate supplies of continence aids to meet care recipients’ needs and they provide care recipients with individualised toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies. For example: regular drinks, aperient medications if necessary and a menu that contains high fibre foods such as fresh fruit and vegetables and a variety of fruit juices. Infection data, including urinary tract infections, is regularly collected, collated and analysed. The home’s continence supplier provides ongoing advice and education for staff and care recipients. Feedback from care recipients/representatives shows satisfaction with the continence care provided to care recipients.

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 managed through consultation between the care recipient and representative, staff, medical officers and allied health professionals. Care staff and recreational activity officers implement a range of strategies to effectively manage care recipients with challenging behaviours. The care recipients’ challenging behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate. Staff are able to recognise the triggers and early warning signs exhibited by some care recipients and put in place appropriate strategies to manage behaviours. The team observed the environment to be calm and care recipients well groomed. Care recipients/representatives said staff manage care recipients’ challenging behaviours well.

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


Care recipients are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by care recipients for transferring and mobility. A care recipient’s mobility status and falls risk are assessed by a registered nurse when the care recipient moves into the home and as their needs change. This is followed by a occupational therapist/physiotherapy review if necessary. Individual treatments include massage, heat treatments and exercises. Falls prevention strategies include the completion of risk assessments. Interventions noted include group exercises and the provision of specialised equipment such as mobility aids, ramps and handrails. Staff are able to discuss an individual care recipient’s needs and were seen assisting care recipients to mobilise within the home. Care recipients said they are satisfied with the program and assistance they receive from staff.

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


The home has systems to ensure care recipients’ oral and dental health is maintained. Care recipients’ dental needs are identified through assessment and consultation with the care


recipient and representative on a care recipient’s entry to the home and as their needs change. Appropriate dental health is planned and staff are informed of the care recipients’ needs. The care recipient’s medical officer is consulted if there are any needs and a referral may be made to a specialist and/or a dentist for further assessment or treatment. Ongoing care needs are identified through care recipients’ feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Care recipients are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Care recipients/representatives said they are satisfied with the oral and dental care provided to them.

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


The home assesses care recipients’ vision and hearing initially on entry and on an ongoing basis. Other sensory assessments for touch, smell and taste are undertaken when assessing care recipients’ nutritional needs, dexterity and interest in activities. These are documented on care recipients’ care plans to prompt and instruct staff on how to care for and engage care recipients appropriately. The home’s activity program features activities to stimulate care recipients’ sensory functions. Staff described types of group and individual activities which encourage active participation from care recipients with sensory deficits. Staff said they employ various strategies to assist care recipients with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance care recipients’ participation, adapting the environment to ensure it is conducive to maximising care recipients’ enjoyment and participation in the chosen activity. Care recipients/ representatives said they are satisfied with the home’s approach to managing care recipients’ sensory losses.

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


The home assists care recipients to achieve natural sleep patterns through a sleep assessment, care planning, choice of time for going to bed and rising, and staff support at night. Staff are able to explain the various strategies used to support care recipients’ sleep. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, repositioning and night sedation if ordered by the medical officer. Care recipients can use the nurse call system to alert the night staff if they have difficulties in sleeping. Care recipients stated they sleep well at night. Care recipients/representatives said they are satisfied with the home’s approach to care recipients’ sleep management.


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.



Refer to Expected outcome 1.1 Continuous improvement for information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 3 Care recipient lifestyle are:

A representative for local high school students approached the home about bringing students to visit. The students were at risk of being disengaged from school and it was an opportunity to gain valuable insight into roles in the aged care sector as well as meeting with care recipients. The students attended and were provided orientation and information about the home. The students and residents enjoyed morning tea and a chat, they played card games together. There was a reminiscent group in which care recipients spoke about their lives when they were young. The visit was very positive. Some of the students left a note of thanks and stated they enjoyed their day, and care recipients said they enjoyed interacting with the students.

The home introduced different stimulating sensory activities. A parachute was purchased as a fun way to socialize and exercise. A drumming circle group was also organised to attend and care recipients were smiling and communicating well throughout this activity. A care recipient's daughter saw her mother participate and commented, "that was the old mum that we know."

A trip to the local war museum was suggested by a volunteer. The outing was discussed at the care recipients' meeting and organised. The care recipients who participated really enjoyed the trip and gave plenty of positive feedback.

A suggestion from a care recipient to display Vietnam war items in the home was approved. A museum has been created and items have been added as they are sourced or donated. The home received positive feedback from care recipients, staff and the general public, and the CEO said it has a calming effect on those who visit.

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”.


Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to Standard 3 Care recipient lifestyle, management are aware of the regulatory responsibilities in relation to compulsory reporting, user rights, security of tenure and care recipient agreements. There are systems to ensure these responsibilities are met.




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 elder abuse, engaging conversations, person-centred activities, choice and decision making.

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/representatives expressed appreciation to staff for the support and assistance staff provide during their entry to the home, the subsequent settling in period and on an ongoing basis. An assessment of care recipients’ specific needs and preferences is undertaken prior to/or on entry to the home including their social history and backgrounds. Care recipients are orientated to the home and staff spend extra one-on-one time with care recipients during the settling in period and as required. One care recipient stated if she is feeling a little sad she would speak to her family and would not speak to care staff. Most care recipients/representatives said care recipients are provided with appropriate emotional support and feel the staff are supportive in helping them to adjust to their new life within the home.

