Published_decision_(SA_and_RA) · Web viewCare recipients and representatives interviewed are satisfied with how care recipients' specialised nursing care needs are managed. 2.6Other

Bupa Baulkham HillsRACS ID: 1014

Approved provider: Bupa Aged Care Australia Pty Ltd

Home address: 4 The Cottell Way Baulkham Hills NSW 2153

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 30 October 2020.

We made our decision on 18 September 2017.

The audit was conducted on 08 August 2017 to 10 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: Bupa Baulkham Hills Date/s of audit: 08 August 2017 to 10 August 2017RACS ID: 1014 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: Bupa Baulkham Hills Date/s of audit: 08 August 2017 to 10 August 2017RACS ID: 1014 3

Audit ReportName of home: Bupa Baulkham Hills

RACS ID: 1014

Approved provider: Bupa Aged Care Australia Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 08 August 2017 to 10 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 08 August 2017 to 10 August 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: 144

Number of care recipients during audit: 141

Number of care recipients receiving high care during audit: 136

Special needs catered for: Dementia (two wings)


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

Interviews

Position title Number

Care recipients and/or representatives 31

General manager 1

Clinical manager 1

Care managers 4

Medical practitioner 1

Registered nurse 1

Care staff 7

Recreational activities officers 3

Business administration manager 1

Business administrator 1

Customer relations consultant 1

Maintenance staff 1

Physiotherapist 1

Catering manager 1

Laundry staff 2

Cleaning staff 1

Sampled documents

Document type Number

Care recipients’ files 17

Medication charts 8

Physiotherapy treatment plans 2

Care recipient administration files including signed resident and accommodation agreements

6

Personnel files 8


Document type Number

Other documents reviewedThe team also reviewed:

Allied health folder (for communication with doctors and allied health professionals)

Audit schedule, audit results, quality indicators, surveys, accident/incident and hazard reports, workplace audits, risk assessments

Care recipient information package, handbook and agreements, privacy collection statements, consent forms, admissions checklist

Care recipient records including advance care directive, assessments, behaviour charts, care plans, continence management instruction card, dietary details, staff care conference, family case conference, consent to change primary treating doctor, incident documents, interim care plan, assessments, map of life, manual handling instruction card, pathology and radiology results, medical directives, pharmacy admission form, pain management treatment record, progress notes, vital signs charts, continence charts, reports from specialists and transfer forms, self-administration assessment and authorisation

Care related documentation including reports from the clinical care system, continence aide allocation folder, dressing guide folder, weight and BMS monitoring chart, nurse call alarms by room report

Cleaners folders and work instructions, daily cleaning schedule

Communication documentation including memoranda, diary (for reminders about appointments), newsletters, handover notes and other publications

Computer based and hardcopy information systems

Consolidated log of reportable incidents, incident forms, correspondence from Department of Health regarding incidents reported, guide to incident reporting flip chart

Continuous improvement plan, improvement logs

Education calendar, training records, attendance records, competency assessments

Feedback system including comments, complaints and compliments

Fire and emergency documentation including annual fire safety statement, fire safety schedule, evacuation plans, fire equipment audits and testing records, fire safety education records and orientation checklists

Human resources documentation including HR policies and procedures, staff handbook, staff orientation program, job descriptions, duty statements, staff rosters and allocation sheets, performance management documentation, privacy and confidentiality statements, police check register, nurse registrations, statutory declarations

Lifestyle program including individual activities plan, activities program, activity evaluations, bus outing suitability folder, consent for photos, focus group schedule and records, diversional therapy daily activity record, lifestyle program on display, venue location suitability checklist

Medication documentation including do not crush guide, medication fridge temperature records, S8 registers, signature register


Menu, food preference lists, specialised dietary requirements, meal order form combined, temperature checks and other food safety documentation, NSW Food Authority licence and audit report

Minutes of meetings including community meeting minutes (each wing), cleaners meeting, leadership meeting, medical advisory meeting, night staff meeting, resident/ relative meeting (each wing), staff meeting, work health safety (WHS) meeting

Policy and procedure manuals, care home services processes, resident journey process, resident journey process – medication management, people management process

Preventative maintenance records, maintenance logs, pest control reports, contractor induction checklists

Self-assessment report for re-accreditation

Work instructions (procedures) including dysphagia management, leisure, interest and activities, supporting restraint free environment

ObservationsThe team observed the following:

Activities in progress, activities program on display, books, puzzles and board games accessible for care recipients, the home’s bus

