shalom care services · shalom care services racs id 5359 121 maloney street north rockhampton qld...

Shalom Care Services RACS ID 5359

121 Maloney Street NORTH ROCKHAMPTON QLD 4701

Approved provider: The Baptist Union of Queensland

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 19 March 2015.

We made our decision on 31 January 2012.

The audit was conducted on 4 January 2012 to 5 January 2012. The assessment team’s report is attached.

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

Home name: Shalom Care Services Date/s of audit: 4 January 2012 to 5 January 2012 RACS ID: 5359

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Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

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

Expected outcome Accreditation Agency

decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal care

Principle: Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.

Expected outcome Accreditation Agency decision




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


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Standard 3: Resident lifestyle

Principle:

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


decision




3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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


decision




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


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Site Audit Report

Shalom Care Services 5359


Introduction This is the report of a site audit from 4 January 2012 to 5 January 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 a site 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 Accreditation 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


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Site audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the site audit from 4 January 2012 to 5 January 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. 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 1997. Assessment team

Team leader: Mary Allen

Team member/s: Stewart Brumm

Approved provider details


Details of home

Name of home: Shalom Care Services

RACS ID: 5359

Total number of allocated places:

65

Number of residents during site audit:

63

Number of high care residents during site audit:

45

Special needs catered for:

Residents requiring a secure environment

Street/PO Box: 121 Maloney Street State: QLD

City/Town: NORTH ROCKHAMPTON Postcode: 4701

Phone number: 07 4923 9500 Facsimile: 07 4923 9503

E-mail address: [email protected]


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

Number Number

Executive manager aged care 1 Acting facility manager 1

Services supervisor 1 Residents/representatives 10

Registered clinical staff 3 Manager clinical systems 1

Care staff 7 Laundry staff 1

Officer manager 1 Cleaning staff 2

Catering staff 1 Chaplain 1

Administrative assistant 1 Activities officer 1

Sampled documents

Number Number

Residents’ files 6 Medication charts 12

Summary care plans 6 Personnel files 6

Weight records 12

Other documents reviewed The team also reviewed: Accident/incident reports Activities planner Audit, analysis tool, program Call bell analysis log Cleaning check sheets Cleaning programs Clinical and lifestyle assessments Clinical incident data Communication diary Complaints data forms Continuous improvement plan Corporate agreement for supply of services Daily bowel records Drinks lists/breakfast list Elder abuse incident register Emergency and disaster response plan Emergency evacuation exercise observer’s checklist Employee guidelines Equipment safety checklist Equipment temperature check lists Fire training records Flu vaccination records for staff Maintenance records


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Mandatory reporting folder Meeting minutes Memorandum Menu assessment Menus Nurse initiated medication list On Boarding program Pest management reports Police certificate register Policies and procedures Proposal for improvement (PFI) forms Proposal for improvement and feedback log QBC feedback forms Records of fire drills Records of service for fire safety equipment Register of practitioners Resident agreement Resident clinical profile - nutrition/hydration Resident diet profiles Resident satisfaction survey Restraint authorisation Restraint management records Shalom Snippet (residents’ newsletter) Staff newsletter Staff procedures and guidelines Strategic plan Supplies incoming goods check list Training records WHSO assessment report Wound management protocol Observations The team observed the following: Activities calendars displayed Activities in progress Charter of Residents Rights and Responsibilities Chemical storage Colour coded equipment Equipment and supply storage areas Evacuation assembly areas Fire safety equipment, evacuation maps and exits Food safety certificates Interactions between staff and residents Living environment Meal service Mission, our values Personal protective equipment Smoking areas Spills kits Storage of medications Suggestion boxes Visitors/contactors sign in/out books


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Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Shalom Care Services (the home) actively pursues continuous improvement in the four accreditation standards by using the Quality Improvement Plan focused on self assessment, risk and procedural management, analysis and evaluation of internal and external audit results and surveys. Stakeholders are also encouraged to use feedback/complaints and proposals for improvement forms and meetings to make suggestions for improvement. The Facility Manager (FM) is responsible for managing the quality improvement system at the home with suggestions being logged and progress being reported on a monthly basis. Initiators of suggestions are contacted by the FM to provide an update on progress with their suggestion. Improvements are discussed at staff and resident meetings where feedback on progress is also provided. Examples of improvements achieved in Standard One include, but are not limited to: In response to feedback from residents that they were having difficulty reading staff name

badges a review was conducted of the name badges and as a result new badges have been introduced. The new badges include photo identification and the first name of the staff member in large letters. Management reported that residents have provided positive feedback in relation to the improvement.

