Published_decision_(SA_and_RA) Web viewPrinciple: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives

Southern Cross St Catherine's VillaRACS ID: 0078

Approved provider: Southern Cross Care (NSW & ACT)

Home address: 126 North Street GRAFTON NSW 2460

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 01 December 2020.

We made our decision on 01 November 2017.

The audit was conducted on 20 September 2017 to 21 September 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: Southern Cross St Catherine's Villa Date/s of audit: 20 September 2017 to 21 September 2017RACS ID: 0078 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: Southern Cross St Catherine's Villa Date/s of audit: 20 September 2017 to 21 September 2017RACS ID: 0078 3

Audit ReportName of home: Southern Cross St Catherine's Villa

RACS ID: 0078

Approved provider: Southern Cross Care (NSW & ACT)

IntroductionThis is the report of a Re-accreditation Audit from 20 September 2017 to 21 September 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 20 September 2017 to 21 September 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of 2 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: 64

Number of care recipients during audit: 60

Number of care recipients receiving high care during audit: 44

Special needs catered for: McCauley Cottage: 8 bed secure unit for care recipients living with dementia


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

Interviews

Position title Number

Care recipients 16

Representatives 7

Head of care 1

Regional manager 1

Manager/registered nurse 1

Registered nurse 1

Quality officer 1

Deputy care team managers 2

Allied health care service team leaders 2

Leisure and lifestyle coordinator 1

Spiritual practitioner 1

Care staff 7

Administration assistant 1

Medical practitioner 1

Volunteers 1

Laundry staff 1

Cleaning staff 2

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files (progress notes, assessments, care and lifestyle plans and associated documentation)

6

Medication charts 9

Personnel files 3


Document type Number

Other documents reviewedThe team also reviewed:

Accident and incident reports

Behaviour management: behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, bed rail restraint authorisations

Catering documentation: NSW Food Authority Audit licence and report, temperature monitoring charts, food safety program

Cleaners schedule and equipment

Clinical monitoring records: anticoagulant therapy, blood glucose levels, blood pressure, neurological observations, pain, hygiene and pressure relief turning charts, case conference records, care plan review schedule

Comments and complaints register

Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list

Education documentation: education schedule, attendance records and evaluation, orientation records, clinical skills, general service workers & maintenance skills assessments, mandatory training records, competency assessments

Emergency and fire safety documentation: annual fire safety statement, care recipient evacuation folder, fire safety system maintenance and inspection records, emergency evacuation folder with care recipients’ details and identification tags, fire and emergency procedures, emergency contact numbers

Human resources documentation: Staff roster, allocation sheet and staff replacement sheet, police checks register, staff handbook, position descriptions, recruitment policies and procedures

Information management: schedule, agenda and minutes of meetings, memoranda, information notice boards, daily handover sheet, communication diaries, care recipient information handbook, accommodation agreements

Lifestyle management: lifestyle past history , leisure and spiritual assessments, activity plans, attendance records, activity evaluations, newsletters, consent forms

Maintenance: stock management and external services documentation including clinical and non-clinical stock management documentation, planned programmed maintenance and records, reactive maintenance log, approved supplier/contractors list, thermostatic mixing valve tests, Legionella test report

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, medication incident reports, nurse initiated medication forms, Drugs of addiction register, complex health care directives diabetic management and oxygen therapy, professional signatures register, self-medication assessment/authorisation

Mobility: mobility assessments, physiotherapy care plans, individual exercise, massage, heat pack therapy and transcutaneous electrical nerve stimulation attendance records


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

Pain management and palliative care: pain assessments, pain management plans, medical orders life sustaining treatment (MOLST)

Regulatory compliance: mandatory reporting register, professional registrations register,

Quality system: continuous improvement register, feedback forms, plan for continuous improvement, clinical indicator data

Self-assessment report for reaccreditation and associated documentation

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

ObservationsThe team observed the following:

Activities in progress

Care recipients utilising pressure relieving and hip and limb protection equipment

Cleaners room with colour coded equipment; chemical stores and safety data sheets adjacent to chemicals to which they refer

