st nicholas nursing home - aged care quality · st nicholas nursing home 5995 approved provider:...

St Nicholas Nursing Home

RACS ID 5995 19 Hampstead Road

HIGHGATE HILL QLD 4101

Approved provider: Greek Ladies Philoptochos Society of St George Brisbane

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 06 December 2018.

We made our decision on 27 October 2015.

The audit was conducted on 14 September 2015 to 16 September 2015. The assessment team’s report is attached.

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

Home name: St Nicholas Nursing Home RACS ID: 5995 2 Dates of audit: 14 September 2015 to 16 September 2015

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 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:

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.





2.4 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: 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.





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.





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

St Nicholas Nursing Home 5995


Introduction

This is the report of a re-accreditation audit from 14 September 2015 to 16 September 2015 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 14 September 2015 to 16 September 2015.

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: Frances Stewart

Team member: Robyn Brown

Approved provider details


Details of home

Name of home: St Nicholas Nursing Home

RACS ID: 5995

Total number of allocated places:

43

Number of care recipients during audit:

42

Number of care recipients receiving high care during audit:

42

Special needs catered for: Care recipients of Greek ethnicity and cultural background

Street/PO Box: 19 Hampstead Road

City/Town: HIGHGATE HILL

State: QLD

Postcode: 4101

Phone number: 07 3844 6063

Facsimile: 07 3846 7344

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Executive director of nursing 1

Care manager 1

Quality manager 1

Education coordinator 1

Human resource manager/administration 1

Clinical nurse 1

Clinical nurse facilitator 1

Enrolled nurse 2

Medical officer 3

Registered nurses 1

Care recipients/representatives 14

Volunteers 5

Kitchen supervisor 1

Laundry staff 1

Diversional therapist 2

Cleaning staff 3

Care staff 3

Maintenance officer/WHS and Fire safety advisor 1

Catering staff 3

Recreational officers 2


Sampled documents

Category Number

Care recipients’ files 4

Wound charts 6

Care recipient administration files 7

Medication charts 12

Staff personnel files 9

Blood glucose monitoring forms on medication charts 7

Other documents reviewed

The team also reviewed:

Catering, cleaning and laundry services: daily temperature monitoring checklist, diet list, food safety plan, laundry manual, menu, menu assessment, safety data sheets, ordering list, refrigerator temperature recording records

Clinical and care assessment documentation: initial and ongoing care needs and preferences, such as care recipient dietary and menu choices, observation charts, including weights, continence, behaviours, sleep, skin integrity, pain, mobility, falls risk, toiletting, oral health and physiotherapy; wound assessments

Comments and complaints: comments and complaints forms, comments and complaints data, external brochures

Continuous Improvement: audits, auditing schedule, continuous quality improvement logs, meeting minutes, care recipient incident forms, self-assessment, surveys, checklists and reports

Education: documentation/orientation checklist, education schedule, employee education documentation and records training certificates

External services: external service agreements

Fire, security and other emergencies: emergency evacuation list and evacuation maps, fire safety maintenance and service records, fire safety maintenance and service records

Human resources management: employee personnel files, employee registration, orientation checklist, performance appraisal, position descriptions, roster,

Infection Control: infection control incidents

Information systems: care recipient admission pack, care recipient handbook, communication book (kitchen),employee handbook, external brochures, memoranda, meeting minutes, newsletters, policy manual, satisfaction surveys, working instructions, visitors book

Inventory and equipment: equipment, imprest system


Living environment: corrective maintenance forms, high cleaning schedule, pest control records, preventative maintenance program

Medication management: medication management policy, audits and schedule eight drug records

Mobility and dexterity and pain management: physiotherapy management, physiotherapy pain management documentation

Occupational health and safety: employee incident forms, risk assessments and hazard reports

Planning and leadership: strategic plan, vision, values, philosophy, objectives and commitment to quality

Regulatory compliance: advised of scheduled re-accreditation audit, fire records, food safety program, mandatory reporting register, police certificates, policies and procedures,

Resident security of tenure and responsibilities: residential agreement.