In response to staff identifying insufficient time to complete laundry and cleaning tasks as

a result residents’ increased care needs, particularly on weekends, audits were conducted and rosters reviewed. This resulted in a new timetable, including increased rostered hours, being introduced for cleaners and an increase in rostered hours in the laundry. Staff expressed satisfaction with the changes including the increased rostered hours.

The Care Manager identified the need for improved communication between staff,

particularly for the 1530 – 2100 hours shift. As a result digitally enhanced cordless telecommunication (DECT) phones have been made available to staff and have resulted in positive feedback from staff.

As a result of an organisational initiative, web based intranet has been introduced at the

home to meet document management needs. The system is inclusive of a word search engine and document management tree, is accessible to all staff and password protected. Staff have received training in using the new system and an electronic survey has been conducted to monitor staff satisfaction and knowledge of the system. Management and staff reported access to information and currency of documentation has been improved with the introduction of the new system.

Executive management of the organisation identified a need for performance

management training for supervisors. As a result all managerial and senior staff have received training in the progressive disciplinary process to manage staff performance. In addition, policies, procedures and relevant forms have been updated and staff provided positive feedback relating to the initiative.


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Following a review of resident feedback following the administration of a satisfaction

survey the content and management of the survey has been reviewed and resulted in changes to the distribution, collation and analysis of completed surveys. Changes resulting from the review include providing one survey for residents/representatives, returning the surveys to a central point external to the home where results are collated and including a wider range of questions. The improvements have resulted in an improved return rate and action plans have been developed to address deficits identified through the responses.

As a result of a review of customer service conducted by executive staff and in order to

improve service a full day’s training session has been developed which includes building positive customer relationships and understanding responsibility of client communication. At the time of the visit administration and supervisory staff had attended the training.

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The Executive Manager Aged Care in consultation with the Chief Executive Officer is responsible for monitoring changes to legislative and regulatory requirements and systems. Processes are in place to ensure service delivery complies with relevant legislation, regulatory requirements, professional standards and guidelines which are communicated to the staff by the Facility Manager. The home has membership with industry organisations and peak bodies; changes to current information are discussed at meetings and education/training sessions are implemented when required; policies and procedures are updated. Staff are notified of changes via meetings, memos, electronic messages and the Aged Care Newsletter. Compliance is monitored by management and senior staff at the home and via audits and feedback. Processes are in place to ensure all staff and other relevant individuals have current criminal record checks. 1.3 Education and staff development: This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively by providing ongoing education and staff development. The Learning and Development Coordinator coordinates the On Boarding training program and the training needs of staff are identified through monitoring of staff practice, regular performance reviews, interest shown by staff in attending particular training sessions and the training needs analysis. Education and training records are maintained for individual staff members; attendance records are maintained for training sessions; the home provides support for staff to upgrade their qualifications and participate in external training opportunities. Staff are informed of available education opportunities through calendars and staff have access to education resources at the home.


