regents garden aubin grove · 2018-12-14 · regents garden aubin grove racs id 7444 248 lyon road...

Regents Garden Aubin Grove

RACS ID 7444 248 Lyon Road

Aubin Grove WA 6164

Approved provider: Regents Garden Group Pty Ltd

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 02 August 2019.

We made our decision on 27 May 2016.

The audit was conducted on 04 May 2016 to 05 May 2016. The assessment team’s report is attached.

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

Home name: Regents Garden Aubin Grove RACS ID: 7444 2 Dates of audit: 04 May 2016 to 05 May 2016

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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 Met


Standard 3: Care recipient lifestyle

Principle:

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 service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities

Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Regents Garden Aubin Grove 7444


Introduction

This is the report of a re-accreditation audit from 04 May 2016 to 05 May 2016 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 04 May 2016 to 05 May 2016.

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

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

Assessment team

Team leader: Ben (Benedict) Carroll

Team member: Alison James

Approved provider details


Details of home

Name of home: Regents Garden Aubin Grove

RACS ID: 7444

Total number of allocated places:

102

Number of care recipients during audit:

101

Number of care recipients receiving high care during audit:

95

Special needs catered for: Nil specified

Street: 248 Lyon Road

City: Aubin Grove

State: WA

Postcode: 6164

Phone number: 08 9494 3300

Facsimile: 08 9494 3350

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

General manager 1

Facility manager 1

Support and development manager 1

Care staff 9

Chef 1

Occupational therapist 1

Maintenance staff 1

Care recipients/representatives 11

Clinical nurse/manager of clinical services 1

Registered/enrolled nurses 5

Administration assistant 1

Domestic services staff 4

Therapy staff 2

Physiotherapist 1

Sampled documents

Category Number

Care recipient assessments, care plans and progress notes 11

Wound care plans 17

Authorisations to self-medicate 4

Personnel files 6

Medication charts and signing sheets 11

Restraint authorisations 8

External services files 2

Other documents reviewed

The team also reviewed:

Activity planners and therapy statistics


Archive records

Asset and equipment register

Audits and surveys

Care recipient agreements and information

Continuous improvement plan and feedback forms

Corrective and preventative maintenance schedule, maintenance log records, cleaning and laundry programs, pest control records, hazards, accident and incident reports

Fire equipment audit reports and emergency procedure manual

Food safety program, four-weekly menu, order records, diet sheets and kitchen records

Infection control guidelines and vaccination records

Medication refrigerator temperature records

Minutes of meetings, newsletters, staff handovers and memoranda, bulletins, and family conference schedules and records

Observation charts (bowels, weights, blood pressures and blood glucose levels)

Physiotherapy pain management records and registered nurse massage records

Policies, procedures and guidelines

Referrals to other health professionals

Register for drugs of addiction

Regulatory compliance folder

Staff duty statements and job descriptions, rosters, and training records including attendance records and evaluation forms.

Observations

The team observed the following:

Access to internal/external complaints, advocacy information and secure suggestion box

Activities in progress and activity calendar displayed

Archived and confidential records securely stored

Charter of care recipients’ rights and responsibilities displayed

Equipment and supply storage areas (medical supplies, continence aids, mobility equipment and sharps disposal management)

Living environment and care recipients’ appearance


Meal and refreshment services

Noticeboards with displayed information, including re-accreditation poster

Poisons permit

Short group observation in Claridges (secure) wing

Wound care trolley.


Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The organisation actively pursues, plans, implements and evaluates continuous improvement activities. Reporting and feedback mechanisms guide staff to identify opportunities for continuous improvement. Information from sources such as suggestion and feedback forms, audits, hazard/incident reports, surveys and meetings are logged, actioned, evaluated for effectiveness and feedback given to stakeholders via meetings. Staff and care recipients reported they are encouraged to provide feedback. Staff, care recipients and representatives reported they are satisfied the home is actively pursuing continuous improvement.

Examples of current or recent improvements in relation to Standard 1 – Management systems, staffing and organisational development are described below:

After analysing the results of a staff training survey, the home introduced on-line self- directed learning packages. Management reported while face-to-face training is still provided, the introduction of self-directed packages has increased the variety of training available to staff. Staff confirmed they have access to a greater variety of training relevant to their roles, and stated they can complete training from home resulting in a better work/life balance. Management reported initial feedback from staff to this initiative is positive.