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

Equipment and supply storage areas

Evidence of test and tag on kitchen electrical equipment

Fire safety systems and equipment

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, isolation packs

Interactions between staff ,care recipients and representatives

Internal/external complaints information and advocacy brochures on display

Living environment

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

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 lounge McCauley Cottage

Sign in/out registers, entry/exit and internal key pad access

Staff work practices and work areas including administrative, clinical, lifestyle, allied health, 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

Southern Cross Care has a system to identify, record and implement continuous improvement initiatives across the four accreditation standards. Initiatives are identified through internal reviews, staff and care recipient feedback and from meetings. Management utilise feedback obtained through feedback forms to identify any improvements as well as recorded compliments and complaints. The home has established a quality improvement committee and the system draws information, feedback and advice from several sub committees to identify, evaluate and disseminate information about continuous improvement initiatives across the accreditation standards. The committee meets monthly and is chaired by the Facility Manager.

Improvement initiatives recently implemented by the organisation in relation to Standard 1 include:

The home has implemented a quality improvement system to increase the effectiveness of monitoring clinical and non-clinical performance across the home. The new system has seen improved results in quality improvement initiatives as activities are more efficiently monitored and evaluated with feedback to and from relevant committees.

Management identified not all information regarding approved protocols and routines, for example protocols regarding doctors’ visits were being effectively taught to all team leaders. The home has established a buddy shift program where all team leaders participate in three to four buddy shifts on commencement with the home. In addition, team leaders are given one-to-one time working with the deputy care team managers and the registered nurse to learn protocols regarding medical practitioner rounds, medication management, incident reporting and management. Management advise the process is on-going and is producing favourable results regarding staff knowledge and practices.

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”.



There are systems and processes to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation demonstrates a professional approach to documenting, reviewing and disseminating changes to policy and practices applicable to the accreditation standards. Staff are informed of regulatory updates by face to face education and training sessions and through the organisation’s intranet service. Staff displayed knowledge and understanding of regulatory requirements applicable to the accreditation standards.

Examples of responsiveness to regulatory compliance relating to Accreditation Standard One include: staff attend compulsory education sessions; information is readily available and accessible on in-house and external complaints systems; and there is documented evidence of criminal history checks, and display of the notification of the re-accreditation audit.

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


There are systems and processes to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. This includes an orientation program comprising of mandatory training in fire safety, manual handling, infection control, elder abuse and other training relating to staffs work requirements. Training is monitored and managed by local staff in conjunction with Southern Cross regional management team. Records are currently managed both in paper based and electronic store. Education records and staff interviews confirm a process of induction, training on entry to the home and participation in on-going education and training including regular competency assessments. The home conducts in-house training and specialised training delivered by external providers on the use of specialised nursing supplies and equipment. Document review of training records confirms the home’s commitment to education and training.

Education provided by the home relating to Accreditation Standard One includes: code of conduct, privacy and dignity, elder abuse.

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".


The home provides care recipients and representatives with access to, and information on, internal and external complaints mechanisms available to care recipients. Information on how to provide feedback and how to make a complaint is on display throughout the home and is documented in the care recipient information handbook. Feedback forms are readily available and a suggestion box is located at the entrance to the home. Feedback can also be made verbally with staff and management. Care recipient and staff meetings are conducted regularly providing further opportunity to raise matters of concern to them. The comment and complaint register is maintained in electronic form and managed by the facility manager. A review of the register revealed care recipients, representatives and staff are aware of and use this form of feedback as required.

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".



Southern Cross St Catherine’s Villa is part of the larger Southern Cross Care (SCC), not for profit, multiservice organisation. SCC’s senior leadership team conducts strategic planning and undertakes day to day operational functions. The organisation has clearly defined mission, vision and values along with a set of principles to guide staff in providing care and support services to care recipients. Facility Managers and staff have the benefit of support and guidance from the SCC head office through regional coordinators and managers who provide oversight and advice to facilities to enhance the provision of care. The home’s quality information system includes committees such as general facility management, medication management, infections control and injury risk management. The home participates in service monitoring programs which includes a process of audits, surveys and monthly reviews.