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1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Residents/representatives and interested parties have access to internal and external mechanisms to raise issues at the home without fear of retribution. Management responds to initiators of complaints and compliments and where appropriate issues are logged in the home’s improvement plan. Residents/representatives are able to raise issues with management; issues can be raised using feedback forms and at meetings and residents reported they are familiar with the mechanisms to raise complaints and that issues are resolved in a timely manner. Residents receive information in relation to comments and complaints mechanisms on entry to the home and a locked suggestion boxes are available for completed forms. Residents/representatives are satisfied with the comments and complaints system. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The home’s mission and philosophy, are displayed within the home and outlined in documents including resident and staff information. Policies, procedures and other documents have been developed to reflect the mission and philosophy of the organisation. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome The home uses a formal recruitment system that includes advertising, interviewing, appointment and orientation of staff. Criminal history checks, evidence of qualifications, registration checks form part of the recruitment process and new staff work buddy shifts when they commence at the home. Residents’ changing care needs, staff availability and skill mix are monitored and form the basis for each shift. Position descriptions, serving a probationary period and participating in mandatory education sessions ensure new staff members are aware of the requirements of their positions. A range of strategies are used to manage staff performance and include probationary period reviews, annual performance appraisals, competency checks, supervision of staff and if necessary a formal disciplinary process. Residents/representatives are satisfied with the responsiveness of staff and the care they receive.


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1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The home has processes in place to ensure that there are sufficient stocks of goods and equipment for delivery of services. Service agreements with suppliers and contractors are used to guide purchases and to maintain goods and equipment. Stock items are rotated and checked for use-by-dates. Education is provided for staff on the correct use of equipment and on-going maintenance of equipment conducted by staff and external contractors is undertaken in accordance with the maintenance schedules. Staff are aware of processes for accessing stores and reported that they have enough goods and equipment to carry out their duties. Residents/representatives are satisfied that appropriate goods and equipment are provided by the home and are available for the delivery of services 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 meets this expected outcome The home has effective information management systems in place and management and staff have access to accurate and appropriate information to help them perform their roles. Staff are able to access information via minutes of meetings, memos, case conferencing, handover notes, notice boards and staff and resident newsletters. Staff have access to information stored electronically and protected access levels are in place to log onto computers. Access to information records and storage sites is restricted to relevant stakeholders. The home has a system in place to securely store archived information and to destroy information when it is no longer required. Residents/representatives and staff are satisfied that the home’s communication processes keep them informed about care being provided and about the current and future activities of the home. 1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome External services are provided to meet the home’s needs through service agreements that outline the home’s specific requirements for the provision of service. Feedback on the performance of external services is monitored through feedback from residents, representatives and staff, comments and complaints, audits and surveys. Service agreements are in place and management review the performance of external services to ensure quality service delivery is maintained and when requirements are not being met appropriate action is taken. Residents/representatives are satisfied with the quality of services sourced externally.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Shalom Care Services (the home) actively pursues continuous improvement in the four accreditation standards by using the Quality Improvement Plan focused on self assessment, risk and procedural management, analysis and evaluation of internal and external audit results and surveys. Stakeholders are also encouraged to use feedback/complaints and proposals for improvement forms and meetings to make suggestions for improvement. The Facility Manager (FM) is responsible for managing the quality improvement system at the home with suggestions being logged and progress being reported on a monthly basis. Initiators of suggestions are contacted by the FM to provide an update on progress with their suggestion. Improvements are discussed at staff and resident meetings where feedback on progress is also provided. Examples of improvements achieved in Standard Two include, but are not limited to: The Care Manager identified difficulty for residents who are immobile being able to

access dental services. As a result the local dental health clinic was lobbied to provide services for immobile residents. In response the clinic has agreed to provide services and at the time of the visit two residents had received dental care provided by the clinic.

Following identification by the clinical staff that new and temporary staff were not able to

easily access clinical management protocols a Clinical Care Manual Resource has been developed. The new manual includes information relating to:

o high care in low care o specialised nursing care o weight management o access to the electronic resident care system o access to best practice resources

Positive feedback was recorded at a staff meeting following the introduction of the resource.

In order to enhance residents’ access to medical practitioners, clinical staff suggested

establishing a weekly clinic at the home. The weekly clinic commenced 1 December 2011 and will be evaluated January 2012.

In response to a suggestion from the Hospitality Services Manager management of

modified diets at the home has been enhanced by aligning practice with Australian Standards for modified diets. Staff were provided with training and resources and dietary profiles for residents have been updated. Management reported this improvement has enhanced the management of modified diets for residents.