A registered nurse at the home has developed a training resource on Parkinson’s disease while completing a Diploma of Management. While staff were able to receive training on Parkinson’s disease prior to the development of the resource, this was delivered by an external organisation. Management reported the delivery of an internal package by an in-house trainer is more convenient and provides them with greater ongoing support to deliver care. Feedback obtained via training evaluation forms is positive.

In response to comments from staff regarding workplace communication and interaction, the home held a multicultural awareness week. Activities and celebrations completed during the week recognised and celebrated differences in staff members’ cultural background. Management reported these activities helped staff understand and resolve cultural differences which can be often misunderstood and may result in friction. Feedback from staff and care recipients has been positive.


1.2 Regulatory compliance

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

Team’s findings


The home has systems that identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home receives legislative updates from industry representatives, consultants and government bodies. Policies and procedures are reviewed and updated as required. Relevant information is disseminated to staff via compliance bulletins and discussed at staff meetings and education sessions. The home monitors compliance with legislative requirements through internal and external auditing programs, observation and performance appraisals. The currency of professional registrations and police certificates of staff is tracked and managed. Care recipients’ fees and charges are set according to legislation, and care recipients and representatives are informed of external complaints processes. Stakeholders were informed of the re-accreditation audit in writing, through meetings and via onsite posters.

1.3 Education and staff development

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

Team’s findings


The home’s education program ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Management identifies training needs through feedback and requests from staff, surveys, audits, accident and incident reports, and observation of work practices. Site orientation and buddy shifts are provided to new staff, and induction, mandatory and optional training is regularly provided. The effectiveness of training is monitored via staff training evaluation forms. Staff reported they have sufficient training opportunities in order to perform their duties.

Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below:

Care management programs

Continuous improvement

Diploma of Management

Traineeships for care staff

Understanding ageing and communication.


1.4 Comments and complaints

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

Team’s findings


Care recipients and other interested parties have access to internal and external comments and complaints mechanisms. The home provides confidential and secure channels for submitting written feedback. Information regarding external complaints services is provided in care recipient agreements, information packages and is displayed throughout the home.

Information regarding advocacy services is available at the home, and staff described procedures to advocate on behalf of care recipients. The home tracks response times to complete actions addressing comments and complaints, and provides feedback to stakeholders in a timely manner. The home measures the effectiveness of the comments and complaints process via audits and surveys, and seeks feedback from care recipients via case conferences and meetings. Issues identified through the complaints process feed into the home’s continuous improvement plan. Care recipients and representatives reported satisfaction with access to the complaints mechanisms without fear of retribution.

1.5 Planning and leadership

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

Team’s findings


The home’s mission statement and commitment to quality services are documented in care recipient information packages and newsletters. Newsletters are regularly issued to care recipients and are available to representatives and visitors in the home’s reception area. All such documents have consistent content.

1.6 Human resource management

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

Team’s findings


There are appropriately skilled and qualified staff sufficient to ensure services are delivered in accordance with these standards and the home’s philosophy and objectives. The management team adjusts staffing levels in accordance with staff feedback and care recipient needs, and in consideration of clinical data. Staff qualifications, skills, experience and their capacity to respond to care recipients’ needs are considered during the recruitment process. Current police certificates are required of all staff. Position descriptions are provided to staff upon commencement of employment. New staff are mentored and buddied with experienced staff until competent to undertake their role, and there are strategies to cover leave and


absenteeism. Staff performance is monitored via scheduled performance appraisals, observation, feedback and the review of ongoing audits. Staff reported they have sufficient time to complete their duties and stated the home effectively manages planned and unplanned leave. Care recipients and representatives reported satisfaction with the skill level and number of staff to provide care.

1.7 Inventory and equipment

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

Team’s findings


The home has adequate supplies of appropriate stock and equipment to deliver quality services. Key staff monitor stock levels and coordinate the maintenance or ordering of new equipment in consultation with the home’s manager. The home maintains an approved supplier list. When necessary, relevant staff are trained in the use and care of new equipment prior to its introduction into the workplace. The home has multiple storage areas to ensure staff have suitable access to inventory and equipment and to prevent damage to these items. Staff reported they have sufficient equipment and supplies to undertake their duties. Care recipients and representatives reported satisfaction with the availability and suitability of goods and equipment to meet their needs.

