Published_decision_(SA_and_RA) Web viewAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 29 August 2017 to 30 August 2017. ... temperature

Chesalon Care RichmondRACS ID: 0540

Approved provider: Anglican Community Services

Home address: 133 Londonderry Road RICHMOND NSW 2753

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 20 November 2020.

We made our decision on 29 September 2017.

The audit was conducted on 29 August 2017 to 30 August 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep MetHome name: Chesalon Care Richmond Date/s of audit: 29 August 2017 to 30 August 2017RACS ID: 0540 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

Home name: Chesalon Care Richmond Date/s of audit: 29 August 2017 to 30 August 2017RACS ID: 0540 3

Audit ReportName of home: Chesalon Care Richmond

RACS ID: 0540

Approved provider: Anglican Community Services

IntroductionThis is the report of a Re-accreditation Audit from 29 August 2017 to 30 August 2017 submitted to the Quality Agency.

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

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

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

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

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 29 August 2017 to 30 August 2017.

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

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

Details of homeTotal number of allocated places: 60

Number of care recipients during audit: 56

Number of care recipients receiving high care during audit: 56

Special needs catered for: 12 Bed secure unit Ebenezer


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

Interviews

Position title Number

Care recipients 15

Representatives 4

Regional manager 1

Facility manager 1

Care manager 1

Registered nurses 2

Care staff 6

Lifestyle staff 2

Chaplain 1

Occupational therapist 1

Medical practitioners 2

Organisational palliative care clinical nurse specialist

1

Workplace trainer 1

Senior external contract services manager 1

Assistant building manager 1

Catering staff 3

Laundry staff 1

Cleaning staff 2

Maintenance staff 1

Sampled documents

Document type Number

Care recipient files (including assessments, progress notes, care and lifestyle plans and associated documentation)

9


Document type Number

Medication charts 10

Continuous improvement logs 15

Other documents reviewedThe team also reviewed:

Accident and incident reports

Behaviour management: Rhythm of Life behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, bed rail risk assessments

Care recipient leave register, visitor attendance register

Care recipients' information package, handbook and agreements

Cleaning schedules and work instructions

Clinical monitoring records: anticoagulant therapy, blood glucose levels, blood pressure, neurological observations, sight charts, pain, hygiene and pressure relief turning charts

Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care

Documentation guides

Education documentation: education calendars, education training attendance records, educational resource information, staff mandatory training requirements, staff competency assessment information, education and training reports

Fire safety and emergencies documentation: inspection records, annual fire safety certificate, emergency evacuation diagrams, emergency management and contingency plan folder, evacuation details of care recipients, emergency evacuation signage, emergency procedures guide flipcharts

Food safety: food safety program, food safety monitoring records, care recipients’ dietary requirements and food preference information and menu

Human resource management documentation: staff roster, employment engagement checklists, employee orientation and induction program, staff appraisal status register, staff handbook, staff induction handbooks, new employee induction checklists, position descriptions and duties lists

Infection control: surveillance data, infection control guidelines, influenza register care recipients and staff, outbreak management report and line listing data

Information system documentation: policies and procedures, flowcharts, meeting minutes, handover record, admission and information pack including resident information handbook, communication diaries, memorandum folders, notices, survey results, contact lists, organisational information

Lifestyle management: lifestyle past history ,”Key to Me’ leisure and spiritual assessments, activity calendars, activity plans, attendance records, activity evaluations, newsletters, consent forms

Maintenance documentation: preventative maintenance schedules, maintenance and approved supplier documentation, maintenance service reports and warm water


temperature check records, pest control reports, legionella species reports, maintenance request logs

Medication management: medication administration plans, signing sheets, PRN medication (whenever necessary) evaluations, clinical refrigerator temperature monitoring records, therapeutic monitoring guidelines and anti-coagulant therapy care plans, cytotoxic management, oxygen therapy care plans, medication incident reports, nurse initiated medication forms, Drugs of addiction register, complex health care directives diabetic management, professional signatures register

