SITE AUDIT REPORT Name of home The Sydney-Lynne Quayle & Fitzroy Lodge Hostels RACS ID 3354 Executive summary This is the report of a site audit of The Sydney-Lynne Quayle & Fitzroy Lodge Hostels 3354 21 Barclay Street HEYWOOD VIC from 16 June 2010 to 17 June 2010 submitted to the Aged Care Standards and Accreditation Agency Ltd. Assessment team s recommendation regarding compliance The assessment team considers the information obtained through audit of the home indicates that the home complies with: 44 expected outcomes Assessment team s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit The Sydney-Lynne Quayle & Fitzroy Lodge Hostels. The assessment team recommends the period of accreditation be three years. Assessment team s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation. Dates of site audit: 16 June 2010 to 17 June 2010 Page 1
Site audit report Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 16 June 2010 to 17 June 2010 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team Team leader: Team member: Monica Sammon Fiona Taylor 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 site audit: Number of high care residents during site audit: Special needs catered for: 33 33 23 Secure dementia specific unit 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 site audit: 16 June 2010 to 17 June 2010 Page 2
Assessment team s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit The Sydney-Lynne Quayle & Fitzroy Lodge Hostels. The assessment team recommends the period of accreditation be three years. Assessment team s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation. Assessment team s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and the reasons for its recommendations are outlined below. Audit trail The assessment team spent two days on-site and gathered information from the following: Interviews Number Number Director of nursing 1 Residents/representatives 10 Registered nurses division one 2 Chief executive officer 1 Registered nurses division two 1 Nurse unit manager 1 Care staff 10 Pastoral representative 1 Administration assistant 1 Cleaning staff 1 Catering staff 2 Maintenance officer 1 Quality and safety manager 1 Domestic services supervisor 1 Clinical nurse educator 1 Physiotherapist 1 Continence liaison nurse/division one 1 Activities staff/physiotherapy assistants External infection control consultant Infection control liaison nurse/division two 2 1 1 Sampled documents Number Number Residents files 7 Medication charts 4 Care plans 7 Personnel files 8 External contracts 5 Resident agreements 4 Other documents reviewed The team also reviewed: Activities meeting minutes/surveys Activities planner Admission checklist Advanced care planning forms Aged care fees policy Dates of site audit: 16 June 2010 to 17 June 2010 Page 3
Allied health communication book Annual maintenance checklist Annual report Bed pole suitability assessment Blood glucose list Bowel charts Bristol stool form chart Building safety, security systems and risk management protocols Bushfire plan Care consultation with resident or representative Change of diet requests Change of dietary requirements Checklist of activities Church service notice/fellowship flyer Cleaners tick sheets and diary Cleaning and maintenance checklist of breathing apparatus Complaints register Compliments register Compulsory education staff matrix Consent to use/disclosure of information Continence communication book Daily refrigerator log Dangerous goods and hazardous substances register Diabetes management record Diabetic regime Dietary review meeting minutes District nursing call in document Documentation monthly sign off care plan Documentation monthly sign off sheet Education attendance sheet and records Education calendar 2010 Emergency lighting book and test register Emergency procedures competency Falls risk assessment tool Family function evaluation Fire log books First aid during seizure chart Fitzroy lodge breakfast list Fitzroy lodge diet and fluid consistencies Food charts Food safety supervisor s certificate Food temperature records Hazard register Health services referral and internal transfer form Incident reports Independent food safety certificate Infection control audits/data Infection control newsletter Infection control performance indicators 2010 Infection data and pathology Infection logs computer/hard copy Infection quality report Infection rates analysis Dates of site audit: 16 June 2010 to 17 June 2010 Page 4
Infection surveillance calendar 2010 Information package Internal audits Job descriptions Laundry shift duty list Leisure and recreation assessment Maintenance checklists Maintenance register Maintenance requisition book Maintenance standards guidelines Mandatory reporting folder Meal quality audit Medication refrigerator temperature check records Menu Menu forms Nurse education newsletter Nurses diary/communication diary Occupational health and safety audit outcome register Occupational workplace health and safety risk management manual for contractors One to one small group records Orientation checklist Orientation proforma Palliative care information pack Peg flush form Permanent and respite discharge check lists Policies and procedures Power of attorney documentation Product allocation chart Quality and safety meeting minutes Quality audit schedule Quality improvement plan post support contact visit Quality improvement system chart Quality indicators folder/data Records of staff upskilling Registered nurses practising certificates folder Registration of food premises Resident activity wish list Resident admission details Resident cat care plan, vaccinations/information Resident consent to influenza vaccinations Resident evacuation checklist Resident evacuation mobility list Resident of the day and general practitioner notification form Resident of the day list Residents information package and handbook Residents meeting minutes Return to work plan Safety inspection program and worksheet Schedule of essential services Social profile Spiritual and cultural needs document Staff activity outing responses Staff external education log Dates of site audit: 16 June 2010 to 17 June 2010 Page 5