Aged Care Quality Agency re-accreditation audit notices on display

Archive room, archiving system in place

Charter of care recipients' rights and responsibilities displayed

Cleaning in progress, trolleys and supplies, chemical stores, laundry delivery

Compliments, suggestions and complaints forms, information on noticeboards for staff, care recipients and visitors, various brochures on display, suggestion box

Dining environments during midday meal services, morning and afternoon tea, staff serving/supervising, menu on display

Equipment and supply storage areas

Fire safety instructions, fire safety equipment, fire panel, sprinkler system, evacuation plans, emergency procedure flipcharts, in/out signing sheets, closed circuit television and signage, other security systems

Infection control including personal protective equipment and infection control practices, food safety, colour coded equipment, hand washing and hand hygiene equipment and waste management

Interactions between staff, care recipients, relatives/representatives, visitors

Living environment – internal and external

Medication administration and storage, medical equipment, palliative care kit, therapy stores and equipment

Purpose, promise and values statements on display

Secure and accessible storage of clinical and administrative files – paper based and electronic care recipient and staff information

Short group observation in recreational area

Staff using maintenance logs, maintenance and repairs being carried out

Staff work practices and work areas including administration, care services, catering, cleaning, laundry and maintenance



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 actively pursues continuous improvement through the implementation of an integrated quality system, which assesses, monitors and evaluates all areas of service provision and care recipient satisfaction. The home’s leadership team meetings monitor the system. Various other meetings provide a mechanism for input and feedback by the range of stakeholders. Examples of other quality activities include the comments, complaints and suggestions system, routine audits, surveys, external reviews, hazard and risk reporting, accident and incident reporting, data collection and other monitoring systems. Improvements are recorded on improvement logs and the continuous improvement plan. Most care recipients said ‘this place is well run’, while one strongly disagreed.

Examples of specific improvements relating to Standard 1 Management systems, staffing and organisational development include:

Building on Bupa’s previous work on its purpose and values, the home has adopted and promoted the Bupa ‘promise’ (Know me and my needs; Help steer my decisions; Be there when I need you). Bupa sees the promise as connecting the organisation’s purpose, strategy, people and customer experience.

As part of the Bupa organisation, the home is participating in its ‘People pulse survey’ which is conducted quarterly across Bupa as a means of measuring employee engagement. In response to results from the survey, the home developed a staff program aimed at building a positive workplace culture of cohesion and harmony. The program included a number of measures including conducting code of conduct education and appointing wellbeing champions. The home’s management advises that the program has been beneficial for employees.

The home has implemented a new system ‘Work day’ which is a means of managing employee information. One of the key advantages is that employees can access the sytem directly when applying for leave, updating their personal detials and other similar matters.

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’s management has systems in operation to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. With support from the Bupa organisational level, the home monitors the regulatory environment through updates from government and industry bodies, industry conferences, internet access and various other mechanisms. Staff are advised of regulatory requirements and any relevant changes to them through various means including memos, updates to policies, meetings and education. Compliance with regulatory requirements and other standards is monitored through a comprehensive audit program as well as day-to-day supervisory arrangements.

Examples of regulatory compliance related to Standard 1 Management systems, staffing and organisational development include:

Ensuring care recipients and representatives were informed of the re-accreditation audit in keeping with legislative requirements

Ensuring care recipients and other stakeholders have access to complaints mechanisms

Ensuring police certificate checks are undertaken for staff, volunteers and applicable contractors

Ensuring relevant staff meet statutory declaration and visa requirements (if applicable)

Monitoring external service providers for applicable insurances, registrations, licences and other necessary regulatory requirements.

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


It was evident from our observations, document review and interviews that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has an education program, which is based on educational needs identified through a wide range of mechanisms. These include staff performance appraisals, the quality improvement system, the changing needs of care recipients, and feedback from various sources. The education program is comprehensive and covers a range of functional areas encompassing all four Accreditation Standards. The program is reinforced by competency assessments in relevant areas. New staff participate in tailored orientation and induction programs. Staff also have access to relevant external educational opportunities and where appropriate are supported to obtain formal qualifications.

Examples of recent education sessions related to Accreditation Standard 1 Management systems, staffing and organisational development include:

ACFI (aged care funding instrument)

Facilitating competency in the workplace

Wellbeing (code of conduct)

Bullying and harassment

Clinical instructor training

Information security awareness

Using equipment (various items).


(See expected outcome 1.6 Human resource management for other mechanisms designed to ensure appropriate staff performance).

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 has policies, procedures and processes to ensure each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Care recipients, representatives, and staff are made aware of internal and external complaints mechanisms through the residents’ handbook, the residents’ agreement, newsletters, complaints forms and residents/relatives’ meetings. There is a procedure to ensure any complaints raised are recorded for review, action, follow up and feedback as appropriate. In our interviews, most of the care recipients said staff follow up when they raise things with them, while two said this happens some of the time. Care recipients and representatives advise they feel comfortable approaching management about any concerns or suggestions they may have.