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2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome The Executive Manager Aged Care in consultation with the Chief Executive Officer is responsible for monitoring changes to legislative and regulatory requirements and systems. Processes are in place to ensure service delivery complies with relevant legislation, regulatory requirements, professional standards and guidelines which are communicated to the staff by the Facility Manager. The home has membership with industry organisations and peak bodies; changes to current information are discussed at meetings and education/training sessions are implemented when required; policies and procedures are updated. Staff are notified of changes via meetings, memos, electronic messages and the Aged Care Newsletter. Compliance is monitored by management and senior staff at the home and via audits and feedback. Professional registrations for all nursing staff are accessed prior to commencing employment at the home and checked annually. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively by providing ongoing education and staff development. The Learning and Development Coordinator coordinates the On Boarding training program and the training needs of staff are identified through monitoring of staff practice, regular performance reviews, interest shown by staff in attending particular training sessions and the training needs analysis. Education and training records are maintained for individual staff members; attendance records are maintained for training sessions; the home provides support for staff to upgrade their qualifications and participate in external training opportunities. Staff are informed of available education opportunities through calendars and staff have access to education resources at the home. Education and training provided by the home ensures staff have the knowledge and skills required for effective performance of health and personal care for residents. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Residents’ care needs are assessed on entry and an interim care plan developed, progress notes and handover processes are also utilised to ensure care staff have current information to provide care. A series of clinical assessments are then undertaken by care staff and the registered nurse; from this information a care plan is developed. Care plans are reviewed three monthly by the registered nurse. Resident/representative consultation occurs during the assessment process and annual case conferences are held. Care delivery is monitored by registered nurses. Residents are referred to their medical officer or specialist service as


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required. Staff are aware of the care requirements of residents. Residents/representatives are satisfied with the care being provided. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Residents requiring specialised nursing care are identified on entry through the initial assessment process, specialised nursing care directives are recorded on the care plan. The registered nurse conducts the assessment and management of specialised nursing procedures. Staff have access to resources and specialist information. Equipment requirements are identified and are available to ensure residents’ care requirements are met. Implementation of specialised care is monitored by the registered nurses. Residents /representatives advised that they are satisfied with the care provided. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome The home has a system and processes in place to assess resident needsfor referral to health specialists such as dietitian, physiotherapist, audiologist, optometrist, and podiatrist. Nursing staff co-ordinate health specialist appointments for residents in a timely manner. Staff and resident representatives support and assist residents to attend external appointments with health professionals of their preference. Care plans are amended as required following referrals. Residents/representatives are satisfied they receive referrals to appropriate health specialists of their choice when required. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome The home has processes in place to ensure that residents’ medication is managed safely and correctly by appropriately qualified and trained staff. Medical officers prescribe medication orders and these are dispensed by various external pharmacy services. The home utilises a combination of multi dose sachet and blister pack systems. Resident medication is stored safely and securely. Medication incidents are recorded and reviewed by the registered nurse. The effectiveness of the system is generally monitored through audits, reviews and observation of staff practices. Residents/representatives are satisfied with the management of their medications, as well as with the assistance and support provided.


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2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome Residents’ pain is identified during initial assessment, and reassessment is undertaken as needed. Care plans are developed from the assessed information and care plans are reviewed by the registered nurse to ensure interventions remain effective. The medical officer and allied health professionals are involved in the management of residents’ pain; strategies to manage pain include non-pharmacological and pharmacological intervention. Non-verbal pain assessment tools are available for residents unable to articulate their pain. Residents/representatives are satisfied with current pain management strategies and the provision of additional assistance if and when pain persists. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome Systems and processes are in place to obtain and record residents’ end of life care wishes in consultation with residents/representatives, on entry to the home or as the needs of residents indicate; information obtained is recorded in the resident’s clinical record and provided to staff as residents’ care needs change. Residents at the end of life are supported and cared for at the home whenever possible and according to the residents’/representatives’ wishes. Residents’ pain, comfort and spiritual needs are managed in consultation with the resident/representatives, to provide physical, psychological, emotional, cultural and spiritual support to residents and family members according to their needs and preferences. Palliative care is monitored by the registered nurses. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Residents’ dietary requirements, preferences, allergies and special needs are identified and recorded on entry to the home and this information is forwarded to the catering staff. Residents are weighed on entry and then monthly and any variations are assessed, monitored and actioned with strategies implemented to manage unplanned weight loss or gain if required. The registered nurses monitor the weight management at the home. Residents are assisted with meals and fluids, and special eating utensils supplied as necessary. Residents/representatives are satisfied that their nutrition and hydration requirements are met