Mobility: mobility assessments, physiotherapy/occupational therapy care plans, individual exercise, massage, heat pack therapy attendance records

Nutrition and hydration: nutritional preferences assessments, weight monitoring records, dietitian reviews/management plans, nutrition and hydration list and supplements list

Pain management and palliative care: pain assessments, pain management plans, advanced care plan directives, palliative specialised nursing care plans

Quality management system: Vision, Mission and Values statements, audit schedules, audit results and reports, clinical indicator results, plans for continuous improvement, compliments, suggestions and complaints

Regulatory compliance documentation: incident management reporting system includes reportable incidents, staff criminal record check reporting system, NSW Food Authority Licence, professional registration records, electrical equipment inspection register and consent forms for the collection and handling of private information

Self-assessment report for reaccreditation and associated documentation

Skin integrity: wound assessments and management plans, photographic wound monitoring records, pressure care directives , podiatry assessments and reports

Work health and safety system documentation: incident and hazard reports, work health and safety documentation, safety data sheets, risk assessment documentation, workplace inspection checklists including work health and safety and maintenance aspects, site safety folder

ObservationsThe team observed the following:

Activities in progress and associated resources and notices

Care recipients utilising pressure relieving and hip and limb protection equipment

Dining environment during midday meal service and morning and afternoon teas including staff serving meals, supervision and assisting care recipients

Equipment and supplies storage

Fire panel, fire-fighting equipment, emergency exits, emergency evacuation diagrams, emergency response guide flipcharts, annual fire safety certificate

Infection control resources including hand washing facilities, hand sanitising gel, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, pest control and waste management systems

Interactions between staff ,care recipients and representatives

Internal and external complaint mechanisms and feedback processes, feedback form box

Living environment


Mobility equipment in use including mechanical lifters, walk belts, wheel chairs, shower chairs, low-low beds and hand rails in corridors

Information noticeboards: posters, notices, brochures and forms displayed for care recipients, representatives and staff

Nurse call system in operation

Re-accreditation audit notice on display.

Secure storage of care recipients' clinical files and confidential staff handover

Secure storage of medications and oxygen; medication administration

Short group observation in Ebenezer lounge

Sign in/out registers, internal key pad access

Staff work practices and work areas including administrative, clinical, lifestyle, catering, cleaning, laundry and maintenance

Vision, Mission and Philosophy statements and Charter of Care Recipients' Rights and Responsibilities displayed


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

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The home utilises a continuous improvement system which includes a quality management system and performance review mechanisms. Improvements are identified through a number of avenues including care recipient and representative meetings, staff meetings, audits, surveys, and review of clinical data. The home also utilises surveys, benchmarking, suggestions, incidents and staff performance appraisals. Part of this system includes ensuring compliance with the Accreditation Standards through the audit program. The home uses these indicators along with other input from stakeholders to identify opportunities for improvement and to develop improvement plans. Care recipients, representatives and staff reported they have opportunities and are encouraged to participate in the home’s continuous improvement activities.

Examples of recent improvements in relation to Accreditation Standard One include:

Management identified the need for appropriate skilled and qualified staff sufficient to ensure the home’s vision, mission and values are met. Consequently the home has recently appointed a clinical educator, workplace trainer and increased night shift staffing levels. Also the home has employed the services of a care manager primarily responsible for managing and supervising clinical care provided to care recipients. Management advised the above appointments will assist in the delivery of high quality care to care recipients.

Management identified the need for staff to have appropriate equipment, resources and work areas where their required duties can be carried out in an efficient and effective manner. As such designated offices have been established for nursing staff and physiotherapy personnel. Management stated the establishment of these offices has resulted in staff being able to undertake their required duties more effectively with required resources and minimum interruptions.

A review of equipment by management identified a number of items were not fit for purpose or needed to be replaced. Consequently lifting and transfer slings, walk belts and beds were replaced with new ones and lifters and weigh chairs purchased. Management advised the new equipment is appropriate for improved quality service delivery.