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 has documented its vision, values, philosophy, objectives and commitment to quality. These elements are encapsulated in Bupa’s purpose, promise and values statements, which are communicated to all stakeholders in the home. The statements are on display in various locations throughout the home, as well as on the Bupa intranet. In addition, staff are made aware of the statement through its staff recruitment, orientation and education processes, staff meetings and other communication.

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 in operation a system of human resource policies and procedures. This system ensures appropriate staffing and skills levels for quality service provision, in accordance with the Accreditation Standards and the home’s philosophy and objectives. The system includes appropriate recruitment and selection processes, induction/orientation, education, and performance management. There are also processes to ensure that staffing levels are sufficient to cater for the mix of care recipients, their changing needs and the demands of the home’s daily routine. We noted that many care and other staff have obtained qualifications and/or attended specific education relevant to their job roles. Most care recipients said staff know what they are doing, while one did not agree.


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


The home has a system in place to appropriately monitor and manage stocks of goods and equipment to provide quality service delivery. Medical and nursing supplies are managed by one of the home’s Care Managers. A physical inventory is undertaken each month and relevant stores are replenished using Bupa’s approved listings. Outbreak and emergency blackout kits were also observed in the home’s inventory. General supplies including PPE, paper towels, toilet paper, chemicals and preventative maintenance are managed by the home’s Maintenance Officer. Physical inventory is conducted weekly with a lead time of approximately one day between ordering and delivery. Chemicals are safely stored on racks in secured cupboards. Adequate stocks of inventory and equipment was observed during the audit and equipment was in a satisfactory state of repair.

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


Our observations, document review and interviews indicated effective information management systems are in operation and support the range of functional areas in the home. The care recipient information system includes administration forms, residents’ handbook, resident agreements, residents’ meetings, newsletters, care recipient assessments, care plans and clinical records. Staff communication systems are in operation to ensure relevant information provision to, and between, staff. These systems include a range of meetings, access to computers, distribution of hardcopy materials, staff noticeboards and induction and training. The home has appropriate security and back up procedures for computer-based information. We observed care recipient and staff records are kept in secured areas to help ensure appropriate security and confidentiality of information. Non-current records are archived and applicable destruction procedures are followed. The majority of care recipients said staff explain things to them most of the time or always, while two said this happens some of the time.

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 has systems and processes to ensure externally sourced services are provided in a way that meets service requirements. Bupa maintains a listing of approved external service providers. Head office is responsible for conducting criminal history checks and managing contracts with approved contractors while the home’s General Manager manages the process for locally sourced providers including Physiotherapists, entertainment staff and hairdressers. Contractors are provided with induction to the facility and are informed about the home’s fire and evacuation procedures by the Maintenance Officer. Staff and care recipients generally expressed satisfaction with quality and timeliness of services provided to the home.


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.



The home’s well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 2 Health and personal care.

Examples of specific improvements relating to Standard 2 include:

With support from the Bupa organisation, the home has introduced a clincial capability framework which is used with registered nurses and care staff to assess and identify their educational needs and develop individual learning plans.

The home has developed the in-house capacity to use a syringe driver, operated by its own specially trained registered nurses, to administer medications for symptom management in care recipients receiving palliative care. The benefit to the care recipients is that this specialised nursing care can now be provided onsite, rather than them being transferred to hospital.

Through the employment of an additional physiotherapy aide, the home has increased its capacity to provide mobility and rehabilitation program. The home’s management advises this has assisted with care recipients’ mobility, dexterity, independence and pain management.

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”.


The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard 2 Health and personal care.

Examples of regulatory requirements in relation to Accreditation Standard 2 include:

Having appropriate arrangements in operation to ensure the correct management and administration of medications

Monitoring relevant registrations of medical, nursing and allied health professionals

Having policies and procedures in operation to ensure the Department of Health is notified if care recipients are reported missing without explanation and the police are notified.




The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 2 Health and personal care.

Examples of recent education sessions related to Standard 2 include:

Clinical assessments, care planning (using electronic care system)

Medication management (various)

Malnutrition

Continence aids and management

Falls prevention and management

Pain management, chronic pain management

Pressure area care, wound management, wounds and nutrition

Dementia care (various aspects), behaviour management

Parkinson’s disease, motor neurone disease

Dysphagia training

Syringe driver training

Reporting processes for missing care recipients (incorporated in elder abuse education).