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’s management invest time on interviewing and selecting appropriate staff that includes reference and background checking New employees are provided with orientation and induction training which includes the home’s mandatory education topics such as manual handling, elder abuse, fire safety and infection control. Employees are provided with information about their employment with the organisation and issued an employee handbook. Staff have access to on-line human resource systems containing policies, management and leadership structure and access to employee welfare services. Mandatory training and assessment is provided and on-going opportunities for education and development are available to staff. There is a buddy system to orientate and introduce staff to the home’s systems, processes and care recipients. Conversations with staff identified several staff are multi skilled and work as nursing, recreation and hotel services staff. Administrative staff manage shift rosters and draw on a pool of permanent and casual staff for shift replacement. Sample checking of rosters revealed that shifts are replaced as required. Staff said they are satisfied with staffing levels and support provided to them by management.

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


The home has systems and processes to appropriately monitor and manage stocks of goods and equipment to provide quality service delivery. Physical stocktakes are conducted monthly by department heads. The administration officer collates inventory requests and places orders with preferred suppliers through the home’s inventory management system. Adequate stocks of inventory and equipment were observed during the audit and equipment appeared to be in good repair. Outbreak and emergency kits were observed in the home’s inventory. Chemicals and oxygen are stored and secured appropriately.

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



Interviews with care recipients and staff, observations and document review revealed there is an effective information management system. There are systems to facilitate communication between management, staff, care recipients and representatives. Information systems for staff include on-line clinical management system to communicate care recipient healthcare needs and treatment, access to policies and procedures to guide staff practices, staff meetings, noticeboards, and incident and accident reporting protocols. The home is currently transitioning to a new on-line human resource management system. The new system has streamlined information exchange and provides real-time access for staff to current events, educational opportunities including self-directed learning. Systems and processes available to care recipients and representatives include care recipient handbooks and monthly meetings; feedback systems including comments and complaints, surveys and information noticeboards display current events and information. Care recipients and staff records are kept in secured locations to ensure appropriate security and confidentiality of information is maintained.

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".


There are systems and processes to ensure external services are provided to meet the home’s care and service needs and quality goals. SCC head office establishes and manages service agreements. Preferred suppliers enter into contracts/ agreements for the supply of goods or services and are required to provide evidence of relevant insurance; license or business registration details and criminal history checks as necessary. The home has access to an established preferred contractor/service supplier list. All work performed is monitored for quality and effectiveness of service through inspection; audits and feedback. A range of allied health professionals and a hairdresser also provide on-site care and services for care recipients. Care recipients and representatives and staff advised they are satisfied with external services provided.


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 improvement for an overview of the home’s continuous improvement system. Improvement initiatives recently implemented by the organisation in relation to Standard 2 include:

Staff identified some care recipients were becoming increasingly frail and were unable to be moved from their rooms without increasing the risk of pressure related injury. Management arranged for the purchase of two air chairs to enable care recipients to attend social functions whilst minimising the risk of injury. Staff were briefed on the availability and proper use of the chairs in March 2017. Staff and care recipient feedback confirms increased attendance at social functions and reduced incidents of pressure related injury.

During the quality meeting, staff reported having difficulty accommodating all necessary equipment and documentation required for blood glucose monitoring on the available medical trolleys. An incident involving a needle stick injury was attributed to an overloaded trolley, limited work space and insufficient space for the necessary equipment. Management purchased an additional trolley specifically to accommodate blood glucose monitoring equipment. Management also replaced existing needles with retractable needles to reduce the likelihood of needle stick injury. Management advise the additional trolley has streamlined the process of blood glucose monitoring which has resulted in more efficient staff practice and reduced impact on care recipient’s daily lives.

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”.


Please refer to expected outcome 1.2 Regulatory compliance for information on the home’s system to identify and ensure compliance with all relevant legislation, regulations and guidelines. Observations confirm information is available for staff on legislation and guidelines relating to health and personal care.

Example of responsiveness to regulatory compliance in relation to Accreditation Standard Two includes evidence of a system to monitor and ensure professional nursing registrations are current, restricted medications are managed securely, policies and procedures to ensure the Department of Health is notified if care recipients are reported missing without explanation and the police are notified.




Please refer to expected outcome 1.3 Education and staff development for further information on the home’s system of providing staff with knowledge and appropriate skills to perform their roles effectively.