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2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome On entry to the home residents are assessed for their skin care needs through the assessment process and in consultation with residents to determine their needs and preferences. Care plans reflect strategies to improve and/or maintain residents’ skin consistent with their general health. Care strategies include the daily application of moisturisers, correct manual handling procedures, pressure area care, and pressure relieving aids. Podiatry services are provided. The registered nurse oversees wound management and is responsible for wound treatments, completion of treatment records, and documenting interventions. Residents/representatives are satisfied with the assistance provided to maintain skin integrity. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome Processes are in place for ensuring that residents’ continence is managed effectively. Residents’ urinary and faecal continence needs are assessed during the entry assessment and supported with the use of focal assessments; reassessments occur as required. Care staff outlined continence management strategies for individual residents and understand reporting requirements should there be a change to residents normal patterns. Residents are satisfied with the care provided by staff in relation to continence management. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome On entry to the home residents with challenging behaviours are assessed, including the identification of known or potential triggers, then a behaviour care plan is developed. Residents are reassessed as care needs change or current interventions are ineffective. Behaviour management is monitored by the registered nurses. Recreational activities are used to enhance effective behavioural management intervention. The team observed staff interacting calmly with residents when attending to cares or when re-directing residents. Residents/representatives are satisfied with the management of challenging behaviours at the home.


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2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome The home has processes in place to ensure that residents achieve optimum levels of mobility and dexterity. Residents are assessed by the registered nurse or a physiotherapist on entry to the home. Assessed needs and strategies for care are communicated to staff through the care plan, and care plans are reviewed to ensure interventions remain effective. Falls are reported and are monitored by the registered nurse. Aids to maintain and improve mobility and dexterity such as walking aids and specific dietary utensils are available. Residents/representatives are satisfied with the assistance they receive in achieving optimum levels of mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Residents’ needs and preferences relating to teeth and denture management and other oral/dental care requirements are identified through the initial assessment. Care strategies are documented on the care plan. Care staff assist residents with their oral care and the care staff arranges dental referrals as necessary. Equipment to meet residents’ oral hygiene needs is available. Residents/representatives are satisfied with the assistance given by staff to maintain their dentures and overall oral hygiene. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Residents care needs in relation to sensory loss which include vision, hearing, smell, touch and taste, is collected through the initial assessment. Care plans identify needs and individual preferences and are reviewed three monthly. Residents are referred to specialists such as audiologists and optometrists according to assessed need or resident request and are assisted to attend appointments as required. Staff receive instruction in the correct use and care of sensory aids and are aware of the interventions required to meet individual residents’ needs. Residents are satisfied with the assistance provided by staff to optimise sensory function. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Residents usual sleep patterns, settling routines and personal preferences are identified during the initial assessment. Care plans are developed and reviewed to ensure


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interventions remain effective. Residents experiencing difficulty sleeping are offered warm drinks and snacks and assisted with hygiene requirements should this be required. The care staff monitor ongoing needs. Residents/representatives are satisfied with the care and comfort measures implemented by staff in relation to promoting sleep.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Shalom Care Services (the home) actively pursues continuous improvement in the four accreditation standards by using the Quality Improvement Plan focused on self assessment, risk and procedural management, analysis and evaluation of internal and external audit results and surveys. Stakeholders are also encouraged to use feedback/complaints and proposals for improvement forms and meetings to make suggestions for improvement. The Facility Manager (FM) is responsible for managing the quality improvement system at the home with suggestions being logged and progress being reported on a monthly basis. Initiators of suggestions are contacted by the FM to provide an update on progress with their suggestion. Improvements are discussed at staff and resident meetings where feedback on progress is also provided. Examples of improvements achieved in Standard Three include, but are not limited to: The diversional therapy staff identified a need to improve the variety of activities offered