1.8 Information systems

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

Team’s findings


The home has effective information management systems. The organisation reviews guidelines and policies and procedures as required, and current versions are available to staff. The home follows procedures to ensure staff and management fulfil legislative reporting requirements such as reporting care recipient assaults and absconding care recipients.

There are secure areas for current and archived documents and the home maintains a directory of archived files. Electronic information is password protected and electronic records are saved daily to onsite and offsite servers. Management routinely collate and trend clinical and non-clinical data, and use ongoing audits and surveys to identify and meet care recipients’ needs. Staff have access to information relevant to their roles via handovers, meetings and via internal communications such as memoranda, noticeboards and bulletins. Care recipients and representatives have access to newsletters, program calendars, family conferences and meetings to keep them aware of information relevant to the home and their care. Care recipients and representatives reported satisfaction with the access to information to assist care recipients in making decisions about their care and lifestyle.


1.9 External services

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

Team’s findings


Externally sourced services are provided in a way that meets the home’s needs and service quality goals. The management team monitors care recipients’ needs to identify required services not already provided by staff. The home engages external providers such as podiatry and hairdressing services to meet care recipients’ needs. Contracts specify required behaviour and require suppliers to maintain police certificates, currency of insurance and, where applicable, professional registrations. The quality of work provided by external contractors is monitored through scheduled annual reviews, audits and surveys. The home seeks feedback from care recipients and representatives via care recipient/representative meetings and evaluates past performance prior to continuing agreements. Care recipients and representatives reported satisfaction with the quality of service they receive from externally sourced services.


Standard 2 – Health and personal care

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



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

In relation to Standard 2 – Health and personal care, staff record care recipient accidents and incidents, and this information is collated and analysed for trends. Clinical audits are conducted to measure and review the clinical care systems. Care recipients and staff are satisfied the organisation actively promotes and improves care recipients’ physical and mental health.

Examples of current or recent improvements in relation to Standard 2 – Health and personal care are described below.

The home held a falls awareness week after an audit indicated an increasing number of falls. During the week, education sessions were held for staff and simulation activities, such as identifying fall hazards within a room, were held for both staff and care recipients. The management team reported the education sessions and activities increased awareness of falls and prevention strategies among staff and care recipients, causing the number of reported falls at the home to stabilise.

Having observed reluctance among staff members to discuss palliative care with care recipients and representatives, the management team developed a specialist palliative care team. The management team reported while staff already had access to relevant guidelines and training, the development of a specialist onsite team to support or assist staff has resulted in an increase in staff confidence and family involvement in palliative care cases. The home is evaluating this initiative by reviewing feedback from care recipients and families receiving palliative care services.


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

Team’s findings


The organisation has systems and processes to identify and ensure compliance with ongoing regulatory obligations regarding care recipients’ health and personal care. Clinical staff complete initial and ongoing assessments of care recipients. Professional registrations for


nursing staff and other health professionals are monitored. Ongoing audits ensure medication is administered and stored in compliance with relevant guidelines. The home monitors changes to clinical guidelines and alerts staff of relevant changes via meetings, education sessions, emails and bulletins. Care recipients and representatives reported care services are provided in accordance with specified care service requirements.



Team’s findings


Management and staff have the knowledge and skills to provide appropriate health and personal care to care recipients. Refer to expected outcome 1.3 Education and staff development for an overview of the home’s systems.

Recent examples of education related to Standard 2 – Health and personal care are listed below:

Care at the end of life

Catheter care

Continence

Depression

Parkinson’s disease

Restraints

Subcutaneous syringe driver education

Swallowing deficits.


2.4 Clinical care

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

Team’s findings


The home uses a multidisciplinary approach to the provision of care including the general practitioner, registered/enrolled nurses, care staff, physiotherapist and occupational therapist to ensure care recipients receive appropriate clinical care. On moving into the home, a range of validated assessments are completed, and a care plan is developed to guide the staff in the clinical care needs of each care recipient. Care plans are reviewed by the registered nurse three monthly, or sooner if changes to care recipients’ needs occur, and further assessments are undertaken at this time. Staff ensure continuity of care by discussing care recipients’ care needs at handover, via a communication book and other documentation.