The education program is reinforced by competency assessments in appropriate areas. In addition, care staff have or are obtaining relevant certificate level qualifications.

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


The home has mechanisms to ensure care recipients receive clinical care that is appropriate to their needs and preferences. Care needs are identified on entry and on an ongoing basis through a review and transfer of information, consultation with the care recipient and/or their representative and assessment processes. Individual care plans are developed by qualified staff and reviewed regularly. There are processes to ensure staff have access to current information to inform care delivery. Care recipients' clinical care needs are monitored, evaluated and reassessed through incident analysis, reviews and feedback. The home regularly reviews and evaluates the effectiveness of the clinical care system and tools used. Changes in care needs are identified and documented. Where appropriate, referrals are made to health professionals. A medical practitioner is on staff and on the premises five days a week. Staff interviews demonstrate they are knowledgeable about the care needs of individual care recipients and procedures related to clinical care. One care recipient stated they were not confident in care staff knowledge. The remainder of care recipients and representatives interviewed stated they are satisfied with the clinical care being provided.


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”.


Care recipients' specialised nursing care needs are identified through assessment processes on entry to the home. Care is planned and managed by appropriately qualified staff. This information, together with instructions from medical officers and health professionals is documented in the care plan. Specialised nursing care needs are reassessed when a change in care recipient needs occurs and on a regular basis. The home's monitoring processes identify opportunities for improvement in relation to specialised nursing care systems and processes. Staff have access to specialised equipment, information and other resources to ensure care recipients' needs are met. Specialised nursing care is delivered by appropriately qualified staff consistent with the care plan. Specialised nursing care provided includes complex pain management, complex Parkinson disease management, oxygen therapy, complex wound care, diabetes management and infection management. Care recipients and representatives interviewed are satisfied with how care recipients' specialised nursing care needs are managed.

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”.


The home has systems to ensure care recipients are referred to appropriate health specialists in accordance with their needs and preferences. Document review shows care recipients are referred to health professionals when necessary including dietician, occupational therapy, psycho-geriatrician, podiatry, specialist mental health service for older persons, specialist physicians and surgeons. Health specialist directives are communicated to staff and documented in the care plan and care is provided consistent with these instructions. Specialised equipment recommended by health specialists is sourced and staff receive training so that clinical care is optimised. Staff practices are monitored to ensure care is in accordance with the care recipients' needs and preferences. Staff support care recipients to attend external appointments with health specialists. Care recipients and representatives interviewed stated they are satisfied referrals are made to appropriate health specialists of their choice and staff carry out their instructions.

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


The home has systems and processes to ensure care recipients’ medication is managed safely and correctly. We observed qualified and trained staff using an accredited pre-packed medication system to administer prescribed medications to care recipients. Staff explained and demonstrated practices and protocols used to ensure care recipients receive their medications safely and correctly including care recipients who chose to self-administer prescribed medications. Evaluation and review of care recipients’ prescribed medication is regularly undertaken by their doctors. The medication management system is regularly monitored through the home’s internal auditing program, its organisation’s medication


management committee, and external auditing. All medication incidents are documented and reported to management and the home’s response including follow up action occurs in a timely manner. Care recipients and representatives are satisfied with the way staff manage care recipients’ medication needs.

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


Care recipients' pain is identified through assessment processes on entry to the home and as needs change. Specific assessment tools are available for care recipients who are not able to verbalise their pain. Care plans are developed from the assessed information and are evaluated to ensure interventions remain effective. Medical officers and allied health professionals are involved in the management of care recipients' pain. The home's monitoring processes identify opportunities for improvement in relation to pain management systems and processes. Staff assess care recipients' verbal and non-verbal indicators of pain and implement appropriate actions, including utilising a range of strategies to manage comfort levels. Care recipients and representatives interviewed are satisfied care recipients' are as free as possible from pain.

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


The home has processes for identifying and managing care recipients' individual palliative care needs and preferences. Assessments are completed with the care recipient and/or representative to identify end of life care wishes and this information is documented in a palliative care plan. The home uses a multidisciplinary approach that addresses the physical, psychological, emotional, cultural and spiritual support required by care recipients and their representatives. There is a supportive environment, which provides comfort and dignity to the care recipient and their representatives. Care recipients remain in the home whenever possible, in accordance with their preferences. Referrals are made to medical officers, palliative care specialist teams and other health specialist services as required. Staff practices are monitored to ensure the delivery of palliative care is in accordance with the end of life plan. Staff described a range of interventions they employ when caring for terminally ill care recipients to ensure their pain is managed and their comfort and dignity maintained. Care recipients and representatives interviewed are satisfied care recipients' comfort, dignity and palliative care needs are maintained.