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 are assisted in joining group activities at the home, as well as being encouraged to attend bus trips and outings. Individual and group activity plans, monthly programs and diversional therapy assessments provide opportunity for care recipients to achieve maximum independence. Individual engagement between care recipients, visitors and staff are encouraged and was observed during the re-accreditation audit. The activities plan shows regular access to outdoor community venues is a significant part of the care recipients’ lifestyle plan and much enjoyed. Care recipients/representatives advised they are satisfied care recipients’ independence is supported by the home as much as possible.

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



The home works to support each care recipient’s right to privacy, confidentiality and dignity. Care recipients are accommodated in single rooms ensuites. The assessment process identifies any care recipients’ specific needs and preferences relating to privacy and dignity. Information about care recipients is securely stored and only accessible to authorised personnel. All staff sign confidentiality agreements as part of their employment and are bound by the code of conduct. Care recipients were observed to be appropriately dressed and well presented. All care recipients/representatives said that care recipients are treated with respect.

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 home offers a wide range of activities of interest to care recipients. The assessment of care recipients’ needs is overseen by the diversional therapist and put in place by the team of recreational lifestyle officers. There is a weekly and monthly program in place however staff advise this is a guide and activities are conducted in accordance with the care recipients’ day to day wishes. A review of care recipient records show the home is conducting engaging activities and outings in consultation with care recipients and representatives. Feedback from care recipients/representatives shows satisfaction with the range of activities offered and the access to outside community visits.

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


The home ensures care recipients’ cultural and spiritual needs are valued and the home provides opportunities to fulfil these needs. The individual requirements of care recipients to continue their beliefs and customs are identified in the assessment process by the diversional therapist on entry. Provision is made for the celebration of special cultural and religious days such as Easter, Christmas, Australia Day and Anzac Day as well as other celebrations of diverse cultures. Church services are a regular occurrence at the home. Care recipients/representatives reported they are satisfied with the support provided for their cultural and spiritual needs.

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".


Care recipients/representatives are supported by the home to decide on their lifestyle and choice of services and activities through initial assessment, recording of their preferences and feedback through surveys, meetings and suggestions to staff. The alternate decision maker for the care recipient is established during the admission process for those care recipients who are unable to make decisions for themselves. A sound understanding and knowledge of the care recipients means staff can gauge and interpret the choices made by


care recipients who are not able to easily express themselves through verbal communication. Care recipients are enabled to exercise choice about their daily preferences for meals, attendance at social activities and rest periods. Care recipients/representatives stated they make decisions for the care.

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".


Care recipients/representatives are provided with 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, when they enter the home. The home's monitoring processes, including feedback, meetings and care reviews, identify opportunities for improvement in relation to care recipient rights, responsibilities and security of tenure. Staff demonstrate an understanding of care recipient rights. Care recipients and representatives interviewed are satisfied care recipients have secure tenure within 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.



Refer to Expected outcome 1.1 Continuous improvement for information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 4 Physical environment and safe systems are:

The home has introduced an electronic computerised meal ordering system. A phone app developed for the home, contains a menu selection where the care recipient can make a choice from three dishes. Menus are first approved by a dietician. Special dietary requirements are entered into the system and an alert will show if a choice of meal selected is not suitable for the care recipient. Food ordering and service has improved. The CEO said care recipients/representatives have provided very positive feedback regarding the ability to choose meals.

As part of the renovation project, the dining room was modernised to provide a restaurant atmosphere. Care recipients chose the curtain colour and flooring. The CEO said care recipients are happy with their choices and the new dining room has created a relaxed and enhanced dining experience for care recipients.

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”.


Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to Standard 4 Physical environment and safe systems, management are aware of the regulatory responsibilities in relation to work, health and safety, fire systems and food safety. There are systems to ensure these responsibilities are met.



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 incident reporting, fire safety, safe food handling, chemical awareness, infection control, use of equipment and 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 and light levels, sufficient and appropriate furniture and safe, easy access to internal and external areas. The safety and comfort of the living environment is assessed and monitored through feedback from meetings, incident and hazard reporting, audits and inspections. Care recipients are accommodated in single ensuite rooms. The home is surrounded by extensive landscaped gardens containing sitting areas and walking paths. There is an outdoor chapel, library and a café in the main building. 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. Many care recipients made positive comments about the cleanliness of the home and feeling comfortable. The majority of care recipients interviewed said they felt safe most or all of the time. However, one out of the sixteen care recipients/representatives interviewed stated that they felt safe only some of the time.

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, 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 in regards to this expected outcome. One care recipient said the safety was the best thing about 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. 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. Care recipients and representatives interviewed are satisfied the hospitality services meet their needs and staff help them to feel at home. Positive comments include: “I’m happy and comfortable”; “They try very hard to make it homely and they do.” The majority of care recipients interviewed said they like the food most or all of the time. However, one out of the sixteen care recipients/representatives interviewed stated that they never liked the food.


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