Care recipients’ incidents and accidents are reported, actioned at the time by the registered nurse and analysed monthly to identify any trends. Staff reported they are encouraged and supported to attend training and education to maintain their knowledge and skills. Care recipients and representatives reported they are satisfied care recipients receive appropriate clinical care.

2.5 Specialised nursing care needs

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

Team’s findings


Registered nurses are responsible for the assessment, identification, planning and monitoring of care recipients with specialised nursing care needs. The registered nurses develop complex care plans that include recommendations from the general practitioner, allied health staff and other health professionals where appropriate. Specialised nursing care needs include PEG (percutaneous endoscopic gastrostomy) care, chronic wounds, management of challenging behaviours, catheter management (indwelling and supra-pubic), oxygen management and diabetes management. Registered nurses are available on all shifts, and other health professionals are contactable when required. Care recipients and representatives reported they are satisfied care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff.

2.6 Other health and related services

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

Team’s findings


Nursing staff refer care recipients to appropriate health specialists in accordance with the care recipients’ needs and preferences. A multidisciplinary team along with input from the general practitioner contribute to each care recipient’s assessments and identify the need for further input from other health professionals. Care recipients are referred internally and externally of


the organisation to a dietician, speech pathologist, mental health services, optometrist, audiologist or dentist when required. Registered nurses use the recommendations to update care plans and medication regimes as directed. A podiatrist attends the home on a regular basis to attend to care recipients’ care needs. Care staff reported they are informed of changes to care recipients’ care needs at handover and via documentation. Care recipients and representatives reported they are satisfied with the access care recipients have to other health professionals.

2.7 Medication management

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

Team’s findings


The home has established processes to ensure care recipients’ medications are managed safely and correctly. Registered and enrolled nurses assist care recipients with their medications via a multi-dose sachet administration system as per the general practitioner’s instructions. The home has emergency medications available for after hours and relevant documentation is maintained. An accredited pharmacist reviews care recipients’ medications on a regular basis, and this information is made available to the general practitioner for their consideration. Medication audits are undertaken regularly and actioned accordingly.

Medication incidents are generally reported, actioned at the time and analysed monthly to identify any trends. Care recipients and representatives reported they are satisfied care recipients’ medications are managed safely and correctly.

2.8 Pain management

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

Team’s findings


Registered nurses assess each care recipient’s pain management needs on moving into the home and on an ongoing basis. A multidisciplinary approach is used that includes the general practitioner and allied health professionals. Specific pain assessment tools in the identification of pain include verbal and non-verbal descriptors for care recipients identified with having a speech or cognitive impairment. Care recipients’ care plans include specific strategies to manage care recipients’ pain. In addition to pain relief medication, the home uses a range of alternative therapies including TENS (transcutaneous electrical nerve stimulation) machine, gentle massage or exercise, medicated rubs, regular repositioning and hot/cold packs. Staff reported they refer to the registered nurse if strategies are not effective. Care recipients and representatives reported they are satisfied care recipients’ pain is identified and managed effectively.


2.9 Palliative care

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

Team’s findings


The home’s approach to palliative care ensures the comfort and dignity of terminally ill care recipients are maintained in accordance with their needs and preferences. At any time during their residency, care recipients and/or their representatives are encouraged to complete an end of life wishes form. Care recipients identified as requiring palliation are reviewed regularly by the general practitioner, and the registered nurse commences an end of life symptom management plan, ensures appropriate equipment is provided and monitors staff to ensure prescribed care is provided. The care recipient and their families are supported by staff throughout the palliation and access additional external palliative care services if required. Staff described ways they support the care recipient and their families during the terminal phase. Care recipients and representatives reported they are confident, when the time arises, staff will manage care recipients’ palliative care competently including their personal care, comfort, privacy and dignity.

2.10 Nutrition and hydration

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

Team’s findings


Staff assess each care recipient’s nutrition and hydration status on moving into the home and on an ongoing basis. Care recipients’ cultural, religious beliefs, likes, dislikes, preferences, allergies and special dietary requirements are identified and communicated to relevant staff. Care recipients are weighed on moving into the home and monthly thereafter, unless directed by the registered nurse, dietician or general practitioner. Care recipients identified as having significant weight loss are commenced on nutritional supplements and, if weight loss continues, referred to the dietician. Texture modified meals and drinks are provided for care recipients identified as having swallowing difficulties and referred to a speech pathologist if required. Modified crockery and cutlery is available to enable care recipients to maintain their independence during meals. Staff were observed assisting care recipients with meals and drinks when required. Care recipients and representatives reported they are satisfied care recipients receive adequate nutrition and hydration.