Staff meeting minutes Staff memoranda Staff orientation manual Staff police check register Standing exercise plan Summary of education evaluation Summary of emergency procedures Summary of issues raised in survey Summary of residents dietary requests Tenancy agreements records Terminal care wishes assessment Test and tag register Trades contractors, medical contractors and volunteers police check registers Walking group flyer Weight records Workplace inspection audits Wound and skin management plan and evaluation Observations The team observed the following: Activities in progress Chemical storage Cleaners room, equipment, stores, signage chemical dispensers. Clinical and non clinical supplies Communication cue cards Community emergency storage area and supplies Continence resources Contractors sign in register Decontamination kit Education resources Emergency information and hazmat box Equipment and supply storage areas Exits External complaints posters and brochures Faulty equipment/do not use signage Feedback forms and signage Fire prevention and fighting equipment Food storage Hairdresser Heywood rural health organisation chart Interactions between staff and residents Kitchen Laundry Living environment Material safety data sheets Meal service and assistance to residents Medical supplies storage Medication and specimen refrigerators Medication storage/prepacked blister system Morning and afternoon tea Notice boards Overhead lifting equipment Oxygen storage and signage Dates of site audit: 16 June 2010 to 17 June 2010 Page 6
Personal protective equipment/hand washing areas/signage Philosophy and goals displayed Policies and procedures online review system Resident cat Residents bedrooms and bathrooms Residents smoking area Schedule eight medication storage and register Staff room Suggestion boxes Thermal trays Training facilities Tray trolleys Visitors condition entry chart Wound trolley Dates of site audit: 16 June 2010 to 17 June 2010 Page 7
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 system of continuous improvement that is informed by opportunity to improve forms submitted by staff, residents and their representatives; by survey results, comments and complaints, incident analysis, internal and external audit results, verbal feedback and observation, government directives and best practice information. Residents, representatives and staff confirm that management are proactive in pursuing improvement and are responsive to feedback. Each identified issue is registered, responsibility delegated, actions documented and outcomes identified. Continuous improvement is monitored monthly by senior management and improvements are communicated via staff meetings and memorandum, residents meetings and direct verbal or written feedback. Recent improvements in relation to management systems, staffing and organisational development include the following: A function was held to ensure that residents representatives are fully informed about actions being taken in response to survey results and to give them an opportunity to ask further questions. An education session on food consistencies and their indications for use was also incorporated. Representatives stated that the information evening was most helpful. An audit identified that staff knowledge in the use of the electronic care planning system was inadequate. Targeted small group education in the use of the online information systems has resulted in improved use by staff and improved access to appropriate online information. To ensure that all staff are aware of the feedback from residents and representatives and to emphasise the requirement for high customer service standards by care staff, the survey results have been discussed with staff during meetings and during appraisals. Evaluation of staff approach is ongoing. The chief executive officer and administration assistant are compiling all resident files and information into one folder for easy access and review of relevant documentation and to maintain safe and secure storage. As part of the resident of the day schedule, a form has been developed and implemented which provides valuable timely information to the resident s medical practitioner, especially in regards to ongoing monitoring and evaluation of the resident s pain management. It includes a monthly snap shot of the resident s urinalysis, copy of medication chart, pain summary, observations, weight, concerns and comments. 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 has a system in place for identifying and ensuring compliance with relevant legislation, regulatory requirements and guidelines, professional standards and required changes to practice. Regulatory and legislative updates are available to management Dates of site audit: 16 June 2010 to 17 June 2010 Page 8
personnel via subscription to an online legislative compliance system, government information and subscription to peak and professional bodies. Changes to policies and procedures are implemented in response to legislative changes and professional standards and supported by subscription to a web based policy resource system. Staff confirm they are appropriately informed via orientation, education, memoranda and staff meetings and compliance is monitored via the home s auditing systems, competencies and direct observation. Residents and their representatives were informed about the accreditation audit and there is a system in place to monitor the criminal record checks of all relevant staff and contractors and the current registration of all registered nurses. 1.