1.2 Regulatory complianceThis 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 systems to identify and ensure compliance with changes in relevant legislation, professional standards and guidelines. The home accesses relevant information through the organisation’s subscription to legislative update services and membership with a peak body. The home receives information from government departments and accesses the internet and other sources. Management communicates changes to staff by documentation, staff meetings and staff education sessions. Compliance with regulatory requirements is monitored through audits, skills assessments, staff appraisals and observations by management.

Examples of regulatory compliance relating to Accreditation Standard One include:

The organisation conducts reviews of all policies and procedures on a regular basis to ensure all relevant legislation, regulatory requirements, professional standards and guidelines are appropriately documented.

Procedures for monitoring the currency of criminal history record checks for staff and contractors are in place. Interviews and documentation confirmed that these have been completed and are current.

The organisation and home have a system whereby external contractors’ registrations and insurances are checked to ensure they are current.

Information brochures on the Aged Care Complaints Commissioner are available within the home.

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


The home has systems that ensure staff have appropriate knowledge and skills to perform their roles. Calendars of education sessions are developed which detail mandatory training sessions and education of interest or importance to various staff members. Learning packages are provided and some of these packages are skills based. Education and training requirements are identified through staff performance appraisals, internal audits and staff requests. Management and staff are supported to attend internal and external courses. Participation records are maintained and reviewed by management when planning future education programs. Staff interviews indicated they are provided with training as part of the home’s orientation process and have access to on-going education.

Examples of education and staff development relating to Accreditation Standard One include:

The home regularly undertakes induction and orientation sessions for new staff.

Calendars of education sessions have been developed through a consultative needs analysis between management and staff.

Staff receive training on a wide range of topic areas relating to the Accreditation Standards.


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


Information about internal and external complaint mechanisms is provided to care recipients and/or representatives on the care recipient’s entry to the home. This information is contained in the care recipient information enquiry/information pack. Information is also communicated on a regular basis through care recipient and representative meetings and information on display in the home. Staff are made aware of these mechanisms through policies and procedures and staff meetings. Feedback forms are available within the home. Brochures about external complaint mechanisms are also on display. Staff demonstrated they have knowledge and understanding of the complaint handling process and of their role in assisting care recipients to raise issues if necessary. Review of complaints and feedback as well as other relevant documents indicates that management responds to issues raised in an effective and timely manner.

1.5 Planning and leadershipThis 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’s vision, mission and values are available in a number of documents including handbooks for care recipients and staff. The home’s vision, mission and values form a part of the staff induction program and are discussed with staff.

1.6 Human resource managementThis 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 a system that aims to ensure there are enough staff with appropriate skills and qualifications to meet care recipients’ care and lifestyle needs. The organisation together with the home’s management team review staffing requirements to ensure sufficiency of human resources. Recruitment procedures ensure the best possible match between candidates and roles are achieved. Staff are provided with position descriptions and there are systems in place for staff orientation, education and performance management. Performance appraisals are conducted and results are fed into the home’s human resource management system. Observations, documentation and care recipient interviews showed there are sufficient staff with the appropriate knowledge and skills to perform their roles effectively.

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



The home has stocks of goods and equipment that support quality service delivery. Specific staff are designated to maintain adequate stock levels and ensure such stock meets the required quality standards. The home has systems to guarantee the integrity of the stock, and stock is rotated as required. Equipment needs are identified through staff requests, audits, asset replacements and acquisition programs. The home has preventative and reactive maintenance programs. Maintenance request reports are maintained and action is taken in an efficient and effective manner to deal with any requests or preventative maintenance tasks. Emergency maintenance requirements are dealt with in a timely manner. Staff are satisfied with the amount of supplies and quality of the equipment available to ensure the provision of quality care and services.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The home has an information management system that provides relevant information to stakeholders. The home’s communication system includes meetings, handbooks for staff, information pack for care recipients, newsletters, policies and procedures, noticeboards, staff handovers and a clinical documentation system. The home utilises these communication channels along with management’s open door policy to disseminate information and to collect feedback. The information management system governs the collection, processing, accessing, reporting, storage, archiving and destruction of information and records. The home has policies covering relevant regulatory requirements for management of information and records including confidentiality and privacy matters. Access to confidential information and records is controlled and limited to authorised staff. Observations demonstrated that care recipient and staff files are stored securely. Staff confirmed they receive and have access to relevant information that allows them to perform their roles effectively. Care recipients and representatives stated they are well informed regarding care recipients’ needs and all other matters appropriate to them.