2.11 Skin care

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

Team’s findings


The home has processes to ensure staff identify and respond to care recipients’ skin integrity and associated health risks on moving into the home and on an ongoing basis. Registered nurses implement specific treatment plans where they identify a care recipient has the


potential for altered skin integrity. A range of equipment is available including air and pressure mattresses, pressure cushions, protective bandaging and the regular application of emollient creams. Staff report incidents of altered skin integrity for care recipients to the registered nurse, and a wound assessment and treatment plan is commenced and reviewed on a regular basis. Staff reported they monitor care recipients’ skin during personal care and report any concerns to the registered nurse. Care recipients and representatives reported they are satisfied care recipients’ skin integrity is maintained and managed effectively.

2.12 Continence management

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

Team’s findings


The home has processes to identify, assess, monitor and manage care recipients’ continence needs effectively. Care recipients are supported to maintain their continence using a variety of methods including appropriate equipment, scheduled toileting and suitable continence aids. Staff monitor and record care recipients’ bowel elimination, and interventions are documented and evaluated for effectiveness. Urinary tract infections are monitored via the home’s incident reporting system, and staff implement strategies as directed by the registered nurse and general practitioner. A continence advisor provides education, training and support in regard to care recipients’ continence needs. Staff reported they have sufficient time, equipment and training to manage care recipients’ continence needs effectively. Care recipients and representatives reported they are satisfied care recipients’ continence is managed effectively.

2.13 Behavioural management

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

Team’s findings


Care recipients’ behaviours are assessed on moving into the home. Specific care plans identify triggers and strategies to guide staff on how to manage and minimise challenging behaviours displayed by care recipients. Nursing staff consult with the general practitioner and refer care recipients to mental health services when required, and recommendations are documented in care plans and evaluated three monthly to ensure they remain effective. Staff attend training on managing challenging behaviours and described ways they meet the needs of care recipients who display challenging behaviours. Care recipients and representatives reported they are satisfied the needs of care recipients with challenging behaviours are managed effectively.


2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


Care recipients are assessed for their level of mobility, dexterity and falls risk on moving into the home by the registered nurse, physiotherapist and occupational therapist. Care recipients are encouraged to maintain their mobility and dexterity by attending the home’s activity program and individual or group exercise programs. Appropriate seating and mobility aids are available to assist care recipients to maintain their mobility, and modified crockery and cutlery is available to support care recipients to maintain their independence during meals.

Care recipient falls are reported and documented by staff, the registered nurse responds at the time of the incident, and care recipient falls are analysed monthly to identify any trends. Care recipients and representatives reported they are satisfied care recipients are encouraged and supported to maintain optimum levels of mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


Care recipients’ oral and dental health is assessed on moving into the home and on an ongoing basis. Care plans outline the amount of assistance each care recipient requires to maintain their oral and dental hygiene. Care recipients are offered the opportunity of seeing the Government dentist annually, or if preferred a dentist of their choice. There is a process to ensure care recipients’ oral and dental equipment is changed on a seasonal basis. Staff described ways they assist care recipients to maintain their oral and dental care. Care recipients and representatives reported they are satisfied care recipients’ oral and dental health is maintained.

2.16 Sensory loss

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

Team’s findings


The home has processes to ensure care recipients’ sensory losses are identified and managed effectively. On moving into the home, qualified staff assess each care recipient’s sensory losses in all five senses. Care plans are developed that outline strategies to assist staff to manage each care recipient’s sensory losses and maximise their independence and participation in activities of daily living. The home’s activity program includes sensory, tactile and auditory activities to stimulate the senses including cooking, craft, gardening and sing-a- longs. Care recipients have access to external health professionals including an optometrist, audiologist and general practitioner if required. Staff described ways they assist care


recipients to manage their sensory losses. Care recipients and representatives reported they are satisfied care recipients’ sensory losses are identified and managed effectively.