Education provided in relation to Accreditation Standard Two includes: palliative care, training on medication policy, continence, modified diets, cardio pulmonary resuscitation refresher training.

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 manager and the registered nurse oversee clinical care at the home. There is a registered nurse is on site five days each week and on call at other times. A comprehensive program of assessments is completed on entry. Individualised care plans are formulated, regularly reviewed and monitored by the registered nurse. 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. Two designated care staff oversee the allied health portfolio and several allied health professionals visit the home on a regular basis including the physiotherapist, pathology services, the podiatrist, the dietitian, speech pathologist 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. 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 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. Two continence link nurses and the registered nurse 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. 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 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 a physiotherapist on site monthly and a designated allied health care staff member daily. 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.




Several care recipients mentioned to staff there are certain things they wished to do in the remaining part of their lives. Staff raised the matter at a staff meeting where it was determined they would do all they could to honour care recipients’ wishes where practical. A ‘bucket list’ committee including management and recreation staff was formed. To date, staff have been able to grant the wishes of several care recipients including arranging a trip to the beach where a care recipient used to surf and arranging visits for care recipients to their former homes in local districts where they met with and shared memories of their homes with current owners. Staff advise feedback from care recipients and relatives has been positive.

The spiritual practitioner identified there were no services available to provide care recipients living in McCauley Cottage with adequate spiritual support. The spiritual practitioner, in conjunction with leisure and lifestyle staff, implemented pastoral support services on Fridays and Sundays. Staff advise they have received positive feedback from care recipients and representatives.

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”.


Please refer to expected outcome 1.2 Regulatory compliance for information on the home’s system to identify and ensure compliance with all relevant legislation, regulations and guidelines. Observations confirm information is available for staff on legislation and guidelines relating care recipients’ lifestyle including the Charter of Care Recipients’ Rights and Responsibilities contained in the care recipient accommodation agreement, handbook and on display in the home.

Examples of responsiveness to regulatory compliance in relation to Accreditation Standard Three is: care recipients’ being offered residential agreements when moving into the home, maintenance of a mandatory reporting register, the maintenance of privacy and confidentiality statements.





Education provided in relation to Accreditation Standard Three includes: privacy and dignity, seniors’ rights, spirituality in palliative care

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. Regular visits from the spiritual practitioner, pastoral volunteers and the leisure and lifestyle officers, care recipient/representatives meetings and involvement of family in the activity program. 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 seven 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, regular shopping trips, monthly milk bar café, sensory hour, meditation, entertainers, bingo, trivia and word games, regular walks, exercise classes and craft. 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 spiritual practitioner; a large group of pastoral volunteers of various denominations regularly visit and regular religious services 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".


Information is provided to explain care and services for new care recipient and/or their representative prior to entry to the home. The Southern Cross Care accommodation agreement is offered to each care recipient and/or representative to formalise occupancy arrangements. The agreement and the care recipient information handbook include information about their rights and responsibilities, care and services provided, fees and charges, complaints handling, their security of tenure and the process for the termination of the agreement. Care recipients and/or representatives are advised to obtain independent financial and legal advice prior to signing the agreement. The Charter of Care Recipients’ Rights and Responsibilities and other relevant information is documented in the handbook. Care recipient and representatives are satisfied with the information provided by the home regarding security of tenure and their rights and responsibilities.


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.




During a care recipient meeting one care recipient informed staff that Maggie Beer was going to attend Grafton as part of the Maggie Beer Foundation series of talks at Grafton TAFE. Two staff from the home, including the head cook and the regional manager attended the talks over two days where Maggie spoke to aged care cooks about their food service and variety. Staff advise it was a positive experience which resulted in the home surveying care recipients about the winter menu and developing new menus.

During organisational planning, staff identified a need for additional space for care recipients and representatives to participate in flower arranging. Lifestyle and maintenance staff worked together to create a flower room in the front courtyard where flower arranging could take place. Management advise the initiative has worked well and has been well received by care recipients and representatives.

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”.


Please refer to expected outcome 1.2 Regulatory compliance for information on the home’s system to identify and ensure compliance with all relevant legislation, regulations and guidelines. Observation confirmed information is available for staff on legislation and guidelines relating to the physical environment and safe systems.

