Audit Report The Sydney-Lynne Quayle & Fitzroy Lodge Hostels 3354 Approved provider: Heywood Rural Health Introduction This is the report of a re-accreditation audit from 21 May 2013 to 22 May 2013 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 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 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 Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 1
Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 21 May 2013 to 22 May 2013. 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: Team member: Dawn de Lorenzo Tamela Dray Approved provider details Approved provider: Heywood Rural Health Details of home Name of home: The Sydney-Lynne Quayle & Fitzroy Lodge Hostels RACS ID: 3354 Total number of allocated places: Number of residents during audit: Number of high care residents during audit: Special needs catered for: 33 29 11 Residents living with dementia Street: 21 Barclay Street State: Victoria City: Heywood Postcode: 3304 Phone number: 03 5527 0555 Facsimile: 03 5527 1900 E-mail address: pstarick@swarh.vic.gov.au Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 2
Audit trail The assessment team spent two days on-site and gathered information from the following: Interviews Number Number Management 4 Residents/representatives 6 Registered and enrolled nurses Care staff 6 5 Lifestyle staff 2 Catering, cleaning and care/laundry staff Infection control staff 2 Dietitian 1 Education staff 2 Maintenance and stores staff 2 Allied health staff 1 Administration assistants 3 5 Sampled documents Number Number Residents files 5 Medication charts 5 Resident agreements 5 Personnel files 5 Lifestyle files 4 Staff education files 5 Other documents reviewed The team also reviewed: Archive register Assets register Audits and audit schedule Catering temperature records Chemical register and material safety data sheets Cleaning schedule and associated documentation Clinical documentation Communication diaries Compulsory reporting file Continuous improvement plan Contractor register Education documentation Essential services documentation External supplier contracts Feedback, complaints, compliments and comments folders Fire safety and emergencies documentation Food safety plan Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 3
Handover sheets Incident reports Infection control documentation and records Kitchen cleaning records Laundry duties lists Lifestyle participation and evaluation records Maintenance documentation Memoranda Minutes of meetings Nursing registrations folder Occupational health and safety documentation Police certificates and statutory declaration registers Policies and procedures Position descriptions Preventative maintenance schedule Recruitment policies and procedures Resident consents Resident newsletter Residents information package and surveys Roster Smoking assessment Staff handbook Staff orientation manual Vision, mission and value statements. Observations The team observed the following: Accreditation assessment signage Activities in progress Aged care advocacy and external complaints information Annual essential safety measure report displayed Archive areas Charter of residents rights and responsibilities displayed Chemical storage Cleaner s room Cleaning in progress Clinical supplies Closed circuit television camera Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 4
Compliments, suggestions and complaints pamphlets and opportunity for improvement forms with box Equipment and supply storage areas Fire fighting equipment, fire panel, alarms, evacuation map, evacuation supplies and resident lists Hand wash stations Interactions between staff and residents Laundry in progress Living environment Lunch service Maintenance room Medication administration Medication delivery from pharmacy Menus displayed Noticeboards Outbreak kit Personal protective equipment Selected residents rooms Staff room Storage of medications. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 5
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 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. The home has a continuous improvement system to identify improvement opportunities and monitor performance against the Accreditation Standards. Residents, their representatives, staff and other stakeholders contribute to the continuous improvement system through verbal and written feedback including attending meetings, electronic mail, participating in surveys and completing forms. There is an online framework with different mechanisms such as internal and external audits, surveys and clinical data including incident reports to also identify areas for improvement. Management introduces changes in a structured manner and monitors their impact to ensure success. Management provides feedback to residents, their representatives, staff and other stakeholders as appropriate through documentation such as electronic mail and verbal means as well as providing required training to staff. Examples of improvement initiatives implemented in relation to Standard 1 Management systems, staffing and organisational development include: Staff suggested processes to ensure all information obtained with resident entry required improvement. Management devised a resident entry form and educated staff as to its use. Management said there has been positive feedback from staff who find the new form concise and ensures they obtain all information required on resident entry in a timely manner. Management recognised the need to improve archiving of records in the home. Management organised for records to be stored off site in a facility contracted to store public records according to regulatory guidelines. Management said this new process remains under evaluation but to date there has been positive feedback from staff regarding reduction in manual handling, more storage space and the ease of procuring these records when required. Staff identified resident discharge procedures required improvement. Management devised a discharge checklist and educated staff regarding its use. Management said there has been positive feedback from staff who find the new tool has improved the resident discharge process. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 6
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. The home s management has systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines across the Accreditation Standards. The home s management has online regulatory compliance software and subscribes to a wide range of legislative associations to ensure they receive notification of changes in legislation and information from various government agencies and industry bodies. Management notifies staff and others of any regulatory changes through such avenues as meetings and education as required. The home s management develop or modify online policies and procedures to ensure alignment with any changes. Management uses various mechanisms to monitor compliance such as regular review of processes including audits and incident reports. Examples of responsiveness to regulatory compliance obligations relating to Standard 1 management systems, staffing and organisational development include: Management notified stakeholders in advance regarding the upcoming reaccreditation audit. Stakeholders have access to information about advocacy services and internal and external complaint mechanisms. There is a system to ensure compliance with police certificates requirements and overseas statutory declarations for all relevant staff. Management monitors the professional registrations of staff to ensure performance of tasks by qualified individuals. 1.3 Education and staff development: This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. Identification of staff development requirements occurs in response to residents needs, performance appraisals, incident reporting, by observation and from verbal feedback. The home has a dedicated education department and offers staff internal education as well as the opportunity to attend outside education deemed of benefit to the home. The home actively promotes and implements up skilling opportunities for staff. There is a mandatory training program in place and includes fire safety and evacuation, cardiopulmonary resuscitation, infection control and manual handling. A range of skills competency assessments, including clinical skills, is undertaken annually. Records of attendance at education and training session are maintained and the education department keeps a file for each staff member containing their attendance certificates and an annual summary which is used during staff appraisals. Staff have access to a commercial aged care education channel and can view the material in their own time if they wish. In-service education attended by management and staff in relation to Standard 1 includes: Up skilling support for eight staff to complete Certificate IV in Frontline Management Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 7
Maximising media Mentoring new graduates Documentation training for the electronic care planning system. 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". Each resident and other interested parties have access to internal and external complaints mechanisms. Management informs residents, their representatives and others about internal and external complaints through brochures, posters, handbooks and meetings. There are forms available for the use of residents and others to lodge comments and complaints with boxes provided for these forms to ensure anonymity. Management also encourages residents, their representatives, staff and others to verbalise complaints either directly to them through an open door policy or in meetings. There are regular surveys conducted to assist in the identification of any trends. The home s management records comments and complaints, analyses them and acts upon them in a timely manner. Management said they provide feedback to residents, their representatives, staff or others as appropriate through means such as meetings, electronic mail or consultations. Residents, their representatives and staff said they are aware of how to make a comment or complaint and would do so if required. 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". The home documents its vision, mission and values in a consistent way and articulates a commitment to quality care. The home communicates these strategic intents to stakeholders through handbooks, during induction programs and by displaying them throughout the home. Our observations of staff practice, feedback from residents and representatives about care and services, and the enthusiasm staff displayed for their responsibilities align with the home s documented purpose and objectives. 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". The organisation has a system to ensure sufficient appropriately skilled and qualified staff deliver services in accordance with these Standards and the residential care service s philosophy and objectives. Management recruit staff primarily through community interest or advertisement either locally or online. The recruitment process includes interviews, reference Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 8
and certification checks with continued monitoring of qualifications once employed. There is a system to ensure staff complete statutory declarations and possess current police certificates. The home s orientation process includes education and supernumerary shifts with documented position descriptions. Management monitor and maintain the skills of staff through education, competencies and appraisals. Management ensure roster coverage through the organisation s staff to fill any vacancies. Staff said they were generally satisfied with the number of staff and adequacy of skills. Residents and their representatives said they were satisfied with the adequacy of resident care and the responsiveness of staff. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Management and staff monitor the performance and maintenance of equipment and stock levels and research equipment prior to purchase to ensure that it meets the home s requirements. Staff are trained in the use and maintenance of any new stock and equipment introduced. The maintenance department manages a preventative and corrective maintenance program and preferred providers carry out tasks not able to be completed by staff at the home. Staff have received training in the new electronic maintenance program. Any unsafe equipment is identified and removed for modification or repair and is returned only if safe and functional. Maintenance records, observations and feedback from residents and staff indicate there are sufficient stocks of supplies and well maintained and equipment. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". There are effective information management systems with confidentiality, privacy and security maintained throughout. Management, staff, residents, their representatives and others have access to current information, activities and events of the home as appropriate through such means as meetings, noticeboard displays, handbooks and posters. Residents and their representatives receive enough information to assist them to make decisions about residents care and lifestyle. Management and staff receive accurate information to help them perform their roles through meetings, memoranda, electronic care planning system, handovers, education, online incident reporting system and policies and procedures system. The home s computer system is backed up daily externally and appropriate staff have logons and passwords. Management archives confidential material securely with the information retrievable in a timely manner. Residents, their representatives and staff said they are satisfied with the communication and information in the home. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 9
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". There is a system to provide externally sourced services to meet the home s needs and service quality goals. Management has a current register of contracted providers and reviews the contracts as required with input from staff and residents to ensure the provision of optimum service. There is a system to ensure contractors have an overseas statutory declaration and a current police certificate. Contractors also receive a manual to ensure familiarity with the home s processes. Residents, their representatives and staff said they are satisfied with the services provided by contractors in the home. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 10
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. Refer to expected outcome 1.1 Continuous improvement for information regarding the home s continuous improvement system and processes. Examples of improvement initiatives implemented in relation to Standard 2 Health and personal care include: Management identified the home s resident of the day documentation required improvement to ensure alignment with the new electronic care planning system. Management devised a new tool and trained staff regarding the new format. Management said, although the new form is not fully evaluated, feedback from staff to date has been positive. Through an audit, management recognised the need to improve medication management regarding medications dispensed out of usual medication round times. Management devised an extra list of medication reminders for these and instructed staff regarding the new reminder protocol. Management said although under evaluation, to date the new process has improved medication management in the home. Through resident feedback, management identified the need to improve resident choice in regards to health services. Management devised a consent form where residents nominate their preferred consultation providers. Management said there has been positive feedback from residents. 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. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home s regulatory compliance system and processes. Examples of regulatory compliance in the home in relation to Standard 2 Health and personal care include: Registered nurses oversee specific care planning activities and care tasks. There are procedures to ensure compliance with legislation in the event of a resident s unexplained absence. Management demonstrates the organisation follows legislation in relation to medication management. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 11
2.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. Please refer to expected outcome 1.3 Education and staff development for information about the home s education and staff development systems and processes. Education conducted relating to Standard 2 Health and personal care includes: Continence care Cardio respiratory emergency management Support for all the registered nurses to attend a four day course on Comprehensive Assessment of the Older Person Wound management. 2.4 Clinical care This expected outcome requires that residents receive appropriate clinical care. Staff and management ensure residents receive appropriate clinical care. Assessment of residents needs occurs upon entry to the home and the development of care plans takes place around these needs. Consultation occurs between the home and residents and their representatives where applicable. The general practitioners and visiting allied health professionals contribute to an holistic approach to care. Review of resident care occurs regularly through the resident of the day program, regular nursing reviews and in response to changing health status. Documentation ensures the monitoring of clinical care through charts, assessments, care plans and progress notes and uses electronic and paper based means. Registered nurses and the nurse unit manager oversee clinical care to residents according to their assessed needs and preferences. Staff confirm they are aware of residents needs and state appropriately qualified staff provide care within their relevant scope of practice. Residents and representatives stated their satisfaction with the clinical care 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. Registered nurses plan, manage and review specialised nursing care needs. Specialised nursing care currently occurs in a number of areas including medication management, diabetic care, wound management, complex behaviour management, catheter care and palliative nursing. Staff receive education to help them manage any specialised nursing care needs. The home has internal access to specialised nursing from a wound care specialist, diabetes educator, continence nurse, lymphoedema nurse and a respiratory nurse. Additional specialised nursing care occurs in consultation with specialist nurses from outside the home if required for such things as pain management in the palliative care phase. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 12