1.9 External servicesThis 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".


The home’s externally sourced services are arranged primarily by way of specified contract agreements. There is a designated process whereby specific criteria must be met in relation to services to be supplied and references and insurance and criminal history record checks are current. All major contracts are reviewed regularly through feedback by the organisation and the home as considered appropriate. Contractor non-performance is recorded and actioned immediately if urgent or at the time of reviewing the contract. To enable staff to contact an appropriate contractor/supplier, lists are maintained at the home and updated as required. Staff are informed of appropriate matters relating to the provision of externally sourced services.


Standard 2 – Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



Refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement system.

Examples of specific improvements relating to Accreditation Standard Two include:

Management identified the need to improve effectiveness of the home’s medication management system. Consequently multi-dose blister medication packs were introduced to replace the single dose packs. Management advised the new multi-dose packs assist to ensure care recipients’ medications are managed safely and correctly.

Management identified through a review of care recipients’ care plans and assessments together with staff feedback that care recipients’ physical and mental health could be further improved and optimised through advice and support from the organisation’s clinical nurse consultants and dementia mental health support service. Consequently the home has engaged these services which management advised has assisted staff in the provision of high quality care to care recipients especially with those with a diagnosis of dementia and complex care needs.

Management identified the need for staff to have the appropriate knowledge and skills to perform their roles effectively when providing care to those care recipients who have a diagnosis of dementia. As such five care staff successfully completed the dementia essentials course which focusses on true person centred care when providing care to care recipients. Management stated the training has enabled staff to more effectively address the needs of care recipients with challenging behaviours.

2.2 Regulatory complianceThis 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 details on the home’s system to identify and ensure compliance with all relevant legislation, regulatory requirements, and professional standards and guidelines.

Examples of regulatory compliance relating to Accreditation Standard Two include:

The home monitors registered nurses’ registrations.

The home monitors the registrations of visiting health professionals to ensure they are current.




Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education relating to Accreditation Standard Two include:

Behaviour management, medication management, wound management, stoma care, documentation of clinical care, palliative care, dementia care.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


There are systems and processes to ensure care recipients receive appropriate clinical care and policies and procedures to guide staff practice. The care manager oversees clinical care at the home. Twenty four hour registered nursing care is provided and a comprehensive program of assessments is completed on entry. Individualised care plans are formulated, regularly reviewed and monitored by registered nurses. Care is planned in consultation with the care recipient and/or their representative, the care recipient’s medical practitioner and allied health professionals. Staff have a sound understanding of the clinical care process. The home has appropriate supplies of equipment and resources maintained in good working order to meet the ongoing and changing needs of care recipients. Care recipients and representatives state they are satisfied with the clinical care provided and representatives say they are informed of changes in the care recipient’s condition and care needs.

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


There are systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Documentation and discussions with staff show care recipients’ specialised nursing care needs are identified when they move into the home and are addressed in the care planning process. Registered nurses coordinate assessments on the care recipients’ specialised care needs. The home liaises with external health professionals including the local area health service to ensure care recipients’ specialised nursing care needs are met. Staff access internal and external education programs and there are appropriate resources and well maintained equipment to provide specialised nursing care. Care recipients and representatives are satisfied with the specialised nursing care provided.

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



Documentation shows the home refers care recipients to external health professionals and any changes to care following specialist visits are implemented in a timely manner. An occupational therapist is on site four days a week and the organisational palliative care clinical nurse specialist twice weekly. Several allied health professionals visit the home on a regular basis including pathology services, the podiatrist, the dietitian, the organisational dementia mental health support services and lifestyle consultants and the Area Health Service Mental Health team. Representatives report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care are implemented.

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


Management demonstrates care recipients’ medication is managed safely and correctly. Registered nurses and medication endorsed care staff administer medications via a blister packaging system. A current pharmacy contract and locked storage of medication promotes safe and correct management of medication to care recipients. The medication system includes photographic identification of each care recipient with their date of birth and clearly defined allergies. Pharmacy and medical practitioner protocols have been established in the home and staff practices are consistent with policy and procedures as evidenced through audits and training. The medical advisory committee review legislation changes, medication and pharmacy issues. Regular medication reviews are completed by a consultant pharmacist. Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned by the care manager. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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


There are systems to ensure all care recipients are as free as possible from pain. Initial assessments identify any pain a care recipient may have and individual pain management plans are developed. Staff are trained in pain prevention and management and use verbal and non-verbal pain assessment tools to identify, monitor and evaluate the effectiveness of pain management strategies. Documentation shows strategies to prevent and manage care recipients’ pain include attendance to clinical and emotional needs, medication and alternative approaches including heat, massage and pressure relieving devices. Pain management measures are followed up for effectiveness and referral to the care recipient’s medical practitioner and other services is organised as needed. Staff regularly liaise with medical practitioners and allied health personnel to ensure effective holistic care planning. Care recipients and representatives report care recipients are as free as possible from pain and staff respond in a timely manner to their requests for pain control.

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



There are systems to ensure the comfort and dignity of terminally ill care recipients and support for their families and those involved in their care. Documentation and staff discussions show the spiritual, cultural, psychological and emotional needs of care recipients are considered in care planning and ongoing pastoral care and emotional support is provided. Representatives are informed of the palliation process and the home is in regular communication with representatives, medical practitioners and specialists throughout the palliative care process.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Documentation demonstrates care recipients’ nutrition and hydration status is assessed on entry to the home and individual needs including swallowing difficulties, sensory loss, special diets and individual preferences are identified and included in care planning. Appropriate referrals to the speech pathologist, dietitian and dentist are made in consultation with the care recipient/representative and others involved in their care. The seasonal menu is reviewed by a dietitian and provides care recipients with an alternative for the midday and evening meal. Care recipients are weighed monthly or more often if indicated and weight loss/gain monitored with referral to medical practitioners or allied health for investigation and treatment as necessary. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements including thickened fluids, pureed and soft food. Care recipients and representatives are satisfied with the frequency and variety of food and drinks supplied.

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


Care recipients’ skin integrity is assessed through the initial assessment process. Staff monitor care recipients’ skin care as part of daily care and report any changes in skin integrity to the registered nurse for assessment, review and referral to their medical practitioner as needed. Staff have access to sufficient supplies of appropriate equipment and resources to meet the needs of care recipients. Staff receive ongoing training and supervision in skin care and the use of specialist equipment such as lifting devices used to maintain care recipients’ skin integrity. The home’s reporting system for accidents and incidents includes skin integrity and is monitored monthly and included in the quality clinical indicators. Care recipients have access to the occupational therapist and other external health professionals. Care recipients and representatives report staff pay careful attention to care recipients’ individual needs and preferences for skin care. Observation confirms the use of pressure relieving and limb protecting equipment.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.



There are systems to ensure care recipients’ continence is managed effectively. The team registered nurses and care manager oversee continence management at the home. Clinical documentation and discussions with staff show continence management strategies are developed for each care recipient following initial assessment. Care staff report they assist care recipients with their continence programs regularly and monitor care recipients’ skin integrity. Staff are trained in continence management including scheduled toileting, the use of continence aids and the assessment and management of urinary tract infections. Bowel management strategies include daily monitoring. Staff ensure care recipients have access to regular fluids, appropriate diet and medications as ordered to assist continence. There are appropriate supplies of continence aids to meet the individual care recipient’s needs. Care recipients and representatives state they are satisfied with the continence care provided to the care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behavioural management needs are identified by initial assessments and behaviour care plans formulated. The home has a 12 bed secure unit ‘Ebenezer’ for care recipients living with dementia. Behaviour management strategies include one-on-one and group activities which are regularly reviewed in consultation with the care recipient and/or representatives and other specialist services. Staff confirm they have received education in managing challenging behaviours and work as a team to provide care. The home has access to other health professionals including the organisational dementia mental health support service and Area Health Service Mental Health Team. Staff were observed to use a variety of management strategies and resources to effectively manage care recipients with challenging behaviours and to ensure the care recipients’ dignity and individual needs were respected at all times. Care recipients and representatives are satisfied with how challenging behaviours are managed at the home.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.


There are systems to ensure optimum levels of mobility and dexterity are achieved for each care recipient. Systems include comprehensive assessments, the development of mobility and dexterity plans and mobility programs. There is an occupational therapist on site four days a week. Individual programs are designed to promote optimum levels of mobility and dexterity for all care recipients. Falls incidents are analysed and are monitored in the quality clinical indicators. Care recipients and representatives report appropriate referrals to the occupational therapist are made in a timely manner. Staff are trained in falls prevention, manual handling and the use of specialist equipment. Assistive devices such as mobile frames, walk belts, mechanical lifters and wheelchairs are available.

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



There are systems to ensure care recipients’ oral and dental health is maintained. Oral and dental health is assessed on entry to the home and documented on care plans. Staff state they receive education in oral and dental care and assist care recipients to maintain daily dental and oral health. Swallowing difficulties and pain are referred to the medical practitioner or allied health services for assessment and review. Care recipients and representatives state care recipients are provided with appropriate diets, fluids, referral and equipment to ensure their oral and dental health is maintained.

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


Sensory loss is assessed on entry to the home and appropriate referrals are made to ensure care recipients’ care needs are managed effectively. Specialist equipment is maintained in good working order and staff are trained in sensory loss. Staff have implemented programs to assist care recipients with sensory stimulation including of taste, touch and smell. Care recipients and representatives report staff are supportive of care recipients with sensory loss and promote independence and choice as part of daily care.

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


Care recipients’ sleep patterns including a history of night sedation are assessed on entry and sleep care plans are formulated. Lighting and noise is subdued at night. Care recipients’ ongoing sleep patterns are reviewed and sleep disturbances monitored and appropriate interventions put in place to assist care recipients to achieve natural sleep. Staff report care recipients who experience sleep disturbances are assisted with toileting, repositioning, snacks and fluids as requested and assessed as needed. Care recipients and representatives are satisfied with the way care recipients’ sleep is managed.


Standard 3 – Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



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

Examples of continuous improvement relating to Accreditation Standard Three include:

The organisation and lifestyle staff identified the need to have up to date and comprehensive information concerning care recipients’ background, interests and aspects of their life which were or are meaningful to them. This information is then summarised into care recipient ‘profile stories’ which assist staff to engage in meaningful communication and/or activities with each care recipients based on their interests or background. Staff stated the profile stories assist staff to provide a more person centred approach to care and lifestyle activities.

Lifestyle staff identified some male care recipients would enjoy participating in activities associated with the establishment of a men’s shed. Consequently a men’s shed has been established and activities in the men’s shed have been incorporated into the home’s lifestyle activities calendar for one day a week. Feedback from care recipients and lifestyle staff has been care recipients very much enjoy participating in activities which occur in the men’s shed.

The organisation together with management identified the need to ensure the home provides care recipients with adequate support in adjusting to life in the home and on an on-going basis. As well as that care recipients’ individual customs, beliefs and cultural and ethnic backgrounds are appropriately valued and fostered. Consequently a pastoral carer has been recently appointed to assist to provide such support and services to care recipients. Management advised the appointment of the pastoral carer has very much assisted in providing care recipients with appropriate emotional support especially when settling into the home’s environment.

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



Examples of regulatory compliance relating to Accreditation Standard Three include:

The “Charter of Care Recipients’ Rights and Responsibilities” is on display.


The care recipient agreements outline security of tenure and are based on applicable legislation.

The home has a system for compulsory reporting according to current legislation.



Examples of education relating to Accreditation Standard Two include:

Customer service and dignity in care, the Montessori approach to dementia care, lifestyle program educational sessions, person-centred individual activity programs.

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


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families. Visits from the Chaplain, pastoral worker, volunteers and leisure and lifestyle officers, care recipient/representatives meetings and involvement of family in the activity program ensure care recipients receive ongoing emotional support. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors including pets are encouraged. Care recipients and representatives are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive.

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


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Community visitors, volunteers and entertainers are encouraged and arranged. The environment encourages care recipients, their representatives and their friends to participate in activities. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.

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



There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs, including the care recipient’s preferred name. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Care recipients’ rooms are managed so that privacy is not compromised; lockable storage is available to all care recipients. Staff handovers and confidential information is discussed in private and care recipients’ files securely stored. Staff practices respect privacy and dignity and care recipients and representatives are satisfied with how privacy and dignity is managed at the home.

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


The lifestyle program offers an extensive range of activities five days a week. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. Lifestyle programs include concerts, bus outings, entertainers, bingo, word games, exercise classes, theme days, happy hour and men’s group. Care recipients are given the choice of whether or not to take part in activities. The results of interviews, document review and observations confirm care recipients and representatives are highly satisfied with the activities provided to the care recipients.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients/representatives are asked about end of life wishes and this information is documented in their file. The home has a Chaplain on site two days and a pastoral worker on site three days each week. Pastoral visitors of various denominations visit and regular religious services and bible study classes are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met.

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



Management demonstrates each care recipient participates in decisions about the services the home provides and is able to exercise choice and control over their lifestyle through consultation around their individual needs and preferences. Management has an open door policy and this promotes continuous and timely interactions between the management team, care recipients and/or representatives. Observation of staff practices and staff interviews show care recipients have choices available to them including waking and sleeping times, shower times, meals and activities. Care recipients/representatives meetings and surveys occur regularly to enable care recipients and representatives to discuss and provide feedback about the services provided. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


Care recipients and representatives reported they are satisfied with the information the home provides to care recipients on entry regarding care recipients’ entitlements, details of tenure as well as the fees and charges. Designated staff members explain the care recipient accommodation agreement to care recipients and representatives prior to care recipients coming to live at the home. Care recipients and representatives are advised to seek independent legal and financial advice. The care recipient information handbook which is provided to care recipients on entry contains information about the services available, privacy and confidentiality, processes for making complaints and care recipients’ rights and responsibilities. Management explained the process for room changes within the home and advised that agreement is always reached prior to any room changes occurring.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Refer to expected outcome 1.1 Continuous improvement for further information relating to the home’s continuous improvement system.

Examples of recent improvements in relation to Accreditation Standard Four include:

Management identified the need to enhance the home’s living environment and as such the dining room has been upgraded and new furniture for communal areas purchased. Management stated these enhancements which are part of a planned upgrade of the home’s living environment has provided a more comfortable and home like environment for care recipients.

As a consequence of a review of the home’s menu by management and consideration of feedback from care recipients a new menu was introduced. The menu now incorporates care recipient food preferences such as such as lamb cutlets, casseroles and take-away foods from different eateries located in the area. Feedback from care recipients and staff regarding menu changes was very positive especially the incorporation of regular take-away foods.

The organisation together with management identified the need to introduce a more efficient and effective planned maintenance schedule and recording system. Consequently a new schedule and recording system has been developed and is being implemented within the home. Management advised the new system has assisted to ensure all required maintenance tasks are undertaken as required and according to appropriate quality.

4.2 Regulatory complianceThis 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”.



Examples of regulatory compliance relating to Accreditation Standard Four include:

The home has current NSW Food Authority licence and the food safety system has been audited by the NSW Food Authority.

The home has a current fire safety certificate on display.

The home provides safety data sheets with stored chemicals.




Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education relevant to Accreditation Standard Four include:

Emergency procedures and first attack fire-fighting course, manual handling, infection control, food safety, safe use of chemicals.

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


The home demonstrates that it is actively working to provide a safe and comfortable environment consistent with care recipients’ needs. The home is a single-storey building with various sections under the one roof. The sections include single and two-bedded bedrooms with shared bathroom facilities and dining and communal areas. The home is well illuminated with natural light. The home’s bedrooms and common areas have centrally controlled air conditioning. There is a preventative and reactive maintenance program in place, including recording of warm water temperatures and regular inspections covering the environment are undertaken. Care recipients and representatives stated they are satisfied with care recipients’ rooms and the communal living environment.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Systems and processes enable the home to demonstrate that management and staff are working together to provide a safe working environment that meets regulatory requirements. The home has processes for the identification and addressing of hazards and incidents. There is safe work practice and work health and safety education for staff. Chemicals are appropriately stored and safety data sheets and personal protective equipment is available at point of use. Staff demonstrated knowledge and understanding of workplace safety issues and responsibilities and we observed safe practices in operation.

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



The home has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire evacuation plans, emergency procedure documentation and exit signs are located throughout the home. Monitoring and maintenance of all fire and alarm equipment is undertaken by contractors and reports provided. Fire equipment is located throughout the home. Appropriately responding to emergency training is included in the orientation program and there are mandatory annual updates. Staff are aware of procedures to be followed in the event of an emergency. Emergency evacuation documentation is readily available which includes information detailing care recipients’ care needs and relevant contact information. Staff stated they are aware of and understand their responsibilities in the case of fire and other emergencies.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


There is an effective infection control program which minimises infections. A care recipient and staff immunisation program is implemented each year. The infection surveillance program includes monitoring, appropriate treatment and follow up review of any infections to reduce the likelihood of further infections. Infection control training and hand washing education are provided for staff during orientation, during mandatory annual education and as needed for all staff. Outbreak management plans and equipment are in place. The home has a food safety program and a pest control program. Personal protective equipment, spill kits and hand sanitising stations were observed throughout the building. Temperature monitoring and thermometer calibration programs are regularly recorded and cleaning schedules are followed throughout the home. Waste is disposed of safely and correctly. All staff interviewed had a good understanding of the importance of infection control.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Care recipients and representatives expressed satisfaction with the hospitality services provided at the home.

Care recipients’ dietary needs and choices are assessed and documented on entry to the home and details provided to catering staff. All food is cooked on site. There is a food safety program and the home has a current NSW Food Authority licence. The home has a seasonal menu with input from a dietitian. We observed food preparation and service and staff practices are according to the appropriate food safety guidelines, including infection control requirements. Appropriate staff have undertaken training in relation to appropriate food handling and infection control. Care recipients said they are very satisfied with catering services provided.

The home presents as clean, fresh and well maintained. Cleaning staff perform their duties guided by documented schedules, work instructions and results of inspections. Cleaning equipment is colour coded and chemicals are securely stored. Staff are trained in the use of equipment, infection control, outbreak management procedures and work, health and safety. Staff demonstrated a good knowledge of infection control, manual handling requirements and safe handling of chemicals.

Laundry services are provided on site. Dirty laundry is collected in appropriate coloured linen bags and transported to the laundry area. There are procedures and work instructions for the


collection and handling of linen. Staff described the processes for the collection and transportation of dirty clothes and linen and distribution of clean linen and clothes to care recipients. Staff confirmed they receive training in infection control and safe work practices.


Documents

Published_decision_(SA_and_RA) Web viewAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 29 August 2017 to 30 August 2017. ... temperature