to residents in the secure unit of the home. As a result a collaborative arrangement has been established with a local high school and music students from the school visit the home on a regular basis. An evaluation of the program undertaken by staff identified the benefits associated with the visits and regular dates for visits have been established.

Staff working in the secure unit of the home identified that some residents were not

participating in activities. As a result a range of new activities including making memory books, wall paintings, quilt making, and visits by entertainers and school children have been introduced. Staff reported this has resulted in decreased agitation in residents, positive feedback from residents’ families and increased participation in activities.

Following a review of the cultural and spiritual life at the home conducted by the

Executive Manager, a part time chaplain has been recruited to enhance lifestyle support for residents. Management reported this improvement has resulted in positive feedback from residents.

Following feedback from residents requesting an exercise program, options were

reviewed and the diversional therapy staff introduced a regular exercise program September 2011. When reviewed October 2011 resident feedback relating to the program was positive.

In response to feedback received from residents which identified that the current

television screen in one wing of the home was too small a large television and DVD has been installed. As a result of the purchase residents have provided positive feedback in relation to being able to view televised and recorded programs.


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3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s findings The home meets this expected outcome The Executive Manager Aged Care in consultation with the Chief Executive Officer is responsible for monitoring changes to legislative and regulatory requirements and systems. Processes are in place to ensure service delivery complies with relevant legislation, regulatory requirements, professional standards and guidelines which are communicated to the staff by the Facility Manager. The home has membership with industry organisations and peak bodies; changes to current information are discussed at meetings and education/training sessions are implemented when required; policies and procedures are updated. Staff are notified of changes via meetings, memos, electronic messages and the Aged Care Newsletter. Compliance is monitored by management and senior staff at the home and via audits and feedback. Processes are in place to ensure that management and staff members understand their responsibilities around the reporting of missing residents, suspected assault and records are kept regarding these. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively by providing ongoing education and staff development. The Learning and Development Coordinator coordinates the On Boarding training program and the training needs of staff are identified through monitoring of staff practice, regular performance reviews, interest shown by staff in attending particular training sessions and the training needs analysis. Education and training records are maintained for individual staff members; attendance records are maintained for training sessions; the home provides support for staff to upgrade their qualifications and participate in external training opportunities. Staff are informed of available education opportunities through calendars and staff have access to education resources at the home. Education and training provided by the home ensures staff have the knowledge and skills required to effectively support residents’ lifestyle. 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome Residents/representatives are provided with information on entry which provides an overview of life within the home. Residents are assessed for their emotional support needs during the initial assessment phase. Residents are monitored for ongoing support needs via the care staff, chaplain and activities officer. Care staff are advised of any ongoing emotional support needs through the handover process. Staff provide residents with one to one support and will refer residents to the registered nurse for additional support as required. Pastoral care support is available to residents. Residents/representatives are satisfied with the level of


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emotional support provided, and residents are encouraged to furnish their rooms to their liking. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome The home assists residents to maintain independence through initial and ongoing review of their needs utilising clinical and social assessments. Strategies to promote and maximize independence are reviewed during the care plan reviews. Residents are supported to access the local community with regular bus outings. Residents are encouraged to maintain friendships and external social networks, residents are supported by the activities officer to achieve this. Care staff are aware of their responsibility to promote resident independence and follow care plans to assist residents to achieve a maximum level of independence. Residents are satisfied with the level of independence and autonomy they can exercise at the home; residents reported they are supported to maintain friendships and access the local community. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome The home has policies and procedures to govern staff practices in maintaining residents’ privacy and dignity. Staff are provided training on privacy and dignity issues during orientation. Resident information is stored in secure locations. Staff practices are monitored by the registered nurses. Staff are aware of strategies to maintain residents’ privacy and dignity when providing resident cares. Residents/representatives are satisfied with the level of privacy and respect for their dignity being provided by staff at the home. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome Information on residents’ social history, interests and lifestyle is collected on entry to the home, through the initial assessment and one to one interview with the resident/representative and a therapy care plan developed. The activities officer develops a monthly activity calendar and this is communicated to residents verbally, via a poster and on noticeboards. Residents provide feedback on activity programs individually and in meetings and surveys. The program is monitored by the activities officer. Residents advised that staff provide encouragement and support to participate in activities they wish to attend and that they have a range of activity opportunities of interest to them.


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3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome Residents’ cultural and spiritual needs are assessed on entry to the home; a care plan is developed as required from the assessment information. Residents have access to religious services. Residents are assisted to attend cultural activities conducted in the home and the community, and days of significance are celebrated at the home. Residents’ ongoing cultural and spiritual needs are monitored by the chaplain and the activities officer. Residents are satisfied with the spiritual and cultural support provided. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome Residents are encouraged and supported to make decisions about their care, lifestyle and routines; information is provided to residents/representatives on entry outlining their rights and responsibilities. Staff provide opportunities for choice and utilise strategies to incorporate choice into residents’ daily care routines and leisure interests and residents are provided a choice with meal selection where appropriate. Staff practice regarding choice and decision making is monitored by the care staff and registered nurse. Residents/representatives are satisfied that they are able to exercise choice in relation to their care and lifestyle. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Processes are in place to provide information to residents in regard to security of tenure and their rights and responsibilities. The residential care agreement offered to new residents contains information about residents’ rights and responsibilities, the terms and conditions of their tenure, fees and charges and information about dispute resolution. Residents/representatives are consulted should any changes in resident care needs require a room transfer, or removal from the home. Residents/representatives are satisfied that they have been provided with sufficient information in relation to security of tenure and understand their rights and responsibilities.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Shalom Care Services (the home) actively pursues continuous improvement in the four accreditation standards by using the Quality Improvement Plan focused on self assessment, risk and procedural management, analysis and evaluation of internal and external audit results and surveys. Stakeholders are also encouraged to use feedback/complaints and proposals for improvement forms and meetings to make suggestions for improvement. The Facility Manager (FM) is responsible for managing the quality improvement system at the home with suggestions being logged and progress being reported on a monthly basis. Initiators of suggestions are contacted by the FM to provide an update on progress with their suggestion. Improvements are discussed at staff and resident meetings where feedback on progress is also provided. Examples of improvements achieved in Standard Four include, but are not limited to: Following discussions at a workplace health and safety committee meeting which

identified potential difficulty in removing residents from the building in an emergency, flexible stretchers that can be used to evacuate immobile people have been purchased. Following purchase of the mats staff received training to use the stretchers and the safety of residents has been maximised.

Based on clinical and care staff feedback relating to increased care needs of residents

including bariatric residents additional specialised equipment has been purchased. The equipment purchased includes electric beds, mattresses, comfort chairs, a hammock sling and dining and lounge equipment to enhance the comfort of bariatric residents. Staff report the new equipment has enhanced resident comfort and safety and workplace health and safety for staff.

In order enhance the comfort of residents attending the hairdresser air conditioning has been installed in the hairdressing salon.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome The Executive Manager Aged Care in consultation with the Chief Executive Officer is responsible for monitoring changes to legislative and regulatory requirements and systems. Processes are in place to ensure service delivery complies with relevant legislation, regulatory requirements, professional standards and guidelines which are communicated to the staff by the Facility Manager. The home has membership with industry organisations and peak bodies; changes to current information are discussed at meetings and


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education/training sessions are implemented when required; policies and procedures are updated. Staff are notified of changes via meetings, memos, electronic messages and the Aged Care Newsletter. There is a food safety program in place and the home has provided training for a Food Safety Supervisor, Fire Safety Advisor and Workplace Health and Safety officer. Processes are in place to ensure compliance with legislation about the physical environment and safe systems. Compliance is monitored by management and senior staff at the home and via audits and feedback. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively by providing ongoing education and staff development. The Learning and Development Coordinator coordinates the On Boarding training program and the training needs of staff are identified through monitoring of staff practice, regular performance reviews, interest shown by staff in attending particular training sessions and the training needs analysis. Education and training records are maintained for individual staff members; attendance records are maintained for training sessions; the home provides support for staff to upgrade their qualifications and participate in external training opportunities. Staff are informed of available education opportunities through calendars and staff have access to education resources at the home. Education and staff development provided by the home ensures staff have the knowledge and skills required for effective performance in relation to physical environment and safe systems. 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 residents’ care needs". Team’s findings The home meets this expected outcome The home has implemented processes to provide a safe and comfortable environment for residents including incident and hazard reporting, environmental safety audits and environmental security measures. Residents are able to bring in small items of furniture and personal items to enhance their comfort and personalise their accommodation. Hand rails are provided in hallways and bathrooms/toilets and the design of internal and external surfaces enable residents to mobilise safely. The building, grounds and equipment are maintained in accordance with preventive and routine maintenance schedules and repairs are attended in a timely manner. Residents reported they are comfortable in the home and feel safe and secure.


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4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome The home has procedures, processes and practices in place to assist in the identification, actioning and review of safety issues. Workplace health and safety information is provided at orientation and mandatory training. Safety performance is monitored through audits/inspections, competency assessments, hazard reporting, risk assessments and incidents/accident reports. Identified issues are reviewed and action taken. Staff implement safe practices whilst performing their role and have access to material safety data sheets and personal protective equipment. Chemical, equipment and supply storage areas are identified by signage. Accidents and incidents are recorded and action is taken to instigate control methods to prevent any reoccurrence. Staff reported that they were aware of their safety obligations and that management was responsive to providing a safe workplace for them. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome There are processes and equipment in place for detection and action in the event of a fire, security breach or other emergency incident within the home. The home’s fire system includes fire detection, alarms, control panel, and fire equipment which is inspected (as per legislative requirements) and maintained by external contractors. Fire evacuation plans are displayed throughout the home; fire exits and pathways to exits are generally free from obstacles and exit doors are clearly marked. Staff attend fire safety training during On Boarding education sessions when they commence employment at the home and annually thereafter; there is a process for monitoring training attendance. Emergency and disaster procedure guidelines are available and staff have knowledge of their responsibility in the event of a fire or emergency situation. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has a process in place to provide an effective infection control program; the surveillance system includes regular clinical data collection and analysis to identify trends and this information is evaluated. Staff are provided with regular infection control training; hand washing facilities are located throughout the facility; staff have access to personal protective equipment and receive regular infection control training. Safe food storage practices are evident in the kitchen and kitchenettes; laundry processes support prevention/minimisation of cross contamination. Cleaning schedules are in place to guide general cleaning including the laundry and food service areas and regular pest controls are conducted. Facilities and equipment such as single use clinical products, sharps containers, waste receptacles and storage areas are provided to enable infection control practices to be


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implemented and staff are familiar with barrier nursing and outbreak procedures. Hospitality services and care staff demonstrated understanding the principles of infection control. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome Residents’ nutritional preferences and requirements are identified on admission and modified as residents’ needs/preferences change. Meals are prepared in the home’s main kitchen, then transported to and plated in the kitchenettes. Residents are supported to maintain their independence, exercise choice regarding food and drink options and have input into the home’s menus through feedback. A food safety program is in place. Cleaning procedures guide staff practice regarding regular cleaning of all areas of the home. Residents’ personal items and flat linen are laundered on-site and processes are in place to manage infection control practices in catering, cleaning and laundry services. Hospitality services are monitored and issues of concern are addressed as appropriate. Residents/representatives are satisfied with hospitality services at the home and staff are satisfied with their working environment.

shalom care services · shalom care services racs id 5359 121 maloney street north rockhampton qld...

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