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


Care recipients' nutrition and hydration requirements, preferences, allergies and special needs are identified and assessed on entry. Care recipients' ongoing needs and preferences are monitored, reassessed and care plans updated. There are processes to ensure catering and other staff have information about care recipient nutrition and hydration needs. Staff monitor care recipients' nutrition and hydration and identify those care recipients who are at


risk. The home provides staff assistance, equipment, special diets and dietary supplements to support care recipients' nutrition and hydration. Staff have an understanding of care recipients' needs and preferences including the need for assistance, texture modified diet or specialised equipment. Staff practices are monitored to ensure nutrition and hydration needs are delivered in accordance with care recipients' needs and preferences. Care recipients and representatives interviewed are satisfied care recipients' nutrition and hydration requirements are met.

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


Care recipients' skin care requirements, preferences and special needs are assessed and identified, in consultation with care recipients and/or representatives. Care plans reflect strategies to maintain or improve care recipients' skin integrity and are reviewed regularly. Skin care needs are monitored, evaluated and reviewed as required. Referral processes to other health specialists are available if a need is identified. The home's monitoring processes identify opportunities for improvement in relation to skin care; this includes a process for documenting and analysing incidents relating to skin integrity. Staff promote skin integrity through the use of moisturisers, pressure relieving devices, repositioning, frequent walks and safe manual handling techniques. Registered nurses provide wound care in liaison with care recipients’ doctors and refer them to wound care specialists as required. Care recipients and representatives interviewed are satisfied with the assistance provided to maintain skin integrity.

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


Care recipients' continence needs and preferences are identified during the assessment process and reassessments occur as required. Strategies to manage care recipients' continence are documented in the care plan and regular evaluation occurs to ensure strategies remain effective. Care staff have an understanding of individual care recipients' continence needs and how to promote privacy when providing care. Changes in continence patterns are identified, reported and reassessed to identify alternative management strategies. Equipment and supplies such as continence aids are available to support continence management. The home's monitoring processes identify opportunities for improvement in relation to continence management; this includes the collection and analysis of data relating to infections. Staff are conscientious of care recipients' dignity while assisting with continence needs. Care recipients and representatives interviewed are satisfied with the support provided to care recipients in relation to continence management.

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


The needs of care recipients with challenging behaviours are identified through assessment processes and in consultation with the care recipient, their representative and/or allied health


professionals. Individual strategies to manage responsive behaviours are identified and documented in the care plan and are regularly evaluated to ensure they remain effective. The home practices a minimal restraint policy; and no restraints were in use at the time of the reaccreditation audit. The home's monitoring processes identify opportunities for improvement relating to behaviour management; this includes the collection and analysis of behavioural incident data. Staff have an understanding of how to manage individual care recipients' responsive behaviours. Lifestyle programs at the home are integral to the behaviour management interventions. Care recipients and representatives interviewed said staff are responsive and support care recipients with behaviours, which may impact on others.

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


The home has programs to maximise each resident’s mobility and dexterity. The home engages external physiotherapists to consult with and assess care recipients’ physiological, mobility and dexterity needs and abilities to develop plans to achieve optimum levels. Physiotherapists conduct a full mobility and dexterity re-assessment every four months for each resident and consult with nursing staff regularly about individual care recipients programs. Care recipients’ progress with exercise and activities programs, including falls prevention programs and recreational activities, is closely monitored and recorded. The home has an adequate supply of physiotherapy and mobility aids and staff are regularly trained in manual handling. Care recipients said they have access to assistance when needed. Except for one care recipient, the majority said they are encouraged to do as much as possible for themselves.

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


Care recipients' oral and dental health needs are identified through assessment processes and in consultation with the care recipient and/or their representative. Care strategies are documented on the care plan and are regularly evaluated and reviewed to ensure care recipients' changing needs are met. The home's monitoring processes identify opportunities for improvement in relation to oral and dental management systems and processes, including clinical monitoring processes and consultation. Equipment to meet care recipients' oral hygiene needs is available. A mobile dental service visits the home regularly to provide increased access to dental services. Care recipients have their choice of dentist. Staff provide assistance with oral and dental care and where necessary referrals are made to health specialists such as dentists. Care recipients and representatives interviewed are satisfied with the assistance given by staff to maintain care recipients' teeth, dentures and overall oral hygiene.