2.17 Sleep

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

Team’s findings


The home has processes to ensure care recipients are able to achieve natural sleep patterns. On moving into the home, a sleep assessment is undertaken for each care recipient to identify their preferred times for settling, rising, nightly rituals, daytime naps and any sleep disturbances. Care plans identify strategies to assist care recipients to settle following a disturbance including warm drink or snack, pain relief, toileting, reassurance or, if prescribed, night sedation. Staff reported they ensure the environment is conducive for care recipients to sleep. Care recipients and representatives reported they are satisfied care recipients are able to achieve natural sleep patterns.


Standard 3 – Care recipient lifestyle

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



Team’s findings



In relation to Standard 3 – Care recipient lifestyle, care recipient meetings and care recipient surveys are used to gather suggestions and trends. Feedback is regularly recorded and evaluated from lifestyle and care activities. Staff encourage and support care recipients and others to provide feedback and suggestions.

Examples of current or recent improvements in relation to Standard 3 – Care recipient lifestyle are described below:

Following feedback from representatives regarding the number of activities, the home has reviewed its activity calendar. The home is trialling the provision of nail care services, previously provided individually to care recipients, as a group activity. The management team reported care recipients enjoy the social interaction this arrangement allows, and will investigate how other routine activities at the home can be used to encourage interaction to care recipients. This development is still being trialled and will be evaluated via staff observation and care recipient feedback.

The home has purchased a microphone and speaker system to be used at large gatherings and meetings. The purchase was made after a care recipient complained they had difficulty hearing proceedings at meetings and guest speakers at special functions. The home has trialled the use of the microphone and speaker system at one event and will seek feedback from care recipients at the next care recipient and representative meeting.


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

Team’s findings


The home identifies and ensures compliance with all relevant legislation, regulatory requirements, professional standards and guidelines regarding care recipient lifestyle. Care recipients are informed about their rights and responsibilities via information packs and agreements. The home provides care recipients with agreements outlining fees, level of care


and services to be provided and tenure arrangements. Staff contracts include a confidentiality clause and contracts are signed on commencement of employment. Staff have access to training and guidelines regarding the reporting of care recipient assaults. Care recipients and representatives reported they are consulted in regard to making decisions about services and are advised when changes in the provision of care occurs.



Team’s findings


Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation to care recipient lifestyle. Refer to expected outcome 1.3 Education and staff development for an overview of the home’s systems.

Recent examples of education related to Standard 3 – Care recipient lifestyle are listed below:

Duty of care

Elder abuse

LGBTI training

Residents’ rights, privacy and dignity

Wellness program.

3.4 Emotional support

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

Team’s findings


Prior to moving into the home, care recipients or their representatives are provided with an information pack that includes the care recipient handbook. Care recipients’ needs and preferences are discussed with the care recipient and/or their representatives, and care recipients are orientated to their room, surroundings and introduced to staff and other care recipients. Staff monitor and support care recipients, and the occupational therapist assesses each care recipient’s social, emotional and cognitive needs. Care plans include the holistic requirements of each care recipient including social and emotional well-being. Care recipients are encouraged to personalise their rooms with furniture, pictures and mementos from home, and family and friends are encouraged to visit on a regular basis. Staff described ways they support care recipients emotionally on an ongoing basis. Care recipients and representatives reported they are satisfied care recipients’ emotional needs are met when moving into the home and on an ongoing basis.


3.5 Independence

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

Team’s findings


The home has processes to ensure regular assessments of care recipients’ needs to maintain independence. On moving into the home, allied health staff undertake an assessment to identify each care recipient’s level of cognition and ability to participate in activities of daily living. Care plans consider the sensory, cognitive and physical ability of each care recipient when promoting independence. The home encourages care recipients to maintain friendships within and outside of the home, regular social outings are arranged, and care recipients have access to in-house polling booths for voting, taxi vouchers, computers, internet and a telephone. A risk acknowledgement is completed when required to promote care recipient independence in choice of lifestyle and activities. Staff described ways they support and encourage care recipients to maintain their independence. Care recipients and representatives reported they are satisfied with the assistance provided by staff to support care recipients to maintain their independence.

3.6 Privacy and dignity

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

Team’s findings


Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Care recipients’ confidential information is stored securely and accessed by authorised personnel only. Care recipients are accommodated in single rooms with an ensuite bathroom, there is appropriate signage when care recipients do not wish to be disturbed or care is being undertaken. Small lounges and dining areas for privacy are available, and external gardens and courtyards when entertaining family and friends. Staff, students and volunteers sign a confidentiality statement on commencement at the home, and staff described ways they ensure each care recipient’s privacy, dignity and confidentiality. Care recipients and representatives reported they are satisfied care recipients’ privacy, dignity and confidentiality are recognised and respected.