Observations

The team observed the following:

Activities in progress

Advocacy and complaint scheme brochures

Archive storage

Assistive feeding devices

Care recipients and staff interactions

“Charter of care recipients rights and responsibilities”

Chemical storage

Cleaning in progress

Comments and complaints forms on display

Displayed menu and activities program

Emergency exits and egress routes

Equipment and supply storage areas

Fire panel and fire equipment

Hand sanitizers and hand-washing facilities

Home’s quality statement on display


Instructional notices and signage

Internal/external living environment

Key coded entry and exit points

Meal and refreshment services in progress and assistance to care recipients

Mediation administration

Mobility equipment in use

Noticeboards with information displayed

Personal protective equipment in use

Quality Statement on display

Spill kits

Short group observation assessment

Suggestion box

Waste disposal.


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

St Nicholas Nursing Home (the home) actively pursues continuous improvement. A comprehensive quality management system incorporates feedback mechanisms comprising of proposal for improvement forms, satisfaction surveys, case conferences, care recipient/representative and staff meetings and comments and complaints process. The home has policies and procedures to guide management and staff in care and service delivery at the home. Monitoring of the home’s performance occurs through the use of an internal quality plan that guides the internal auditing program to ensure all areas of the Accreditation Standards and regulatory requirements are being adhered to by the home. Any deficiencies identified are referred to the Quality Committee for action. Care recipients/representatives and staff are satisfied the home actively pursues continuous improvement. In addition, there are processes for the collation and analysis of quality indicators.

Recent examples in Standard 1 Management systems, staffing and organisational development include the following:

The home has reviewed staffing levels in response to feedback, increased incidents, increased care recipient dependency and staff workload concerns. The introduction of two new short shifts has successfully been implemented from 6.00 to 10.30am and 4.00 to 7.00pm. As a result there has been a reduction in behaviour management incidents; care recipients care needs are supported as per their wishes. Care recipient and staff feedback has been favourable; “very helpful”, “enjoy being up for breakfast and out of bed”.

As a result of the number of visitors/volunteers participating in the life of the home. A visitor/volunteer training day has been scheduled annually to support visitors/volunteers with favourable response. The training day includes general fire and first response, manual handling, feeding, speech pathology and infection control. Volunteers indicated within the evaluation of the training day that the day was value adding to their experience at the home.


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 to identify all relevant legislative, regulatory requirements, professional standards and guidelines and ensure the home complies. Management networks with external organisations and government departments to ensure advice is received about new or amended regulatory requirements. Professional advice is sought on the interpretation of regulatory changes as required and relevant information is incorporated into the organisation’s policies, procedures and practices. Changes are highlighted in memoranda and discussed at meetings. Staff have access to legislation, standards and guidelines to inform their practice. Policies and procedures are reviewed annually and updated as required. Monitoring activities are conducted, including audits, observations, surveys; incident reporting and identified issues are captured in the quality management system. There are systems to ensure staff qualifications and registrations and other mandatory records are maintained in accordance with relevant legislation and/or regulations. The home is aware of its regulatory responsibilities in relation to criminal history certificates and the requirements to provide advice to care recipients/representatives about re- accreditation site audits in both English and Greek.

Particular to this Standard, the organisation has systems to ensure police certificates are undertaken and maintained and care recipients and representatives are advised of scheduled re-accreditation audits in both English and Greek.

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 ensures management and staff have appropriate knowledge and skills to perform their roles effectively through the provision of ongoing education and staff development. The training needs of staff are identified through legislative requirements, performance appraisals, hazard and incident data, feedback mechanisms, audits and the observation of staff practice. The home utilises televised education programs and staff are informed of scheduled training via calendar and text messaging. These visual teaching aids are especially helpful to staff who are from a non-English speaking background and feedback has been favourable. Management and staff are supported to attend external courses and conferences. Management maintains training records and evaluations. Staff performance is monitored through assessments of competency following training, on the job practice monitoring and formal performance appraisals. Care recipients/representatives are satisfied management and staff have appropriate knowledge and skills and perform their roles effectively. To enhance the knowledge and skills, the home schedules Hot Topics Registered Nurse training days and an annual visitor/volunteers day.

Particular to this Standard, staff have attended education sessions on the Accreditation Standards and complaints and feedback mechanisms.


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/representatives and interested parties have access to internal and external complaints mechanisms to raise suggestions or concerns. The home informs all stakeholders about the complaints process through meetings, care recipient/employee packs and care recipient/staff orientation. Complaints information is on display throughout the home in English and Greek. Complaints are registered, investigated, complainants are informed about actions taken to resolve the issues and consolidated records are maintained. Care recipients/representatives are aware of the home’s comment/complaints mechanisms, are confident about making a comment/complaint and are satisfied that issues are resolved in a timely manner.