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has processes in place to ensure that management and staff have the necessary skills and knowledge to perform their roles effectively and for their ongoing performance to be monitored. The director of nursing and quality manager participate in networking groups and all staff have access to an extensive education program delivered via audiovisual resources, internal presenters, expert consultants, professional and peak bodies. Training needs are determined by staff appraisals, direct feedback, complaints, incidents and education evaluation. Staff participation is closely monitored and education sessions are evaluated and reviewed. Staff have job descriptions and skills are monitored by direct observation, competencies, appraisals and the internal audit system. A training room, library and relevant resources are available and staff confirm they are actively encouraged and supported to further their qualifications and to attend external educational opportunities. Education sessions relevant to management systems during 2010 include quality systems; strategic direction; online documentation system; litigation; incident investigation and reporting; teamwork and managing conflict; care planning and documentation; certificate three and four in aged care for selected staff and diploma of management for selected staff 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". The home has formal and informal complaint mechanisms throughout the home that are accessible to residents, representatives, staff and visitors. Information about complaint mechanisms is communicated via the residents meetings, the resident information book and via the signage, brochures and opportunity to improve forms displayed in the home. Residents and their representatives have been surveyed and the results acted upon. Residents and their representatives confirm they feel comfortable to speak at the meetings or to approach management with any concerns they have. Complaints are documented and responded to appropriately and staff are aware of the mechanisms to assist residents or relatives with making comments or complaints. Dates of site audit: 16 June 2010 to 17 June 2010 Page 9
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 organisation has documented and displayed their philosophy and goals throughout the home. The philosophy, goals and quality systems are documented in the resident information handbook and the staff orientation handbook includes information on the quality systems used at the home. The organisation documents its commitment to its philosophy, goals and quality in the annual report and all meetings terms of reference address quality issues. 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 home has systems in place to ensure that there are appropriately skilled and sufficient staff employed for delivery of high quality care to residents. Staff have job descriptions, are appropriately supervised and educated and undergo annual appraisals. Recruitment and rostering responds to resident needs and external specialist services are available including physiotherapy, dietetics, speech pathology, wound consultancy and mental health teams amongst others. Casual staff are available and all staff undergo orientation. Records of interview and referee checks, qualifications, education, professional registration and police record checks are maintained. Staff skills are monitored via competencies, the audit system, direct observation and feedback from all stakeholders. Residents and their representatives are satisfied with the skills and standard of care and attention given. Staff state management is supportive of staff and confirm they are encouraged to maintain and upgrade their skills. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Staff in all areas of the home confirm that the home has appropriate levels of supplies and equipment, and residents and their relatives state that adequate goods and equipment are provided and maintained in good condition for their care. Staff can request new equipment, participate in trials when indicated and confirm they are educated in equipment use and work procedures. There are systems in place for ordering, storage and rotation of goods and supplies. Equipment used by both staff and residents is cleaned and well maintained via monitored preventative and reactive maintenance systems, and staff state that maintenance requests are actioned promptly. Dates of site audit: 16 June 2010 to 17 June 2010 Page 10
1.8 Information systems This expected outcome requires that "effective information management systems are in place". All stakeholders as appropriate have access to current information on the processes and general activities of the home. Information is disseminated via staff meetings, resident meetings, noticeboards, education, staff memorandums and newsletters and care consultations. Relevant information handbooks are distributed to residents and/or their representatives and to staff. Key clinical data is collected, analysed and reported, and staff have access to accurate information to provide appropriate clinical care and services to residents via residents files and care plans, handover, specialised care folders, communication books, position descriptions and policies and procedures, which are reviewed according to need and predetermined review dates. Online information is password protected, and confidential documents are stored securely, accessed only by appropriate staff and disposed of securely. Residents and their representatives confirm that information is available to them and staff confirm that relevant appropriate information is accessible. 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". External providers provide services according to the needs of the residents and the necessary goods required for health and hospitality provisions. Relevant management personnel negotiate and actively review the contracts, based on feedback from the home s management team and staff and according to the performance of the contractor in the provision of quality service. Residents are also able to provide feedback via the home s feedback mechanisms. Contractors sign written agreements, register their presence in the home and those who have unsupervised access to residents are required to have a current criminal record check. Non-medical contractors undergo induction and are required to comply with work safety standards. Management, staff and residents state that they are satisfied with the systems in place to manage the services provided by external contractors. Dates of site audit: 16 June 2010 to 17 June 2010 Page 11