3.7 Leisure interests and activities

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

Team’s findings


The home has processes to encourage and support care recipients to participate in a wide range of activities of interest to them. On moving into the home, therapy staff gather information from the care recipient and representatives to identify past and current interests, and a care plan is developed. The activity program incorporates a range of activities for gross


and fine motor, sensory and cognitive abilities. Therapy staff include special events such as Mother’s day, Father’s day and Melbourne Cup day as well as social outings in the program. New activities are evaluated and care recipients are asked to participate in an annual survey as well as provide feedback on activities at the care recipient/representative meetings. Staff reported they encourage and support care recipients to attend activities and their refusal not to attend activities is respected. Care recipients and representatives reported they are satisfied with the encouragement and support care recipients receive from staff to attend and participate in activities of interest to them.

3.8 Cultural and spiritual life

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

Team’s findings


On moving into the home, staff identify care recipient’s individual interests, customs, beliefs and cultural and ethnic backgrounds, and this information is documented in their care plan. Care recipients have access to visiting religious personnel and community volunteers, and staff access additional multicultural resources when required. Culturally significant days are celebrated including ANZAC Day, Remembrance Day, Christmas and Easter, as well as other days of significance to care recipients. Staff reported ways they support care recipients’ customs, beliefs, cultural and ethnic backgrounds. Care recipients and representatives reported they are satisfied care recipient’s individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered.

3.9 Choice and decision-making

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

Team’s findings


Management and staff support care recipient’s individual choices and decisions. Family conferences, care recipient/representative meetings, surveys and the home’s continuous improvement program provide opportunities for care recipients and/or their representative to provide feedback and participate in the care and services provided. Staff reported they encourage and support care recipients to make decisions about clothing, meals, activities to attend and time to attend to personal care. Care recipients and representatives reported they are satisfied care recipients are encouraged, supported and enabled to exercise choice and control over their lifestyle whilst not infringing on the rights of others.


3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


There are processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Care recipients and their representatives are provided with information that includes the care recipient agreement on, or prior to, moving into the home. Care agreements outline the security of tenure, fees and charges, external complaints and advocacy processes, and the Charter of care recipients’ rights and responsibilities. The Charter of care recipients’ rights and responsibilities is displayed at the home and, when applicable, changes of rooms are discussed with care recipients and/or representatives. Care representatives and other interested parties have access to external complaints and advocacy information, and there are processes to maintain anonymity and confidentiality. Staff advocate on behalf of care recipients. Care recipients reported they are satisfied they have secure tenure within the home and understand their rights and responsibilities.


Standard 4 – Physical environment and safe systems

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



Team’s findings



In relation to Standard 4 – Physical environment and safe systems, staff conduct environmental audits and collect information in relation to hazards and incidents to identity trends. Surveys and feedback systems are used to measure and review the living environment and ensure safety of care recipients, staff and others. Care recipients and staff are satisfied management actively works to improve the home’s physical environment.

Examples of current or recent improvements in relation to Standard 4 – Physical environment and safe systems are described below:

Upon receiving feedback from staff and representatives regarding the temperature in communal areas in Claridges wing, the management team replaced heaters with reverse cycle units. Staff reported these units are more effective in warming the wing and produce less noise. The management team advised they are planning further adjustments, including the installation of fans to better direct warm air in communal areas. Feedback will be sought from family members upon implementation and trial of the fans.

The home has repositioned an alarm sensor previously located at the entrance of the building. The alarm is triggered when care recipients at risk of absconding and wearing security bracelets approach the sensor. Prior to the relocation of the sensor to outside the entrance, the alarm was triggered by care recipients in the foyer. The management team reported the relocation of the sensor has reduced the number of false alarms sent to staff, resulting in a more effective security system.


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

Team’s findings


The home has systems to ensure ongoing regulatory compliance in relation to the physical environment and safe systems. Workplace buildings, catering, fire equipment and procedures are regularly inspected, audited and/or reviewed. Safety data sheets and infection control guidelines are available to relevant staff and to guide staff practice. The home has a food


safety program, and staff are provided with relevant training to deliver safe practices and to follow correct procedure. Staff demonstrated knowledge of regulatory compliance requirements.