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



Sensory losses are identified through assessment processes and in consultation with care recipients and/or their representative. Care plans identify individual needs and preferences and are reviewed regularly. Care recipients are referred to health specialists, such as audiologists and optometrists, according to assessed need or request and are assisted to attend appointments as required. The home's monitoring processes identify opportunities for improvement in relation to how sensory loss is managed, including clinical monitoring processes and consultation with care recipients, representatives and health professionals. Staff receive instruction in the correct use and care of sensory aids and are aware of the assistance required to meet individual care recipients' needs. The homes physiotherapist provides guidance to staff on managing mobility and care in relation to sensory loss of the skin or balance. Care recipients and representatives interviewed are satisfied with the support provided to manage care recipient sensory needs.

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


Care recipients' sleep patterns, including settling routines and personal preferences, are identified through assessment processes on entry. Sleep patterns are monitored hourly for days to assist in developing individualised plans for sleep. Care plans are developed and reviewed to ensure strategies to support natural sleep remain effective and reflect care recipients' needs and preferences. The environment is optimised to ensure it supports natural sleep and minimises disruption. Care recipients experiencing difficulty sleeping are offered a range of interventions to promote sleep, including aromatherapy, activity patterns, soft music, and warm drinks. Where appropriate, medical officers are informed of sleep problems. Environmental and clinical monitoring processes identify opportunities for improvement in relation to sleep management. Staff support care recipients when normal sleep patterns are not being achieved. Care recipients and representatives interviewed are satisfied support is provided to care recipients and they are assisted to achieve natural sleep patterns.


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.



The home’s well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 3 Care recipient lifestyle.

Examples of recent improvements relating to Standard 3 include:

As part of the Bupa organisation, the home has implemented the ‘Person first’ approach, which it defines as putting the person living with dementia, their experiences, well-being, needs and feelings at the centre. It is about seeing the person first and the dementia second. This is an ongoing program, which the home continues to enhance. In the last year, the home has appointed three person first trainers and conducted extensive person first education for staff. The home’s management advises that the process is supporting staff to work in a truly person centred way.

The home has commenced participation in the Bupa volunteer program. The program, which involves considerable numbers of high school students, enables the home to provide increased group and ono-on-one activities for care recipients especially on weekends. The ono-on-one activities include cards, board games and chatting.

The home has introduced a program of regular visits by pre-school children. These visits have shown that they provide positive interactions for care recipients. They are keenly anticipated. In addition, the visits assist with building and maintaining the care recipients’ ties with the community.

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”.


The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard 3 Care recipient lifestyle.

Examples in relation to regulatory requirements for Standard 3 include:

Having various arrangements in operation to meet obligations regarding staff and care recipients’ confidentiality and privacy provisions

Ensuring care recipients’ security of tenure and informing them of their rights and responsibilities

Having mechanisms to ensure the appropriate reporting of suspected or alleged incidents of elder abuse.




The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 3 Care recipient lifestyle.


Protecting residents – incident management and reporting incidents including compulsory reporting

Person first (extensive education program covering various aspects of person centred care).

Moreover, various care recipient lifestyle issues such as privacy and dignity are covered indirectly in the staff education program in the treatment of issues relating to care recipients’ health and personal 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".


Care recipients' emotional needs are identified on entry and on an ongoing basis. Processes to assist care recipients include the provision of information prior to entering the home, support during the settling in period, involvement of family and significant others and an individualised lifestyle plan. Emotional support is provided to care recipients on an ongoing basis based. Concerns relating to emotional health are referred to appropriate support services. Care recipients decorate their room with personal items to help create a homelike environment. Lifestyle staff and volunteer programs provide care recipients with emotional support on a one-on-one basis. The home's monitoring processes, including feedback and care reviews. Staff engage with care recipients and support emotional wellbeing in accordance with care recipient preferences. Care recipients and representatives interviewed are satisfied care recipients are supported on entry to the home and on an ongoing basis, including times of personal crisis.

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".


Care recipients' needs and preferences are assessed on entry and on an ongoing basis to ensure there are opportunities to maximise independence, maintain friendships and participate in the life of the community. Consideration is given to sensory and communication needs. Strategies to promote care recipients' independence are documented in the care plan and are evaluated and reviewed to ensure they remain current and effective. The living environment is monitored and equipment is available to ensure care recipients' independence is maximised. The home's monitoring processes including feedback, and


environmental and care reviews, identify opportunities for improvement in relation to care recipient independence. Staff advise that they actively encourage care recipients to do as much for themselves as possible as part of the person first approach to care. In addition, care recipients are encouraged to maintain and develop their social networks. Care recipients and representatives interviewed with one exception are satisfied with the assistance provided to achieve independence, maintain friendships and participate in the community within and outside the home.