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. The home has a system of continuous improvement which is informed by multiple mechanisms and links to resident, representative and staff feedback. For further information see Expected outcome 1.1 Continuous improvement. Recent improvements in relation to health and personal care include the following: A second camera has been purchased and located in the medication room to ensure that residents photographs on the medication charts can be updated as the need arises. To ensure that the administration of nutritional supplements is signed for, the system has been revised. The dietician now orders the supplements and the record of administration is kept in the kitchenettes rather than the medication charts. In response to a medication incident where the dinner medication was administered at the wrong time, the medication blister packs are now marked as breakfast, lunch and tea. A walking group has commenced once per week to assist with maintenance of residents mobility and enhance their lifestyle activities. In response to relative feedback, a new pain pathway which involves planning and education and an information pack for families has been implemented. A new regional group has been created. Staff have received extensive mandatory education and two palliative care link nurses have been linked to the wider services. The speech pathologist, dietician and social worker have been working closely with residents with swallowing difficulties and weight loss. Residents and their families have been supported with ongoing one on one visits from the specialists and extensive education, training, and resources for staff. Residents and representatives state that demonstrations and discussion has allayed their fears and concerns regarding the presentations and taste of textured modified food. The social worker has provided emotional support to residents and their families in relation to advance planning and future medical care. The outcome has been very positive for residents, stating they feel safe and informed of their choices and wishes. Staff state they feel confident and supported in caring for residents with swallowing and eating difficulties and relating to their families. 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. The home has a system in place for identifying and ensuring compliance with relevant legislation, regulatory requirements and guidelines, professional standards and required changes to practice. For further details see Expected outcome 1.2 Regulatory compliance. The home complies with medication management regulations and guidelines, and a division one registered nurse oversees the care of all high care residents and specialised nursing care procedures. Information on best practice in relation to resident care is accessed by Dates of site audit: 16 June 2010 to 17 June 2010 Page 12
clinical management and the clinical nurse educators and the implementation of policy and procedure changes is monitored by internal audits, competencies and direct observation of staff practices. 2.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has processes in place to ensure that management and staff have the necessary skills and knowledge to perform their roles effectively and for their ongoing performance to be monitored. For further details see Expected outcome 1.3 Education and staff development. Education sessions relevant to health and personal care available in 2010 include urinary continence management; wound management; snake bite; blood taking; motor neurone disease; assessment; clinical skills; cardiopulmonary resuscitation; oral health; challenging behaviours; sensory loss; diabetes management; Parkinson s disease; medication management; pressure care cushions; bowel management; depression in the elderly; ulcers; pain management and palliative care. 2.4 Clinical care This expected outcome requires that residents receive appropriate clinical care. The home demonstrates that residents receive appropriate clinical care. On entry to the home residents clinical care needs are discussed, assessed and documented initially on an interim care plan. Comprehensive assessments are conducted over a twenty eight day period, information is transferred to the computer software system and a care plan is developed and available for staff on computer and hard copy. Residents have a complete review as part of the monthly resident of the day schedule, a summary of the month is provided to the medical practitioner and consultation occurs with the resident and or representatives. Residents care needs are overseen by the director of nursing, nurse unit manager and registered division one nurses. Changes are updated and a new care plan printed and communicated to staff. The clinical services committee which involves the home s management, medical and allied health practitioners reviews residents of concern at fortnightly meetings. Staff confirm they are updated of changes, are well supported in their roles and are provided education. Residents and representatives are happy with the care residents receive according to their needs and preferences. 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. The home demonstrates residents specialised nursing needs are identified and met by appropriately qualified nursing staff. Residents specific nursing care needs are identified through the initial assessment process and care plans are individualised to meet the residents specialised needs. Care plans are reviewed as part of the resident of the day schedule and residents and representatives are consulted in regards to current and ongoing care and concerns. The medical practitioners are informed monthly of the residents care review and referrals are made to allied health specialists as required. Specialised care needs include insulin and non insulin diabetics, pain management, swallowing difficulties and Dates of site audit: 16 June 2010 to 17 June 2010 Page 13
catheter care. Clinical portfolios and specialised dietary, palliative and pain committees review residents ongoing needs and concerns, implement changes and support staff through education and training. Residents and representatives are satisfied with the specialised care residents 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. The home demonstrates that residents are referred to appropriate health specialists in accordance with each resident s needs and preferences. Prior to entering the home residents and their families are provided with information regarding the visiting allied health services. Residents are comprehensively assessed, specialised care needs are identified and individualised care plans are developed. The organisation provides primary care health in the surrounding rural communities and therefore the home has access to regular services of primary health care staff such as a dietician, speech pathologist, social worker, physical instructor and occupational therapist. The physiotherapist and podiatrist regularly visit and referrals are made to allied health practitioners in accordance with the resident s assessed needs and preferences and the residents are seen in a timely manner. Residents and representatives confirmed residents are referred to appropriate specialists as required. 2.7 Medication management This expected outcome requires that residents medication is managed safely and correctly. The home demonstrates that medication is stored and managed safely and correctly. Residents medication requirements are discussed, assessed and documented on entry to the home in consultation with the resident, representatives and medical practitioner. Medications are administered from a blister pack by registered nurses, division one and medication endorsed registered nurses, division two and by the personal care workers. All undertake annual competency assessments. The residents medical practitioner reviews their medications regularly. Medication audits and external pharmacy reviews and audits are conducted regularly. Medication incidents are documented, reviewed by relevant committees and the clinical educator and actioned as appropriate. Staff confirm they have annual competencies, attend education in medication management and have access to online medication resources. Residents and representatives are satisfied that residents medications are managed safely and correctly. 2.8 Pain management This expected outcome requires that all residents are as free as possible from pain. The home demonstrates that all residents are as free as possible from pain. On entry to the home, the resident s pain is assessed by qualified staff who identify their ability to communicate pain, the type, triggers, location, duration and severity of the pain experienced. Care plans document the resident s pain management needs and strategies as discussed with the resident, their families, staff and medical practitioner. Staff administer regular pain medication as ordered by the medical practitioner and monitor the response through observation of the resident s verbal and non verbal responses. A monthly summary of the resident s pain and medications required is provided to the medical practitioner and complex Dates of site audit: 16 June 2010 to 17 June 2010 Page 14
pain issues are referred to the external palliative and pain management services. Staff confirm they receive education in regards to effective pain management strategies and assist residents with position changes and massage. Residents and representatives confirm they are satisfied with how pain is managed. 2.9 Palliative care This expected outcome requires that the comfort and dignity of terminally ill residents is maintained. The home demonstrates that the comfort and dignity of terminally ill residents is maintained. On entry to the home residents terminal care wishes are discussed with the resident, and/or representatives and documented. Terminal care wishes are reviewed regularly as part of the resident of the day schedule and a palliative care management plan is implemented as required. The social worker and pastoral services are available for emotional support and discussion with residents, their families and staff. In response to a palliative care review, the organisation developed the pain and palliative care committee, provided education to staff and arranged placement of staff at other palliative care units, resulting in the provision of holistic care to residents and their families. Pain management is closely monitored and reviewed by the registered nurse and medial practitioner. Resources and support are sourced through the external palliative care services. Staff confirm they have received valuable education in regards to pain and palliative management and provide emotional support to residents and their families at the time. 2.10 Nutrition and hydration This expected outcome requires that residents receive adequate nourishment and hydration. The home demonstrates that residents receive adequate nutrition and hydration. On entry to the home each resident has a food and fluid assessment which identifies food preferences, eating and drinking habits, meal sizes, likes and dislikes, special diets and cultural needs. Residents nutrition and hydration is regularly reviewed through the dietary committee and weights are monitored monthly or more frequently if there are concerns. Clear pathways guide staff in the ongoing management for loss and gain of weight. The dietician and speech pathologist work within the organisation and regularly visit residents in the home and provide extensive support and education for residents, their families and staff. Catering staff ask residents daily of their meal choices and changes to residents dietary requirements are communicated though handover and change of diet form. Residents receive nutritional supplements, textured diets and thickened fluids as appropriate and special cutlery and crockery promote resident independence. Staff confirm they receive support from the registered division one nurse who has completed dysphasia training and education in assisting residents with swallowing difficulties. Residents and representatives confirm they are satisfied with the home s approach to meeting residents nutrition and hydration needs. Dates of site audit: 16 June 2010 to 17 June 2010 Page 15