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 organisation has documented the home's vision, values, philosophy, objectives and commitment to quality. This information is displayed in the foyer of the home in English and Greek.

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 has sufficient skilled and qualified staff. The home has policies, procedures and flowcharts for the recruitment and selection of staff, including reference checks, criminal history checks and ensuring current professional registrations. Employment contracts, work instructions, buddy shifts, orientation and ongoing education sessions ensure staff are aware of the requirements of their positions. Annual staff performance appraisals are conducted for all staff. Agency staff are oriented prior to working at the home. Management monitors care recipients’ changing care needs, staff availability and skill mix to ensure adequacy of staffing. Rostering processes ensure a registered nurse is allocated to all shifts to deliver clinical care and supervise care staff. Staff on leave are replaced with appropriately skilled or qualified staff, including agency staff as required. Care recipients/representatives are satisfied with the quality of care, lifestyle and services provided by the home and are satisfied with the


availability of and assistance provided by management, registered staff, assistants in nursing and environmental services staff

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


Stocks of appropriate goods and equipment are available. Preferred suppliers are used for the provision of goods and equipment. Management of stock is delegated to senior clinical, lifestyle, maintenance and environmental staff. Supplies of stock are rotated and are monitored to ensure sufficiency for service delivery. Management is responsible for the identification of equipment needs through consultation with staff and care recipients/representatives, the maintenance program and/or the safety reporting system.

New equipment and supplies are assessed to determine suitability of use prior to purchase and staff are trained prior to using the new equipment. The home undertakes annual planning as part of a capital replacement program for the replacement of equipment and other capital items; however, equipment is also purchased and/or replaced throughout the year as required. There are effective preventative and corrective maintenance programs in place with staff having access to the maintenance reporting process. Care recipients/representatives and staff are satisfied with the supply of goods and equipment.

1.8 Information systems

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

Team’s findings


The home’s information management systems are effective. The home utilises a combination of paper based and electronic information systems for the dissemination and storage of information. Information is provided to staff and relevant stakeholders through written and electronic correspondence, including minuted meetings, handbooks, care plans, handovers, work instructions, flowcharts and memoranda. Case conferences involving consultation between care recipients, representatives, medical officers and staff are conducted. Communication systems and meetings ensure care recipients are provided with information about daily activities and services and representatives are advised about incidents and changes in care. Confidential information (electronic and hardcopy) is securely stored and access is controlled through the use of password protection with regular back-ups completed. Obsolete information is archived and procedures are in place for storage and retrieval. Information management systems that support continuous improvement, regulatory compliance, education, safety and maintenance are operating effectively. Care recipients/representatives are satisfied management provides them with the information to make informed decisions.


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 has systems to ensure external service providers meet the home’s needs and service goals. The home has long standing service providers to assist with the provision of maintenance, care and service requirements. All contractors visiting the home are required to register at reception. External providers’ performance is monitored by management and action is taken to address performance issues. Preferred providers’ roles and responsibilities letters outline the home’s requirements and the quality of service to be provided and there are systems to ensure external providers have a current criminal history check. The Work health and safety/ Fire safety advisor (WHS/FSA) monitors external contractors servicing the firefighting and fire monitoring equipment. Staff and management are satisfied with the external service contractors providing the home’s care and service needs. Care recipients/representatives and staff are satisfied with 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 information about the home’s continuous improvement systems and processes.

Examples of recent improvements undertaken or in progress by the home in relation to Standard 2 Health and personal care include:

To provide care recipients with the opportunity to purchase suitable footwear and reduce the risk of falls, the home has arranged for an external footwear representative to visit the home with samples of suitable footwear twice a year, summer and winter. The physiotherapist has assessed all care recipients for suitable footwear. This activity provides a shopping experience for care recipients to purchase their own footwear while improving care recipients’ mobility and balance. Management stated that care recipients have been given a sense of independence in choosing their own foot wear.

As a result of feedback about care recipients experience with bed baths and design of the new wing of the home, management has successfully trialled a reclining shower chair. Management has conducted risk assessments and gathered staff and care recipient feedback. The new equipment is on order and due to arrive with the next month. During the trial staff experienced reduced manual handling incidents. Management stated that care recipients were relaxed and less anxious, experiencing improved health outcomes, increased privacy and dignity and no longer calling out or expressing discomfort.



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


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to health and personal care. Management maintains and monitors systems to ensure care recipients’ care is in accordance with the Quality of Care Principles 1997.

Particular to this Standard, the organisation has systems to ensure registrations of registered staff remain current.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills. Staff demonstrate skills and knowledge relevant to their roles and are satisfied with the support they receive from the home to identify and develop their skills.

Education provided relevant to Standard 2 includes, but is not limited to, palliative care, continence management, nutrition and hydration, understanding dementia and surviving a stroke, caring for a person with dysphagia, oral health, ageing process, sensory loss – hearing and vision, physiological changes, reduced diet, diabetes, hyperglycaemia and foot care.

2.4 Clinical care

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

Team’s findings


The home has systems and policies to ensure care recipients receive clinical care appropriate to their needs. Care recipients’ clinical care needs are identified on entry to the home. An initial assessment is completed by the registered nurse and identifies the clinical needs of the care recipients. A comprehensive set of assessments are completed on the identified needs. Care plans are generated based on the results of the assessments undertaken and on information received by medical officers, transfer documentation and from care recipients and representatives. Care requirements are documented and communicated to relevant staff through the handover sheets and progress notes. Families are invited to participate in a case conference as required. Review of documentation confirms the process. Care recipients have


a choice of medical practitioner. Staff receive ongoing education and are able to demonstrate they are knowledgeable about the care requirements of individual care recipients and procedures related to clinical care. Care recipients/representatives say the care received is appropriate and meets care recipients’ needs and preferences.

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


The home has systems to identify the specialised nursing care needs of care recipients. The initial and ongoing assessment and development of an individualised plan for specialised nursing care and technical health care needs is formulated. The home employs registered nurses 24 hours per day, seven days a week, who manage and oversee care recipients’ specialised nursing and technical health care. Staff are able to access health professionals through referrals and the Telehealth video conferencing, Mater Aged Care In An Emergency (MACIAE). The documentation review confirms that appropriate management strategies and treatment regimens are in place, including for the management of diabetes, palliation and wound care. Care recipients/representatives interviewed say the specialised nursing care needs are assessed and managed appropriately by 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


The home ensures referrals are arranged for appropriate health specialists in accordance with assessed needs and preferences. Review of documentation confirms care recipients’ needs are assessed and they are referred to other health and related services when needed. These include physiotherapy, podiatry, dentistry, speech pathology and optometry. Care recipients/representatives confirm care recipients are referred to appropriate specialists as needed and that staff assist them to access these services.

2.7 Medication management

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

Team’s findings


The home demonstrates that the management of medication is safe and meets relevant legislative and regulatory requirements and professional standards and guidelines. A pre packed medication system is in place whereby medications are packed by a pharmacist and administered by registered nurses and medication competent staff. Paper based medication charts include a photo of the care recipient and a list of any allergies, and any specialised


administration procedures the care recipient may require. Medications in use are stored in and administered from medication trolleys which are secured when not in use. Staff are required to demonstrate competency with medication management; internal audits and review of medication management are conducted and a multidisciplinary Medication Advisory Committee meets regularly. Care recipients/representatives confirm they are satisfied with the home’s management of medication.

2.8 Pain management

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

Team’s findings


The home has systems and processes to ensure care recipients’ pain management needs are regularly assessed, monitored, reviewed and documented. A pain management program managed and overseen by physiotherapists is ensuring all care recipients are as free from pain as possible. A full assessment of the individual care recipients by the care staff and physiotherapist identifies the care recipients with pain and the level of pain. The process includes care recipients with communication and cognitive deficits. Alternative strategies to medication interventions for the management of pain are provided. These include repositioning of the care recipient, massage, gentle exercise and appropriate equipment. The effectiveness of the interventions is monitored daily by the physiotherapist and any changes are reported to the medical officer and the registered nurse as required. The staff consult other allied health services as necessary to manage care recipients’ complex pain needs.

Care recipients/representatives confirm that staff regularly monitor care recipients’ pain relief needs and they are maintained as free as possible from pain.

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 can demonstrate that the dignity and comfort of care recipients who are terminally ill is maintained in consultation with care recipients and representatives. There are systems to ensure care recipients and representatives have the opportunity to record their end of life wishes. The registered nurses oversee the palliation of care recipients with the introduction of the updated documentation that is supported by a Palliative Approach Team. Document review and interviews with representatives revealed that the care team, including general practitioners, specialists and care staff are committed to supporting care recipients at the end of their lives. The priest or other religious representatives are contacted according to the care recipients wishes. Care recipients /representatives confirm the home’s practices maintain care recipients’ comfort and dignity.


2.10 Nutrition and hydration

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

Team’s findings


The home demonstrates care recipients receive adequate nutrition and hydration. Regular assessments of care recipients’ dietary and hydration preferences and needs are conducted and communicated to relevant staff. The changing needs and preferences of care recipients are closely monitored through observation, weight recording, care recipient meetings, regular surveys and discussions with care recipients and representatives. All meals are prepared at the home and dietary supplements, special diets and specially prepared food for care recipients with swallowing difficulties are catered for. The menu has been developed in consultation with a dietitian and provides for meal choices. Care recipients’ swallowing ability is assessed by a speech pathologist if indicated. Adapted crockery and cutlery is available and staff supervise and assist care recipients with their meals when required. All care recipients interviewed stated the meals are culturally specific and well presented.

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 practices and processes to ensure the skin integrity of care recipients is maintained in a state consistent with their general health status. The assessment includes risk assessments, regular care plan reviews, documentation of care and providing for care recipients specific skin, hygiene, continence, hair and nail care needs. Skin care needs are assessed, monitored and evaluated on an ongoing basis in consultation with care recipients, representatives, medical practitioners and other health professionals where appropriate. Staff document daily on the skin integrity of the care recipients and report changes to the registered nurse. Podiatry and hairdressing services are available at the home. Care recipients/representatives confirm they are satisfied with the care provided.

2.12 Continence management

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

Team’s findings


Care recipients’ continence needs are assessed on moving to the home. The system includes individual continence assessments, the development of a care plan and toiletting program if required, which is regularly reviewed and evaluated. The need for reassessment of a care recipient’s continence status is directed and supervised by the registered nurse and the care plan is updated as required. Evaluation of management strategies, including basic care regimes for indwelling and supra pubic urinary catheters, scheduled toiletting programs and the provision of continence aids is undertaken. The home has a range of continence care


products and aids to assist in maintaining and promoting the optimal continence of care recipients. Care recipients/representatives interviewed reported satisfaction with the program, stating that the home manages care recipients’ continence effectively.

2.13 Behavioural management

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

Team’s findings


The home has effective systems to manage care recipients behaviours. Behaviour management assessments are conducted in consultation with care recipients/representatives and appropriate health professionals. Access to a geriatrician and mental health team are accessed when necessary by the home. Other care needs that impact on behaviour, such as pain management and sleep are also considered when assessing behaviours. Staff receive education in managing challenging behaviours and work as a team to provide care. We observed the environment to be calm, care recipients well-groomed and participating in activities of interest to them. Staff interviews and observation of staff/care recipient interaction confirm staff are familiar with appropriate behaviour management strategies. The appropriate documentation is completed when a restraint is required. Care recipients/representatives confirm they are satisfied with the home’s management of behaviour and the care provided.

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


The home has an effective system to ensure optimum levels of mobility and dexterity are achieved for all care recipients. The physiotherapists oversee and manage the care recipient’s mobility and dexterity programs daily. The physiotherapists developed an exercise program for the care recipients to participate in with the assistance of the staff. Group exercises and individual programs have been formulated that encourage care recipients’ mobility and dexterity. Changes in mobility are identified and documented as part of the care planning process. Representatives expressed satisfaction with the mobility and dexterity program being managed by the physiotherapists. We observed care recipients using mobility aids and handrails suitably placed throughout the home. Incidents are reported, responded to in a timely manner and feedback is regularly provided to staff, care recipients/representatives, medical and other health related personnel and presented at appropriate meetings. Care recipients/representatives interviewed are satisfied with the efforts made to maintain care recipient mobility.


2.15 Oral and dental care

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

Team’s findings


The home has policies and procedures to maintain care recipients’ oral and dental health. Assessments are conducted and care needs are documented on care plans. Where appropriate, care recipients are encouraged and supported to maintain their independence in terms of oral hygiene and care of teeth. Assistance with denture care is provided as required and routine dental equipment replacement is provided by the home. Care recipients have access to a dentist of their choice and staff will assist in arranging appointments if required. Care recipients/representatives confirm they are satisfied with the oral and dental care provided by the home.

2.16 Sensory loss

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

Team’s findings


The home has a system to identify and effectively manage care recipients’ sensory losses. Assessments of the sensory needs are completed on entry to the home and when a change in the health status is identified. Care plans are developed from the information gathered ensuring effective management of care recipients to ensure their sensory losses are managed appropriately. A review of clinical documentation confirms the home liaises with a variety of allied health professionals as necessary to ensure that sensory needs are identified and addressed. Staff can identify various ways they assist care recipients who have sensory loss. Staff assist care recipients with their sensory aids ensuring they are functioning correctly. Care recipients expressed satisfaction with the management of their sensory loss

2.17 Sleep

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

Team’s findings


The home provides an environment and support for care recipients to assist them to achieve their natural sleep patterns. Assessments are completed to identify usual sleep patterns and preferred routines prior to settling for the night. The information identified is then incorporated into care plans. Care recipients are kept as free from pain as possible, and the use of continence aids minimises disturbance during the night. The home uses an electronic sensor program in the rooms of care recipients to ensure staff are alerted to the unscheduled movement of the care recipients from their beds. Care recipients/representatives indicated they are satisfied with the care and attention staff provide care recipients to achieve an optimal sleeping pattern.


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



Examples of recent improvements undertaken or in progress in relation to Standard 3 Care recipient lifestyle include:

The home has introduced a weekly Men’s group, recreating the atmosphere of a Greek Kafeneon (coffee house) which is a large part of the Greek culture. The men meet regularly to play games, chat and more recently music has been introduced. Volunteers assist with the facilitation of the group. Management and the volunteer facilitator stated care recipients feedback has been positive. The men attending stated they “enjoy the music, chats and jokes”.

The Bereavement Support Program has been implemented as a result of two initiatives. Firstly, to complete the roll out of the Palliative Approach Toolkit and secondly the cultural dynamic of the home is unique. The Bereavement Support Program offers families an alternative to attending multiple funerals to pay their respects to care recipients who have passed away. It also offers families a way of staying connected to their time within the home being able to attend the continuing memorial services each year. The memorial service provides the relatives/representatives, other care recipients, staff and friends of the deceased care recipient with closure. There is also an opportunity to identify families and staff members who require professional help to manage their experience of grief and loss. The home plans to hold memorial series three times a year. When a care recipient passes away the family will be sent a sympathy card with an invitation to the next memorial service enclosed. The memorial is also advertised in the home’s newsletter to advise staff of the service. Relatives/representatives stated “excellent presentation”, “very moving”, “should have happened earlier”.

Following Privacy and Dignity education and circumstances arising in a breach, the home has reviewed the privacy and dignity policy. All staff have received a fact sheet about considering privacy and dignity while administering care. An audit tool has been developed to monitor staff practices. Management confirmed staff had a heightened awareness of ensuring privacy and dignity of the care recipients when providing care.



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


Refer to expected outcome 1.2 Regulatory Compliance for information about overarching systems implemented to identify and ensure compliance with relevant regulatory requirements.

Relevant to this Standard, the home is aware of its regulatory responsibilities in relation to security of tenure, privacy and compulsory reporting. There are systems in place to ensure these responsibilities are met. Management maintains and monitors systems to ensure care recipients’ care is in accordance with the Quality of Care Principles 1997.

Particular to this Standard, the organisation has systems to ensure reportable and non- reportable events are managed according to legislative requirements.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills.

Education provided relevant to Standard 3 includes, but is not limited to, advocacy, cultural diversity, elder abuse, grief and loss, respecting patients’ choices, privacy and dignity and Greek vocabulary and culture.

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


Care recipients’ emotional status and needs are identified and supported. Discussions with care recipients and their representatives provide the home with information related to care recipients/representatives needs for emotional support. The care recipients’ emotional needs are assessed and their life, social and cultural history and leisure and lifestyle activities are documented. Significant dates and times of grief and loss are noted and staff indicate an awareness of these times for the care recipients. Visiting families and friends are welcomed and care recipients are invited to bring in small personal items and photos to help remind them of their past. The staff interactions show warmth, respect, empathy and understanding when they speak with the care recipients. The home’s priest also provides one-on-one attention to


care recipients during times of special need. Family and friends are encouraged to visit and community groups provide further emotional support for the care recipients.

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 demonstrates care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. The initial clinical assessment identifies the life choices in relation to a range of activities of daily living and lifestyle choices. The effectiveness of the assistance provided to care recipients in relation to their independence is monitored through regular review of care plans, satisfaction surveys, comments and complaints and care recipient/representative meetings. The activities program is distributed to care recipients and displayed throughout the home.

The home welcomes visits from community groups and encourages care recipients to participate in life outside the home if able. Care recipients/representatives are satisfied with the assistance provided to achieve maximum care recipient 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


Staff recognise and respect each care recipient’s privacy, dignity and confidentiality. Care recipients are accommodated in single and multi-bed rooms with shared bathrooms. Call bell alarms are provided for care recipients to wear if needed. Staff sign confidentiality agreements on commencement of employment and confidential care recipient records are stored securely. Permission is sought from care recipients for the disclosure of personal or clinical information and the display of photographs and care recipients understand that their consent is required before treatments are carried out. Care recipients’ end of life wishes including cultural and religious requirements are discussed and documented on entry. Staff and management interviews and observation demonstrated an awareness of privacy and dignity issues in their daily practices. Care recipients/representatives are satisfied the care recipient’s right to privacy, dignity and confidentiality is 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 systems to encourage and support care recipients to participate in a range of activities of interest to them. A review of documentation indicates that activities staff have a comprehensive record of each care recipient’s life history and interests with the help of families. A monthly activities program is developed, distributed and displayed and activities are scheduled seven days a week. The program is evaluated regularly and modified in response to ongoing care recipient feedback, including through care recipient meetings, audits and surveys. A large number of volunteers also visit the home and provide many care recipients with regular one-to-one support. The Greek Orthodox Ladies Philoptochos Society are great supporters of the home and several volunteer on a regular basis. The care recipients/representatives are satisfied care recipient participation is encouraged and supported and the activities offered by the home are of interest to the care recipients.

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 individual interests, customs, beliefs and cultural and ethnic backgrounds of care recipients are valued and fostered. Care recipients’ needs and preferences are identified on entry and care plans are developed and reviewed regularly. Special dates of cultural significance to current care recipients are celebrated, including birthdays, Christmas, Easter and Mother’s and Father’s days. Other cultures are respected when identified and the needs of the care recipients are met. The Greek religious service is available for all care recipients to view through the home television in-house digital service and all care recipients are assisted to attend. Care recipients/representatives confirm the cultural and spiritual needs of the care recipients are recognised and supported.

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


The home demonstrates that each care recipient/representative participates in decisions about the services of the home and is able to exercise choice and control over lifestyle through consultation around care recipients’ individual needs and preferences. Management demonstrates an open door policy resulting in continuous, timely interactions with staff and


care recipients/representatives. The care recipient handbook outlines the services provided and avenues for making suggestions and complaints. Information on care recipients’ rights and responsibilities is provided to care recipients on entry and the Charter of care recipients’ rights and responsibilities is displayed in the home. Care recipients/representatives are satisfied with their participation in decisions concerning services received by the care recipients.

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


Management demonstrated care recipients have secure tenure within the residential care service and understand their rights and responsibilities. On entry to the home, care recipients/representatives are provided with a handbook that details information relating to their rights and responsibilities, feedback mechanisms and privacy and confidentiality. Care recipient agreements are offered to all care recipients and include details regarding security of tenure and documents care and services provided. Staff are informed of care recipients’ rights through orientation and ongoing training with care recipient satisfaction monitored through surveys and feedback. Care recipients are satisfied they have appropriate access to information regarding their rights and feel secure in their tenure.


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



Examples of recent improvements undertaken or in progress in relation to Standard 4 Physical environment and safe systems include:

As a result of feedback from care recipients’ representatives that the ‘ambience’ of the home was very clinical and not homelike, there has been a purchase of outdoor furniture, foyer furniture and updating of the interior decorations. A family member is overseeing the interior decorating. Management stated that the feedback has been positive and the atmosphere is very welcoming. In the recent satisfaction survey, care recipients stated “despite the age of the building, it is well maintained and conducive to an enjoyable and comfortable atmosphere”.

Management identified the need to refurbish the bathrooms in the home due to extensive wear and tear. Non-slip vinyl has been installed to replace the tiles and grouting making cleaning more efficient. Toilets have been replaced and fold down rails installed to meet care recipients’ needs. During the refurbishment process, management ensured open and transparent communication with care recipients/representatives. Additional staff were rostered to support care recipients during the refurbishment. Care recipients representatives have commented positively on the new design.


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


Refer to expected outcome 1.2 Regulatory Compliance for information about the home’s systems and processes to maintain regulatory compliance.

The home has systems to ensure compliance with legislation relevant to the physical environment and safe systems. The home has a food safety program and processes for monitoring fire and occupational health and safety requirements.




Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills.

Education provided relevant to Standard 4 includes, but is not limited to, fire and emergency response, infection control, workplace health and safety, chemical training, safe food handling, Thickening by Flavour Creations, risk assessments and manual handling.

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


Management actively work to provide a safe and comfortable environment consistent with care recipients’ care needs. Care recipients’ environmental needs and preferences are identified and met ensuring access to items, such as call bells and mobility aids. Care recipients are encouraged to personalise their rooms with furnishings, photos and decorations. There are indoor and outdoor areas, including gardens providing care recipients with the opportunity to participate in outside activities. Staff assist to make care recipients safe and comfortable through ensuring access to items, such as call bells and mobility aids. Restraint authorities are sought for care recipients requiring protective assistive devices and are reviewed regularly. Management and staff monitor the living environment through cleaning schedules, preventative and corrective maintenance programs, internal auditing programs, hazards and incidents. The home is secured each evening ensuring a safe environment for care recipients and staff. Care recipients and representatives are satisfied the living environment is comfortable, safe and secure.

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 work to provide a safe working environment that meets regulatory requirements. The home has processes to assist in the identification of required improvements to meet relevant occupational health and safety legislation. Staff are informed of their occupational health and safety responsibilities during orientation and ongoing training, through policies, meetings and memoranda. Staff are trained in the use of new equipment and there are work instructions to guide safe staff practices. Staff access appropriate inventory and equipment to


promote safe work practice and regular manual handling training ensures the safety of staff and care recipients. Current safety data sheets and appropriate supplies of personal protective equipment are available. The home manages staff incidents effectively by investigating and taking action to minimise recurrence. Reporting of safety issues or concerns are raised and followed-up through the effective maintenance program, including maintenance requests and preventative maintenance program, incident/accident reporting, improvement forms, verbally and through hazard forms. Staff confirm they follow processes to maintain 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 work actively to provide an environment and safe systems of work that minimise fire, security and emergency risks. The home has processes for the ongoing security, safety, fire and other emergencies of the home. Staff receive comprehensive training regarding the emergency and response systems during orientation and annual compulsory training. Emergency evacuation plans are on display throughout the home and management ensures emergency exits and egress routes are free from obstruction.

Evacuation practices/drills are held to test the home's emergency systems and staff knowledge. Evacuation lists are updated as care recipients are admitted and discharged from the home. Fire equipment is maintained by a qualified external contractor and there are effective processes to monitor the maintenance of essential services equipment. Care recipients, visitors and contractors sign in and out to assist in identification of who is in the building. Staff have the opportunity to carry personal duress alarms on night duty shifts, if they choose. Care recipients said they feel safe and secure in the home.

4.7 Infection control

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

Team’s findings


The home’s infection control program is effective. The food safety program and laundry practices support the infection control program and training is provided to staff at orientation and annual compulsory training. Infection data is collated and analysed to identify trends and action is taken. Staff practices are consistent with the home’s infection control procedures, including hand-washing procedures, clinical practice, use of personal protective equipment and waste management for general, clinical and sharps disposal. Catering, cleaning and laundry procedures also include the use of colour coded cleaning and catering equipment.

Regular pest control services are engaged. Staff are aware of the outbreak management policy and staff practices in the event of an outbreak. Management and staff are knowledgeable about infection control principles and practices and have access to infection control guidelines and reference resources if needed.


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


Environmental services are provided in a way that enhances care recipients’ quality of life and the working environment for staff. Care recipients’ dietary needs and meal preferences are identified on admission and an ongoing basis, entered onto a dietary analysis form which is communicated to the kitchen and servery. All meals are cooked on-site in a central kitchen and delivered to each area for serving. The home has a food safety program and processes are effective in reporting variances in temperatures. The menu is displayed in the dining room in both Greek and English. Dining rooms and table settings enhance care recipients’ dining experience. Cleaning of care recipient rooms, communal areas and high cleaning is completed as per the cleaning duty lists and staff are provided instruction in the use of personal protective equipment, general cleaning equipment and chemicals. Care recipients’ clothing is labelled by the home to minimise loss during laundry process. Laundry services for care recipients’ personal items and tableware are managed through the on-site laundry with all other laundry attended by an external contractor. The home has an established cleaning and maintenance program to ensure the living and working environment is clean and safe. The effectiveness of environmental services is monitored through meetings, audits, improvement process and satisfaction surveys. Catering staff are trained in food handling processes. Care recipients/representatives are satisfied with the catering, cleaning and laundry services provided. Catering, cleaning and laundry staff are satisfied with their working environment.

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