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


Care recipients' preferences in relation to privacy, dignity and confidentiality are identified on entry and on an ongoing basis to ensure these needs are recognised and respected. Strategies for ensuring privacy and dignity are planned and implemented; this information is documented in the care plan. The living environment supports care recipients' need for personal space and provides areas for receiving guests. The home's monitoring processes, including feedback, meetings and care reviews, identify opportunities for improvement in relation to the home's privacy, dignity and confidentiality systems and processes. Staff have received education in relation to privacy, dignity and confidentiality and their practices support this. Care recipients and representatives interviewed said staff treat everyone with respect and feel their information is secure.

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".


Care recipients' interests and activities of choice are identified on entry; barriers to participation, past history, and cultural and spiritual needs are recognised. This information is documented and regularly updated to inform staff of care recipients' current preferred leisure choices. A varied program of activities is available and is reviewed and evaluated to ensure it continues to meet the needs and preferences of care recipients. Each area has an activities program that is tailored for the current care recipient’s needs and preferences and includes group, one-on-one and community activities. Games, reading materials and puzzles are located at destination points throughout the home for care recipients to access. Local schools and preschools participate in regular group activities within the home. Family and visitors are welcomed to participate in the activities program. In addition to the program delivered by the lifestyle staff, care staff interviewed participate in delivering one-on-one lifestyle activities to their care recipients and expressed an understanding of the importance of lifestyle in a person first approach. One care recipient stated that they would like organised activities on the weekends, while the majority of care recipients are satisfied with activities and confirm they are supported to participate in activities of interest to them.

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



Individual care recipients' customs, beliefs and cultural and ethnic backgrounds are identified on entry through consultation with the care recipient and their representatives. Relevant information relating to care recipients' cultural and spiritual life is documented in care plans, which are regularly evaluated and reviewed. The home has access to support services such as interpreters and community groups and provision is made for the observation of special days. The home recognises and celebrates culturally specific days with festivities consistent with the care recipients residing in the home, such as Easter, Anzac Day, and Remembrance Day. Care recipients' cultural and spiritual needs are considered in meal planning and the facilitation of leisure activities. The home's monitoring processes identify opportunities for improvement in relation to the way care recipients' cultural and spiritual life is valued and fostered. Staff support care recipients to attend and participate in activities of their choice. Care recipients and representatives interviewed confirmed care recipients' customs and beliefs are respected.

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".


The home has processes to ensure care recipients and their representatives are provided with information about their rights and responsibilities on entry to the home and on an ongoing basis. The home assesses each care recipients' ability to make decisions and identifies authorised representatives where care recipients are not able to make decisions for themselves. Staff are provided with information about care recipients' rights and responsibilities and provide opportunities for the care recipient to exercise choice and make decisions when providing care and services. Staff practices are monitored to ensure care and services delivered are in line with the choices and preference of care recipients. Staff demonstrated their understanding of care recipients' rights to make choices and how to support them in their choices. Care recipients are satisfied they can participate in decisions about the care and services they receive and that staff respect their choices.

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".


The home has processes to ensure care recipients have secure tenure within the residential care service, and understand their rights and responsibilities. On entry, care recipients/ representatives receive a residential agreement and handbook. The residential agreement sets out the standard requirements under the Aged Care Act 1997 including rights and responsibilities, and security of tenure. The charter of care recipients’ rights and responsibilities is displayed in the home. Designated staff discuss the information in the agreement and information pack with each care recipient/representative. In addition, we were advised any proposed relocation of care recipients’ within the home is fully discussed with the care recipients/representatives, and care recipients are supported in their transfer.


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.



The home’s well-developed and effective approach to continuous improvement, described in expected outcome 1.1 Continuous improvement, operates across the four Accreditation Standards, including Standard 4 Physical environment and safe systems.

Examples of improvements relating to Standard 4 include:

The home has installed shade sails in the garden courtyard of one of its care recipient communities, The Orchard. Feedback from a recent care recipient meeting indicates that because of the improvements more people are now using the area.

The home has recently improved the living environment of one of its care recipient communities, Billy’s Farm, by removing the carpet and installing new flooring, and decorating the area with paintings, pictures, plants and other enhancements. The home’s management advises that there has been positive feedback from care recipients and families.

The home is currently conducting a laundry improvement project. This involves streamlining laundry systems to make them more efficient. Key to the changes will be the purchase of different coloured bags for each of the home’s communities to allow separation of personal clothing for washing and distribution. This will ensure more control of the process and better turnaround. The coloured bag system, as well as the recent introduction of a free labelling service, will also assist the easier identification of clothing and reduce the incidence of missing items. The laundry currently operates daily; however, changes to the laundry schedule will result in services operating Monday to Friday only. To compensate for this, the home is increasing the number of staff in the laundry on Mondays to deal with the weekend backlog. The home is also purchasing additional linen supplies to ensure stocks do not run out.