2.11 Skin care This expected outcome requires that residents skin integrity is consistent with their general health. Residents skin integrity is consistent with their general health. On entry to the home residents skin integrity is assessed and a care plan is developed that documents specific management and prevention strategies such as hygiene times and preferences, pressure relieving mattresses, sheep skins and foam wedges. Care plans are reviewed regularly. Wound management is attended according to the skin management plan devised by the registered and district nurses who have wound care qualifications. The organisation is supported by a newly formed regional wound committee and wound consultant. Alterations to residents skin integrity are recorded on incident reports and reviewed regularly. Complex wounds are photographed and appropriate nutritional supplements are implemented. Staff confirm they attend ongoing manual handling training and lifting equipment is well maintained. Residents and representatives confirmed they are satisfied with the skin care provided. 2.12 Continence management This expected outcome requires that residents continence is managed effectively. The home demonstrates practices in continence management are effective in meeting residents needs. Residents continence management and requirements are discussed, assessed and documented on entry to the home. Care plans detail the resident s continence needs such as independence or level of assistance, routines, special dietary and fluid intake, natural stimulants, type of continence aids, voiding times and bowel habits and are reviewed regularly for their effectiveness. Residents continence care is overseen by the continence nurse who consults regularly with the visiting regional continence consultant and continence aid supplier and provides ongoing education to staff. Staff confirm ongoing education and support has increased their awareness in continence management. Residents and representatives stated that residents continence issues are met discreetly and residents dignity is maintained. 2.13 Behavioural management This expected outcome requires that the needs of residents with challenging behaviours are managed effectively. The home has strategies and processes in place to assess, manage and review residents with challenging behaviours. The organisation s management team regularly discuss potential residents entering the home to ensure that appropriate care, safety and services can be provided for all individuals. Residents are comprehensively assessed in consultation with the resident, representatives, medical practitioners and allied health specialists to identify specific behaviours, triggers and strategies. Individualised care plans are developed and reviewed regularly to ensure management and strategies are effective and referrals are made to appropriate allied health specialists as required. Behaviour incidents are recorded on the online incident recording system, reviewed and actioned as appropriate. Staff are trained in undertaking and managing residents individual behaviours with respect and privacy. Residents and representatives are satisfied with the home s approach in managing challenging behaviours. Dates of site audit: 16 June 2010 to 17 June 2010 Page 16
2.14 Mobility, dexterity and rehabilitation This expected outcome requires that optimum levels of mobility and dexterity are achieved for all residents. The home demonstrates that optimum levels of mobility and dexterity are achieved for all residents. Residents are assessed on entry, plus the physiotherapist assesses to identify mobility, dexterity and rehabilitation needs. Care plans and exercise programs are developed in consultation with the resident, representatives, medical practitioner and allied health services to ensure appropriate care and assistive devices are in place. The physiotherapist visits the home twice a week for ongoing resident review, after falls and as care needs change and ensures residents have appropriate aids and assistive devices such as wheeled walkers, motorised wheel chairs, footwear, cutlery and floor line beds. The physiotherapy assistants help residents with their individual exercises and offer regular group exercises and activities that promote flexibility, strength and range of movement. The home is well lit, handrails and regular environmental checks ensure safe mobility for residents. Staff awareness of resident related falls and the use of appropriate aids has been increased through the falls prevention program. Residents and representatives are satisfied with the home s approach to optimising residents mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that residents oral and dental health is maintained. The home demonstrates residents oral and dental health is maintained. On entry to the home residents oral and dental hygiene needs and preferences are identified by the oral and dental assessment which includes state of teeth and dentures, routines, condition of lips, gums and tongue. Care plans detail residents individual needs and specific care to maintain optimum oral and dental hygiene and are reviewed regularly as part of the resident of the day. Residents dentures are labelled with permission, storage containers and teeth cleaning products are provided. Residents have access to a visiting dental technician and are assisted to appointments with dentists of their choice as required. Residents are encouraged to attend to their own oral and dental care and staff prompt and assist as required. The clinical educator and a personal care worker have recently completed an oral and dental training course, staff have been provided information and training of staff is planned in promoting oral and dental care in all residents. Staff confirm the dysphasia nurse provides ongoing support and guidance with residents care needs. Residents and representatives are satisfied with the way residents oral and dental care is managed. 2.16 Sensory loss This expected outcome requires that residents sensory losses are identified and managed effectively. The home demonstrates that residents sensory losses are identified and managed effectively. On entry to the home residents are assessed for their sensory abilities and aids required and care plans are developed to reflect these needs and strategies implemented to promote sensory stimulation. Residents with identified sensory losses have tailored activities that promote touch, taste and smell through massage and walks in gardens. Residents have access to hearing and auditory services, are assisted to appointments as required and have access to specialised resources such as large print and talking books. Staff are supported by Dates of site audit: 16 June 2010 to 17 June 2010 Page 17
a trained audiometry health care staff member within the facility and referrals are made as appropriate to allied health services such as audiologist, optometrist, occupational therapist and speech pathologist. Staff assist and attend regular maintenance of hearing and visual devices. The home is well lit, attention to floor surfaces and handrails and regular environmental checks ensure safe mobility for residents. Residents and representatives are satisfied with the home s approach to managing residents sensory losses. 2.17 Sleep This expected outcome requires that residents are able to achieve natural sleep patterns. The home demonstrates that its practices enable residents to achieve natural sleep patterns. On entry to the home an initial assessment of the resident s normal sleep and rest patterns are conducted in consultation with the resident and representatives. Care plans are developed to document residents sleep patterns and aids that are required to enhance their sleep such as rising and settling times, warm drinks, bedding, massage and aromatherapy. Sleep patterns are reviewed regularly and the medical practitioner is notified if interventions are not effective. Medications are provided for sleep disturbances and pain management is assessed by the medical practitioner and monitored by nursing staff for their effectiveness. Staff are educated in the importance of maintaining a safe and quiet environment and assist residents with their continence management as required overnight. Residents and representatives confirmed that residents are able to achieve natural sleep patterns. Dates of site audit: 16 June 2010 to 17 June 2010 Page 18
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. The home has a system of continuous improvement which is informed by multiple mechanisms and links to resident, representative and staff feedback. For further information see Expected outcome 1.1 Continuous improvement. Recent improvements in relation to residents lifestyle include the following: In response to the survey results, residents have been asked to state what they would like to see included in the lifestyle program. A residents wish list has been developed and some have been implemented with others planned. To improve the options available in the lifestyle program and to increase the residents contact with the outside community, some staff have volunteered to assist and residents have been provided with improved opportunities. For example, going to the football with staff members. In response to a suggestion, the home has purchased an electronic game involving movement. The use of this is incorporated into the activity program and increases the range of activities available as well as encouraging mobility. 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. The home has a system in place for identifying and ensuring compliance with relevant legislation, regulatory requirements and guidelines, professional standards and required changes to practice. For further details see Expected outcome 1.2 Regulatory compliance. Residents and relatives are provided with a resident agreement and an information book which details information relating to their security of tenure, internal and external complaints mechanisms, rights and responsibilities and privacy information. Staff confirm they receive information related to privacy, elder abuse, absconding residents, mandatory reporting responsibilities and residents rights during their orientation, the education program and during work appraisals. 3.3 Education and staff development This expected outcome requires that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has processes in place to ensure that management and staff have the necessary skills and knowledge to perform their roles effectively and for their ongoing performance to be monitored. For further details see Expected outcome 1.3 Education and staff development. Three staff are studying a certificate in leisure and lifestyle and education Dates of site audit: 16 June 2010 to 17 June 2010 Page 19
sessions relevant to resident lifestyle include a cross cultural training day specific to indigenous culture; person centred care and elder abuse; 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". The home has systems in place to identify and address residents emotional needs on entry to the home and ongoing. Prospective residents, families or representatives meet with the Director of Nursing and nurse unit manager to discuss the care and services provided, a tour is conducted and a tailored information package is given. Initial assessment of prospective residents ensures that the home can provide the level of care that the resident requires. Residents emotional needs are identified through discussion with the resident, their family or representative, clinical and lifestyle assessments and social profile information. Care plans are developed that recognise the resident s holistic, cultural, spiritual and emotional needs and are reviewed regularly as part of the resident of the day. All staff are involved in supporting residents in the transition to residential care, on a day to day basis and during an acute crisis. Residents and their families are offered the support of the social worker and pastoral services and referrals are made to the aged care mental health team. The effectiveness of support provided to residents is assessed through mechanisms such as satisfaction surveys, comments and complaints and verbal feedback from residents and representatives. Residents and representatives indicated satisfaction with the home s provision of initial and ongoing emotional support. 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". Residents are assisted to achieve maximum independence and to maintain their friendships and links with their communities. On entry to the home, discussion and assessments in consultation with the resident and representative identify the resident s level of independence. Care plans are developed and reviewed regularly to ensure the resident s independence needs and preferences are encouraged and maximised. Strategies to promote independence include use of appropriate mobility aids and assistive devices, voting rights, large print and talking books and managing their financial affairs. Residents are encouraged to maintain their friendships and links in the community with shopping trips, visits from local schools, country women s groups and internet communication with families. Residents and representatives are satisfied residents independence is supported. 3.6 Privacy and dignity This expected outcome requires that "each resident s right to privacy, dignity and confidentiality is recognised and respected". Each resident s right to privacy, dignity and confidentiality is recognised and respected. Residents are all accommodated in single rooms with their own en suites or a shared bathroom. Staff were observed using the residents preferred names, rooms are personalised Dates of site audit: 16 June 2010 to 17 June 2010 Page 20
and small private spaces are available for residents to spend quiet time with family and friends. Residents information is stored securely and staff have levels of password access to the computer data and adhere to the confidentiality policy. Residents right to privacy is discussed on entry to the home and consent forms are signed for release of personal information, use of photographs and names on their doors. Staff state they assist residents with their care in a private and respectful manner. Residents and representatives are satisfied their privacy, dignity and confidentiality is recognised and respected. 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". Residents are encouraged and supported to participate in a wide range of interests and activities of interest to them. On entry to the home a detailed social profile, leisure, spiritual, cultural and lifestyle assessments are completed in consultation with the resident and representatives and a care plan is developed to reflect these needs. Resident of the day review and care plan evaluations ensure the accuracy and currency of information and residents are involved in evaluating lifestyle opportunities through satisfaction surveys, resident meetings and suggestions. Feedback from a recent satisfaction survey has made positive changes to the lifestyle program such as a wish list, more variety of activities and internet communication with families. The activities program includes one on one time and group activities and is tailored to residents abilities. The program includes exercises, outings tailored to individuals such as speedway, fishing and football, shopping trips, entertainers, school group s, luncheons, games and craft. The home has a number of dedicated volunteers that assist with the program, spend one on one time with residents and help with shopping, outings and attending appointments. Residents are aware of the activities program and the community program in adjoining hospital and have a choice of involvement and attendance. Participation records are kept. Residents and representatives are satisfied with the range of activities and interests provided. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". The home has processes that ensure the identification and communication of the individual interests, beliefs and cultural and spiritual needs of each resident. The organisation has a cultural diversity plan which is discussed at the compulsory training day and by the quality and safety committee. An interpreter service and resources are available for staff if indicated. The home has a dedicated room for resident s religious and cultural needs and an ecumenical service is held weekly and Sunday visits occur by the Salvation Army. Residents are assisted to participate in their local church community and pastoral visits and support are available to residents and their families as requested. National and culturally specific days are celebrated such as Australia Day, ANZAC Day, Christmas, Easter, Chinese New Year, NADOC and grand final football are celebrated. Days of significance are celebrated such as birthdays and anniversaries according to the resident s wishes. There is a system in place to identify residents specific cultural diets. Residents and representatives are satisfied that residents cultural and spiritual needs are met. Dates of site audit: 16 June 2010 to 17 June 2010 Page 21