Team’s findings


Management and staff have the knowledge and skills to perform their roles effectively in relation to physical environment and safe systems. Refer to expected outcome 1.3 Education and staff development for an overview of the home’s systems.

Examples of education relevant to Standard 4 – Physical environment and safe systems are listed below:

Chemical training

Fire safety essentials

Fire warden training

Food safety essentials

Infection control

Manual handling

Occupational health and safety

Table service role play

Use of hoists.

4.4 Living environment

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

Team’s findings


The management team actively works to provide a safe and comfortable environment which is consistent with care recipients’ needs. The home provides single rooms with an ensuite, and accommodates requests for couples to share rooms. Access to the home is secured, and staff and external providers conduct nightly security checks. Signage and availability of mobility aids promote care recipients’ independence. Care recipients personalise their rooms and have access to communal and garden areas for private use and/or to participate in group activities. Hazards and accidents are reported and regular inspections and audits are completed to


review the effectiveness of cleaning and maintenance programs. Staff described processes to promote the safety and comfort of care recipients. Care recipients and representatives reported they are satisfied the home ensures a safe and comfortable environment which meets the care recipients’ needs and preferences.

4.5 Occupational health and safety

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

Team’s findings


Management actively works to provide a safe working environment that meets regulatory requirements. Staff receive training at orientation regarding occupational health and safety (OHS) policies and procedures, and relevant training such as manual handling and chemical safety is provided during induction and annually thereafter. Designated staff participate in monthly workplace inspections and OHS is a standing agenda item at general staff meetings. More frequent communication occurs via staff meetings and the release of staff memoranda. The home has a corrective and preventative maintenance program, and equipment at the home is routinely inspected and serviced. New equipment is assessed for suitability prior to implementation and staff are provided with training for the use and care of new equipment.

Staff described the process for identifying and actioning hazards and accidents, and stated the management team provides a safe working environment.

4.6 Fire, security and other emergencies

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

Team’s findings


Management and staff actively work to provide a safe and secure environment and to minimise the risk of fire and other emergencies. Fire, security and emergency procedures and emergency manuals are available to staff, care recipients and visitors, and inform them how to proceed in the event of emergencies such as fire, medical emergencies and bomb threats. The home is equipped with fire prevention and firefighting equipment such as extinguishers, sprinklers, fire blankets and fire doors. Independent inspection, testing and maintenance of these is conducted by approved professionals. Staff attend fire and evacuation training at orientation and annually thereafter, and the home maintains a current evacuation list. The home monitors staff knowledge and compliance via assessments and audits. The home maintains a no smoking policy and has a pest management program. Staff interviewed described procedures to be followed in the event of a fire or other emergency.

Care recipients reported fire evacuation procedures are broadcast monthly and stated they feel safe and secure within the home.


4.7 Infection control

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

Team’s findings


The home has an effective infection control program. The home’s infection control program is developed and managed by the manager clinical services. Staff are informed of policies and procedures at orientation and receive infection control training annually. The home uses a consultant who monitors changes to ensure compliance with relevant legislation. A food safety program guides food storage and preparation practices. Information on individual care recipient’s infections is collated upon moving into the home and on an ongoing basis thereafter. A vaccination program is available to staff and care recipients. The home completes scheduled audits to analyse infection trends and promote staff compliance with the infection control program. Staff demonstrated knowledge of infection control guidelines.

4.8 Catering, cleaning and laundry services

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

Team’s findings


Hospitality services are provided in a way that enhances care recipients’ quality of life and the staff working environment. Care recipients’ food preferences, allergies, likes and dislikes are identified and recorded when care recipients move into the home, and these are updated as required. Dieticians have input to a four-weekly menu which reflects care recipients’ dietary needs and preferences. Personal items and bed linen are laundered onsite, and there are processes for the labelling and the storage of unclaimed items to minimise loss of clothing. Staff complete cleaning of individual rooms and communal areas in accordance with a structured program. Hospitality services are discussed at care recipient and representative meetings, and feedback received at meetings or via the complaints program is reviewed at subsequent meetings. Care recipients and representatives reported they are satisfied the home’s hospitality services meet care recipients’ needs and preferences.

regents garden aubin grove · 2018-12-14 · regents garden aubin grove racs id 7444 248 lyon road...

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