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”.


The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards, including Standard 4 Physical environment and safe systems.

Examples of regulatory requirements in relation to Standard 4 include:

Displaying relevant regulatory information concerning work health and safety legislation


The installation of fire safety systems including sprinklers, displaying the fire safety statement in accordance with legislative requirements, and staff undertaking mandatory fire safety training

Various arrangements to ensure the home meets food safety requirements such as those encompassed in the NSW Food Authority's vulnerable person's food safety scheme and its licensing and audit requirements.



The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard 4 Physical environment and safe systems.


Fire and emergency procedures

Work health and safety (WHS)

Prevention of occupational violence

Manual handling

Infection control, hand washing

Food safety

Chemical awareness

Steam cleaning.

In addition, specific staff have attended training courses related to their specialist roles such as fire coordinator training.

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 144-bed facility comprising three levels including communities such as Billy’s Farm and Apple Yard on level 1, Mulberry Place and Strawberry Fields on level 2 with The Orchard community located on level 3. All care recipient rooms are single rooms with ensuite and are air-conditioned for comfort. Communal lounge and dining, along with access to well-maintained outdoor garden areas with barbeque facilities are located in each community. Staff monitor the general state of community environments and are aware of how to request maintenance and repairs. Care recipients can provide feedback about the living environment verbally to staff or in writing by placing their comments in a suggestion box located in the main foyer. Care recipients commented, and observations generally confirmed, that the state of the living environment is satisfactory.

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



The home’s management team are working to provide a safe working environment that meets regulatory requirements. Management, in conjunction with work, health and safety representatives, work to provide staff with a safe work environment. This is achieved through the delivery of education and training on safe work practices including hazard and incident reporting, and manual handling. It is also done through monitoring the environment for safety risks and hazards and maintaining systems to record and correct identified risks. Personal protective equipment and emergency management kits are maintained and readily available in case of an emergency. Staff are aware of the home’s health and safety processes.

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 are actively working to provide a safe and secure environment for care recipients. The home has a fire and emergency evacuation plan that includes evacuation maps and assembly areas displayed around the home. Staff and contractors are provided with fire and emergency management training on induction and as part of ongoing education. Fire extinguishers and blankets are located at several points 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 logbooks confirmed the currency of the maintenance and inspection schedule. Contractor and visitor sign-in registers help to monitor who enters the home. Access to each of the home’s communities is via security-coded doors. Care recipient’s rooms all have nurse call bells located beside their beds and in bathrooms. One care recipient said they were concerned about their safety in the case of a fire due to poor mobility.

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


The home has systems in place to manage infection control. The clinical management team and registered nurses monitor and manage infection control procedures and guide staff on best practice infection control. Infection control training is provided to staff on induction and through on-going training including the importance of hand washing. Hand sanitizers are positioned in prominent places throughout the home for visitors and staff to use. Effective sanitation and waste disposal practices are exercised at the home. The home has a food safety program and appropriate pest control, waste management, laundry and cleaning practices. Observations revealed consistent practice among staff to reduce infection including hand washing practices, the use of protective equipment, separation of linens and clothing and the use of colour-coded equipment.

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".



The home has systems to manage its hospitality services to enhance care recipients quality of life. Each care recipient’s dietary and nutritional details are communicated to the catering manager on entry to the home to inform catering staff of the care recipient’s personal preferences and dietary needs. Information on care recipient’s allergies and requirements for textured and modified food and fluid is maintained in the home’s kitchen and at serveries within communities. The catering manager is informed of the changing dietary needs of care recipients by care managers. A food safety program guides catering staff regarding food preparation, storage, delivery and serving processes. In our interviews, the majority of care recipients said they like the food most of the time or always, while three said some of the time. One care recipient said they never like the food, but ‘It’s not the food, it’s the way we get it’. There is a program for the routine cleaning of all areas of the home that includes daily cleaning of care recipients’ rooms, communal and service areas along with a ‘spring clean’ to two care recipient rooms on a rotating roster each day. All washing including linens and care recipients’ clothing is conducted on-site. Laundry staff demonstrated appropriate practices for the separation and cleaning of linens and clothing. (An improvement project is currently being undertaken in the laundry. Refer to expected outcome 4.1 Continuous improvement for further details.) Care recipients/representatives confirmed their satisfaction with the level of cleanliness and the laundry services at the home.


Documents

Published_decision_(SA_and_RA) · Web viewCare recipients and representatives interviewed are satisfied with how care recipients' specialised nursing care needs are managed. 2.6Other