Monitoring of specialised nursing care needs occurs through care plan reviews, the formal audit schedule and feedback from residents and representatives. Residents and representatives interviewed are satisfied with specialised nursing care services they receive. 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. Staff ensure the referral of residents to specialists and other health services as required and preferred. Medical practitioners visit the home regularly and residents can choose to retain their own doctor if they desire. The physiotherapist assesses residents on entry to the home and reviews all residents according to schedule, following a fall, or if their health status changes. A podiatrist visits regularly and referral to the dietitian and speech pathologist occurs as needed. Assistance from staff is available so residents can attend outside appointments as required. The home has recently introduced consent to refer forms so that residents only receive referrals to health services they wish to receive. Residents confirmed their satisfaction with access to other health and related services. 2.7 Medication management This expected outcome requires that residents medication is managed safely and correctly. Registered nurses manage and oversee medication administration. We observed competency tested care staff and nurses administer medication safely and correctly from dose administration aids. Current photos on medication charts identify residents and the home has a policy for assessing and managing residents who wish to self-administer any medication. Pharmacy reviews of medication occur regularly and external pharmacist audits occur. A medication advisory committee discusses any medication issues at regular meetings. We observed general medications stored securely and controlled drugs are stored with additional security in line with legislative requirements. Residents and representatives confirm that medication administration occurs in a safe and timely manner. 2.8 Pain management This expected outcome requires that all residents are as free as possible from pain. Staff ensure residents pain management occurs effectively. Assessment of residents for previous and current pain occurs on entry to home. Regular review of residents' pain occurs as part of the resident of the day program, nursing reviews and as changes in pain status indicate. The home implements a variety of pain management strategies with and without the use of medication. Pressure area care and pressure relieving equipment such as cushions and mattresses are utilised to reduce and manage pain. Liaison with doctors and physiotherapists ensures pain management is optimal. Additional pain consultation occurs during the palliative phase and involves input from outreach programs as appropriate. Residents said staff respond appropriately whenever they have pain. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 13
2.9 Palliative care This expected outcome requires that the comfort and dignity of terminally ill residents is maintained. The home accesses medical care for residents as necessary during the palliative care phase and seeks outreach support from outreach services as needed. Additional nursing care, spiritual and complementary care is available to residents and support is accessible to families at this time. Families are encouraged to contact staff at any time during the final phase of a resident s life and visitors have access to assistance and support to stay at their loved one s side for extended hours. The home establishes a resident s advanced care wishes upon entry to the home and revisits these wishes as the resident s health needs require. Review of documentation indicates palliative care delivery occurs through appropriately qualified staff in consultation with the resident s medical practitioner and family. 2.10 Nutrition and hydration This expected outcome requires that residents receive adequate nourishment and hydration. Staff ensure the adequate management of residents nutrition and hydration needs. On entry to the home, staff assess the residents nutrition and hydration needs and care plans and catering information ensure the delivery of these needs. When assessing nutrition and hydration, staff consider allergies, preferences, clinical, religious and cultural needs. Consultation with the dietitian ensures optimal nutrition management. Weighing of residents occurs regularly in line with their individual weight management plan. A dietitian and speech pathologist help manage any nutrition and hydration concerns. Weight management programs which may include the use of supplementation or restrictions, manage losses and gains in weight. The rotating menu and the provision of alternative meals ensures catering services allow for individual preferences. Staff are aware of residents requirements for texture-modified diets and thickened fluids and catering staff receive training in this. Residents said they are happy with the food provided and state they have enough to eat and drink. 2.11 Skin care This expected outcome requires that residents skin integrity is consistent with their general health. Staff assess and care for residents in a way that promotes optimal skin integrity. Skin integrity is assessed on entry to the home, when care plans are reviewed and as health needs change. Promotion of skin integrity occurs through the application of a barrier cream as well as attendance to good pressure area care as needed. Further enhancement of skin integrity occurs through the provision of pressure relieving devices such as furniture, mattresses and cushions. Assistance for residents to maintain their skin, hair and nails in a healthy state is given and a visiting podiatrist and hairdresser help them maintain their nails and hair. Monitoring of skin tears and wounds occurs, with records of care provided reflected on appropriate charts. The home has policies and procedures for wound management and Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 14
specialised consultation is available from wound care specialists if further advice is required. Residents are satisfied with the home s approach to maintaining their skin integrity. 2.12 Continence management This expected outcome requires that residents continence is managed effectively. Staff ensure the effective and dignified management of residents continence needs. The home assesses residents continence needs on entry to the home and as their needs change. Assessments take into consideration the staff assistance levels required by the resident and any continence aids needed. The home s approach to continence management encourages promotion of resident independence and dignity. Staff discreetly attend to residents continence care and verify they have access to sufficient continence aids for residents needs. The continence nurse provides education to staff at the home to ensure aids are appropriate for the residents individual needs. Residents are satisfied with their continence care and the promotion of their independence in this area where safely possible. 2.13 Behavioural management This expected outcome requires that the needs of residents with challenging behaviours are managed effectively. The home ensures the effective management of residents challenging behaviours. The resident population includes some residents with dementia related illness, cognitive decline and psychiatric illness. Staff state they receive adequate education to assist them to manage residents with challenging behaviours and keep disturbances to other residents to a minimum. The home has a dedicated unit to help keep residents with dementia related illness safe and to manage any wandering behaviours. Residents report the management of challenging behaviours is good and the behaviour of other residents does not disturb their sleep or impact on their own wellbeing. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that optimum levels of mobility and dexterity are achieved for all residents. Staff provide care that promotes residents mobility and dexterity. Assessment of each resident s mobility and dexterity needs occurs upon entry to the home and the provision of mobility aids is available if needed. Physiotherapy services are utilised to assess all residents mobility and dexterity and reviews occur regularly. Assistive devices such as those for eating are available and their use promoted. Observations by the team and confirmation by staff indicate adequate mobility and dexterity aids to cater for residents needs. In-bed mobility aids such as bed poles are used to give residents independence in moving in and out of bed if the residents are deemed safe to use them. The physiotherapist assesses and reviews the safety and appropriateness of these aids for each one used. Residents report that staff support their mobility and dexterity if needed and help them to maintain their independence in this area with the assistance of aids if required. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 15
2.15 Oral and dental care This expected outcome requires that residents oral and dental health is maintained. Staff assistance ensures the maintenance of optimal oral and dental health for residents. Assessments for oral and dental needs and preferences occur on entry and development of plans of care occur around these assessed needs. Staff consider the assistance required for daily care of teeth, mouth and dentures as appropriate. Referral to attend dentists and dental technicians occurs as required and staff assistance to attend outside appointments is available for residents if needed. Staff assist and prompt residents with daily dental hygiene and observe and document any relevant dental issues. During the palliative phase, staff ensure the provision of extra oral and dental assistance. Formulation of specific management strategies for residents with swallowing difficulties occurs and may include the provision of texture modified diets and staff assistance with meals. Residents confirm staff provide assistance with their swallowing, oral and dental hygiene. 2.16 Sensory loss This expected outcome requires that residents sensory losses are identified and managed effectively. The home ensures the effective assessment and management of residents sensory losses across all five senses. Assessment for sensory deficits occur upon entry to the home and as changes in care needs require. The home helps residents to attend appointments with their own preferred provider if required. The home accesses specialist providers for such things as hearing and vision assessments. Staff assist residents with their sensory aids including hearing aids and glasses. The home is uncluttered, has good lighting, adequate handrails, large print books and accessible signage. Staff are aware of individual needs and assist residents who require help with care, maintenance, fitting and cleaning of aids and devices. Residents state staff assist with their sensory loss needs. 2.17 Sleep This expected outcome requires that residents are able to achieve natural sleep patterns. Staff ensure residents sleep management occurs in a natural and non-invasive way. Staff assess normal sleep and wake patterns for the individual residents on entry to the home and supports these as much as practically possible through the care planning process. The home use a variety of methods to promote sleep and consults with medical practitioners if medication is required. Review of documentation confirms staff respect residents wishes regarding sleep. Residents state the home is quiet at night, staff respect their preferred wake and sleep times where practical and they generally sleep well. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 16
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. Refer to expected outcome 1.1 Continuous improvement for information regarding the home s continuous improvement system and processes. Examples of improvement initiatives implemented in relation to Standard 3 Resident lifestyle include: Residents indicated they would like more choice in the hairdressing services provided to them. As a result, management organised for residents to have their own individual hairdresser provide hairdressing services if a resident desires. Management said there has been positive feedback from residents who enjoy having this choice. Residents requested a personal computer course. The home organised for interested residents to attend a course locally. Management said those residents who have completed the course to date have given positive feedback as they enjoy contacting friends and relatives through electronic mail and other computer applications. Management identified the need to improve the system of menu selection for residents in the secure area of the home. Management said there has been positive feedback from residents who feel more actively involved in their selection of menu. 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. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home s regulatory compliance system and processes. Examples of regulatory compliance in the home in relation to Standard 3 Resident lifestyle include: Management has policies and procedures concerning elder abuse and compulsory reporting and maintain a register folder. Policies and procedures comply with privacy legislation to ensure the security and privacy of confidential information. Management give residents and their representatives information on resident rights and responsibilities, services provided and the complaints scheme on entry to the home. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 17
3.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. Please refer to expected outcome 1.3 Education and staff development for information about the home s education and staff development systems and processes. Education conducted relating to Standard 3 Resident lifestyle includes: The new resident transitioning to care: a new way of life Cultural diversity in ageing Advocating for clients Seniors rights. 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". There is a system to ensure each resident receives emotional support adjusting to life in the home and on an ongoing basis. Prior to entry to the home, management give residents and their representatives information regarding the entry process, explain services and provide a tour with introductions to staff and other residents as possible. Lifestyle staff assist care staff in offering support to residents adjusting to the new environment. Management and staff encourage representatives to participate in the home initially and on an ongoing basis. Staff complete an assessment and care plan which includes emotional needs of residents and review these regularly. The lifestyle program provides individual time with residents with an aim to maintain personal interests where possible. Residents personalise their rooms as they wish. Residents and their representatives said they were satisfied with emotional support for residents. 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". Management and staff encourage residents to achieve maximum independence and maintain community ties. Lifestyle care plans identify residents needs to participate in specific interests, maintain their independence and retain ongoing community and social associations. Interviews, documentation review and observations confirm the fostering of residents independence. Management and staff encourage and support residents to maintain contact with friends and family as well as participate in activities in the community. Residents personalise their rooms as they wish. Residents said staff assist them to be as independent as possible. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 18
3.6 Privacy and dignity This expected outcome requires that "each resident s right to privacy, dignity and confidentiality is recognised and respected". Management and staff recognise and respect each resident s privacy, dignity and confidentiality. There is a privacy policy and resident information is securely and appropriately stored. Residents have lockable drawers to store private items as they wish. Quiet areas are available for residents to meet privately with visitors. Staff assist residents in a respectful manner when attending to activities of daily living. Residents and/or their representatives sign various consent forms as required. Staff said they were aware of respecting each resident s privacy and dignity including knocking on doors prior to entering resident rooms. Residents said staff treat them with dignity and respect. 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". Management and staff encourage and support residents to participate in a range of activities both in groups and on an individual basis. Lifestyle staff complete an assessment in consultation with each resident and their representative to identify such information as each resident s social, leisure and recreational preferences. This assessment forms the basis of the care plan which undergoes regular review. Lifestyle staff plan daily activity programs in both groups and individual settings and offer a range of activities including the celebration of special occasions. The home s volunteers assist lifestyle staff with activity programs on a regular basis. Lifestyle staff evaluate and redesign programs as necessary based on resident feedback and participation. Information from resident meetings and surveys also assists lifestyle staff in planning programs. Residents said they are satisfied with leisure interests and activities offered in the home. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Management and staff ensure residents individual customs, beliefs and cultural backgrounds are fostered and valued. Lifestyle assessments and care plans document cultural and spiritual needs. There are regular church and communion services and fellowship groups with an area dedicated for any individual religious or cultural needs. Management and staff ensure the celebration of cultural and significant days. Staff have access to services specific to cultural sensitivities. Residents said they are satisfied with cultural and spiritual life in the home. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 19
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". Management and staff promote and support residents to exercise choice and decision making over his or her lifestyle while not infringing on the rights of others. Residents have input into the services they receive such as preferred rising and settling times, dining preferences, level of participation in activities and preferred title and name. Management encourages residents and their representatives to provide feedback about care and services through meetings, surveys and consultation. Staff encourage residents to make their own decisions. Residents said they are satisfied with the opportunities provided to them to make their own choices. Residents said other residents in the home do not infringe on their rights. 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". Residents have secure tenure within the home and there are processes to ensure they understand their rights and responsibilities. The home communicates information about security of tenure, residents rights and responsibilities, specified care and services and independent complaint mechanisms through the resident information pack, resident agreement and via brochures and posters on display within the home. Management discuss these topics with residents and representatives on entry. A process of consultation and agreement precedes a change in a resident s room. Residents and representatives are satisfied with the security of resident tenure. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 20
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. Refer to expected outcome 1.1 Continuous improvement for information regarding the home s continuous improvement systems and processes. Examples of improvement initiatives implemented by the home in relation to Standard 4 Physical environment and safe systems include: Residents suggested the outdoor designated smoking area needed improvement to make the area brighter and more accessible. Management organised for the installation of another light as well as the placement of a door bell to alert staff residents required assistance to access the area. Management said feedback has been positive. Management identified the need to improve security in the home and organised for the installation of a closed circuit television camera. Management said there has been positive feedback from staff who feel this has improved the home s security. Through an audit management recognised the need to improve the maintenance system in the home and are in the process of converting from a paper based to a computerised system. Management said although in the early stages, to date feedback from staff has been positive as the system is easy to use with the ability to send any request through to the maintenance department in an improved and timely manner. A resident suggested an indoor garden in the home could be improved by converting it to a sitting room. Following a donation, management organised for the conversion and a sitting room with curved walls, appropriate seating and a television now replaces the old garden. We observed a quilt wall hanging and management said a local community group provides various quilts to display as required. Residents and staff interviewed said they are pleased with the new area and residents and their representatives enjoy the extra space for visiting. 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. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home s regulatory compliance system and processes. Examples of regulatory compliance in the home in relation to Standard 4 Physical environment and safe systems include: Management has processes to provide a safe working environment to meet regulatory requirements. There is a system to demonstrate compliance with fire safety regulations. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 21
There are infection control guidelines in the event of an outbreak. There is independent auditing of catering in compliance with food safety regulations. 4.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. Refer to expected outcome 1.3 Education and staff development for information about the home s education and staff development systems and processes. Education conducted relating to Standard 4 Physical environment and safe systems includes: Chemical handling Fire and emergency training Food safety Infection control No lift training. 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". Management at the home is actively working to provide a safe and comfortable environment consistent with residents care needs. Residents have individual rooms with private or shared bathrooms with individually controlled heating. There is safe access to clean, comfortable and well-maintained communal, private, dining and outdoor areas with sufficient and appropriate furniture. Management and relevant staff monitor the safety of the facility including preventative and routine building and equipment maintenance. Management monitors comfort and safety in the home through regular audits and inspection tours. Staff help to make the residents safe and comfortable through ensuring access to items such as call bells and mobility aids. Residents said they feel safe and comfortable in the home. 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". Management is actively working to provide a safe working environment to meet regulatory requirements. Staff have input into the home s occupational health and safety system through meetings and reporting of any hazards. A dedicated committee meets regularly and occupational health and safety representatives have received appropriate training externally. Dates of re-accreditation audit: 21 May 2013 to 22 May 2013 Page 22