Examples of responsiveness to regulatory compliance in relation to Accreditation Standard Four include: Maintenance and test records of the fire panel and firefighting equipment, workplace environmental audits, safety data sheets readily available to staff in relevant work areas.





Education provided in relation to Accreditation Standard Four includes: infection control, outbreak management, fire and emergency procedures, manual handling

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 is a 64 bed, single level facility that meets the comfort and safety needs of care recipients and staff. Care recipients have safe access to clean and well maintained communal, private, dining and outdoor areas and are accommodated in single rooms with ensuite bathrooms. Communal areas are furnished appropriately with sufficient furniture and fixtures and care recipient’s rooms are furnished to their own liking. All communal areas and some bedrooms are air-conditioned with the remainder having ample ventilation, ceiling fans and heating to maintain comfortable internal temperatures and ventilation. Regular environmental and cleaning audits are conducted and maintenance and repairs are carried out as necessary. The home’s preventative maintenance schedules are managed by an on-site maintenance officer and approved external service providers are engaged as required. Interviews, observation and document review confirms staff are aware of the home’s systems to request repairs and maintenance and that care recipients are satisfied with the state of their 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".


Management and staff are working to provide a safe working environment that meets regulatory requirements. Southern Cross Care utilise a quality information system to monitor and manage services to care recipients and a safe working environment for staff. Health and safety representatives meet regularly to review reported incidents and discuss risks and hazards. Regular education and training is conducted including manual handling and infection control. Information about safety and welfare is disseminated to staff through the homes on-line human resource management system. Personal protective equipment and emergency management supplies and kits were observed during the audit. The home’s stores, equipment and supplies appeared to be stored in a safe manner.

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".


Management and staff actively work to provide a safe and secure environment for care recipients and staff. The fire and emergency evacuation plan includes evacuation maps and assembly areas displayed throughout the home. Staff and contractors are provided with fire and emergency management training on induction and as part of on-going education. Fire


hydrants and extinguishers are located at several locations in each community and are regularly inspected and tagged. The fire alarm system, hydrants and sprinkler systems are subject to regular inspection by licensed contractors. Sample checking of physical systems and log books confirmed the currency of maintenance and inspection schedule. Contractor and visitor sign-in registers help to monitor who enters the home. Care recipient’s rooms have nurse call bells near beds and in bathrooms. All care recipients interviewed said they feel safe at the home.

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


There is an effective infection control and surveillance program. The home has an infection control coordinator and there is a system to document, monitor and review the level of infections within the home. Observations confirm consistent staff practice to reduce cross infection such as the use of hand washing facilities, personal protective and colour-coded equipment. The home has a food safety program, pest control and waste management systems; monitors laundry and cleaning practices and has an outbreak management plan. Preventative measures include education for all staff with specific education and training relevant to staff positions and roles. Care recipients and staff are offered vaccinations. Staff demonstrate an awareness of infection control relevant to their work area.

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".


There are systems to manage hospitality services and to enhance care recipients’ quality of life and the staff’s working environment. Care recipient’s dietary and nutritional requirements are communicated to kitchen staff to inform them of care recipient’s personal preferences and dietary needs. Information regarding allergies and requirements for textured and modified food and fluid is maintained in the home’s kitchen. Kitchen staff maintain a diary for staff to communicate changes to care recipients’ dietary needs as required. All meals are prepared on-site in the home’s kitchen. A food safety program guides kitchen staff in safe practices for food preparation, storage, delivery and serving. There is a program for the routine cleaning of all areas of the home including the kitchen, communal and service areas, daily cleaning of care recipient’s rooms along with a scrub clean of care recipient bedrooms and bathrooms once a week. All washing including flat linen and care recipient’ clothing is conducted on-site. Laundry staff demonstrated appropriate practices for the separation and cleaning of linens and clothing. Laundry staff work Monday to Friday. The laundry can be utilised on weekends by staff in case of need. Most care recipients were generally satisfied with the standard of catering, cleaning and laundry services at the home.


Documents

Published_decision_(SA_and_RA) Web viewPrinciple: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives