Published_decision_(SA_and_RA) · Web viewThe home has laminated several copies of the operating instructions and these are stored with the generators. Maintenance staff run a regular

Tinonee Gardens - The Multicultural VillageRACS ID: 0369

Approved provider: Tinonee Gardens the Multicultural Village Ltd

Home address: 15 Tinonee Road WARATAH NSW 2298

Following an audit we decided that this home met 34 of the 44 expected outcomes of the Accreditation Standards. We decided to vary this home’s accreditation period. This home is now accredited until 15 February 2018.

We made our decision on 15 August 2017.

The audit was conducted on 24 July 2017 to 02 August 2017. The assessment team’s report is attached.

The short period of accreditation will provide the home with the opportunity to develop and implement effective monitoring systems while addressing the areas identified as not met.

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 Not met

1.7 Inventory and equipment Met

1.8 Information systems Not 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.

2.1 Continuous improvement Not met


2.3 Education and staff development Not met

2.4 Clinical care Not met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Not met

2.8 Pain management Not met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Not met

2.12 Continence management Met

2.13 Behavioural management Not 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: Tinonee Gardens - The Multicultural Village Date/s of audit: 24 July 2017 to 02 August 2017RACS ID: 0369 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 Not 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: Tinonee Gardens - The Multicultural Village Date/s of audit: 24 July 2017 to 02 August 2017RACS ID: 0369 3

Audit ReportName of home: Tinonee Gardens - The Multicultural Village

RACS ID: 0369

Approved provider: Tinonee Gardens the Multicultural Village Ltd

IntroductionThis is the report of a Review Audit from 24 July 2017 to 02 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:

34 expected outcomes

The information obtained through the audit of the home indicates the home does not meet the following expected outcomes:

1.6 Human resource management

1.8 Information systems

2.1 Continuous improvement

2.3 Education and staff development


2.4 Clinical care

2.7 Medication management

2.8 Pain management

2.11 Skin care

2.13 Behavioural management

3.6 Privacy and dignity


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Review Audit from 24 July 2017 to 02 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: 187

Number of care recipients during audit: 171

Number of care recipients receiving high care during audit: 165

Special needs catered for: N/A


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

Interviews

Position title Number

Executive Officer 1

Director of Clinical Care 1

Service Managers 2

Clinical Care Coordinators 2

Registered Nurses 8

Care staff 16

Care Recipients and/or Representatives 41

Resident Engagement Manager 1

Quality Manager 1

People and Culture Manager 1

Payroll Manager 1

Finance and Administration Manager 1

Education Coordinator 1

Occupational Therapist 1

Therapy Assistant 1

Activities Officer 1

Maintenance Manager/Laundry Services Manager

1

Maintenance staff 3

Finance Assistant/Work Health and Safety Representative

1

Laundry staff 3

Cleaners 2


Sampled documents

Document type Number

Care recipients’ files 22

Incident reports 43

Medication charts 34

Mandatory reporting folders 4

Activity attendance records 8

Referrals - creative therapy (internal) 3

Referrals – Dementia Services Australia (DSA) (external)

2

Other documents reviewedThe team also reviewed:

‘Changing Seasons’ and ‘Looking Forward Looking Back’ books developed by care recipients and art students

Action plans

Care recipients’ information handbook and residential agreement

Catering information including: notification of change forms, care recipient dietary information forms, catering duty statements, food safety plan folder, likes and dislikes listings, central kitchen and cottage kitchenette cleaning audits, catering roster, recipe cards, catering meeting minutes, temperature records for the delivery, storage, preparation and transportation of meals, fruit and vegetable sanitising records, cleaning schedule, central kitchen food delivery records, pest control records, certificate of calibration for thermometers and infection control audit

Clinical documentation including clinical handover and exception reports, clinical indicator reports (blood glucose levels (BGL), catheters, weights, pressure injury), accident and incident reports and medical reports, advanced care directives, bowel charts, observation records, wound charts, continence management, meals and drinks, skin charts, wound management/dressings, mobility and pain charts, medical officers directives of care, food supplement and special diet list, electronic care documentation, physiotherapist documentation including assessments, care plans, staff handover sheets - Dementia services, Grevillea and Lower Cluster and nurse diaries.

Clinical policies and procedures

Comments and complaints folder

Education folder 2017, education emails from various external education services and education matrix

Laundry cleaning program, laundry audit and safety data sheets

Legislation: police checks, registered nurse registrations, first aid certificates, NSW Food Authority licence

Lifestyle activity calendar, group therapy programs, leisure & lifestyle plans and creative therapy referral folder


Maintenance system including: computerised maintenance log system, external contractors service agreement review register, contractor central listing, contractors handbook, thermostatic mixing valve service records (October 2016) and temperature checks, Legionella testing reports, service agreements, risk assessment on the use of bain marie, testing and tagging of electrical equipment records and laminated operating procedures for the small portable generators

Medication management: medication profiles, allergy alerts, BGL monitoring, international normalised ratio (INR) monitoring, as required medications (PRN), nurse initiated medications (NIM), pharmacy communication, incident reports, drugs of addiction register, medication care plans, medication incidents, medication refrigerator temperature records

Nutrition and hydration management: care recipient dietary requirements, daily menu and dietitian reviews

Roster and computerised roster

Service folder – certificates of currency, police checks and service agreements from various external service providers

Staff handbook

Work health and safety: meeting minutes, risk assessments, hazard reports, work place audit reports, newsletters from industry organisations on work health and safety and staff incidents information

ObservationsThe team observed the following:

Activities in progress including India day lunch in the resource centre

Equipment and supply storage areas including temporary centralised storage arrangements

Interactions between staff and care recipients including lunch and beverage services including presentation and meal tray delivery, staff supervising, use of assistive devices for meals, availability of drinks and a small group observation in Rosemary/Lavender and Jonquil wings

Living environment

Personal protective equipment (PPE) outside care recipients rooms during the outbreak

Cleaning in progress and associated equipment and storage

Menu displayed

Medication administration round and storage of medications

Oxygen cylinders

Sign in and out books

Portable generators

Outbreak kits

Evacuation plans, logbook for fire detection system, fire certificate on display near main panel, inspection tags on fire fighting equipment, mimic panels and main fire alarm system panel


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

Tinonee Gardens - The Multicultural Village (the home) has a quality management system which includes the use of internal audits, feedback and suggestions from staff, care recipients and representatives as well as participating in a commercial benchmarking audit program. Information is discussed at the quality meeting to monitor the improvements. The home also utilises feedback through comments forms to identify any improvements as well as recording compliments and complaints. Staff and care recipients meetings also provide forums through which suggestions for improvements can be discussed. A sample of improvements relating to Standard One includes the following:

The quality manager advised that the organisation moved to another computerised management system to improve reporting and data analysis in August 2016. Data on the aged care funding instrument (ACFI) and care recipient demographic information (not clinical information) has been exported from the previous computerised system.

A workforce review, which commenced at the end of 2016, was undertaken to identify any changes required as part of the development of the new section (Banksia) which is currently under construction. As a result of this review the organisation has created two new senior positions. A director of clinical care was appointed in May 2017 to provide improved oversight of clinical care matters. A people and culture manager was also appointed to manage the human resource system. These areas had previously been managed by the executive officer or service managers.

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 executive officer advised the organisation belongs to various industry organisations and peak aged care bodies which provide periodic updates and industry newsletters. The organisation also subscribes to a commercial legislation updating service which provides hard copy updates of new legislation. Information is also provided from various State and Commonwealth government departments. The executive officer advised information on any changes is sent to the senior managers in various sections. Information is discussed when required at the Board meetings as part of the governance of the organisation. Policies and


procedures are reviewed and ratified by the relevant committees. These are accessible to staff across the home via a shared drive. Staff advised any changes are discussed at staff meetings, education sessions or via memos.

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


The home has a system to assist in ensuring staff members have appropriate knowledge and skills. The organisation sets a series of mandatory education topics which all staff are required to attend. This was confirmed in interviews with staff. The people and culture manager advised feedback on education requests are sourced through staff appraisals, education requests as well as from issues identified at the home. This information is then used to develop the education calendar. Education sessions relevant to Standard One include: workplace bullying and harassment and the aged care funding instrument (ACFI).

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 systems to ensure care recipients and their representatives have access to information regarding the internal and external complaints processes. This includes displaying information about the internal and external complaints system on the noticeboards in each of the cottages. Information on raising complaints is contained within the handbook and residential agreement. These are provided to care recipients and their representatives as part of the entry process to the home. Comments forms and suggestion boxes are located in the cottages to provide access to the internal complaints process. Representatives from the board of management attend the home to speak with care recipients and their representatives. The home has a resident committee and resident representatives for each of the cottages who are able raise issues with management or the board.

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 organisation’s vision, mission and values have recently been reviewed. The new versions have been placed in each cottage on public view. These statements are presented through key documentation such as the handbooks for care recipients and staff. This information is given to all care recipients and/or their representatives and staff on entry to the home or commencement of employment respectively.

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".


Team’s findingsThe home does not meet this expected outcome

The home does not have a system to ensure there is enough appropriately skilled and qualified staff to meet the needs of care recipients. Staffing levels are not being managed to ensure adequate staffing levels and skills mix are maintained. Feedback from staff members indicated that on occasions when other staff are ill relief staff are from nursing agencies and they are not aware of the care needs of the care recipients. Care recipient representatives advised that they are aware that staff are very busy and commented about care needs not being met.

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 to ensure there are adequate supplies of goods and equipment. Staff members said they are provided with sufficient supplies of equipment and goods to provide care and services to the care recipients. Staff in key areas explained the ordering systems and stock rotation process. The home has a maintenance program to ensure all equipment is working effectively. This includes the use of external contractors to service major items of equipment if and when needed.

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


The home does not have an effective information management system. Deficiencies in information management are adversely impacting on care recipients’ clinical care, medication management, pain management, skin care and behaviour management. Effective systems are not in place to ensure accurate, relevant and current information regarding care recipients’ care needs is available to staff. Our review of the home’s information management system identified it to be incomplete and not effective.

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 organisation has systems to monitor externally provided services and goods meet specific requirements. Key information such as insurances and relevant licences for companies and contractors are sought on an annual basis. The home also undertakes an annual renewal of service agreements with service providers when needed. The quality of service provision is monitored on an ongoing basis. Key staff members explained the processes involved to manage any episodes of poor service or goods. Staff members stated any equipment or goods supplied are of good quality.


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 does not have an effective continuous improvement system in place to monitor performance and identify issues relevant to the health and personal care for care recipients. Whilst the home participates in a commercial benchmarking audit program, these audits do not comprehensively cover clinical care. As a result management was not alerted to deficiencies in performance against the Accreditation Standards in a timely manner. Some improvements have been made these include:

The home is involved in the Aged Care Emergency Program (ACE) and the Aged Services Emergency Team (ASET) in the region. An ACE coordinator has provided education for registered nurses on transfer requirements. The home has the contact telephone numbers to enable registered nurses to call the ACE or ASET staff to seek medical advice in emergency situations. In key situation the ASET nurse can call the paramedics to the home if needed to attend to some care situations e.g. attend to sutures.

The organisation has introduced a care placement officer to provide assistance with the community in finding accommodation at the home. The care placement officer can conduct tours of the home and provide pre-admission information.

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


Refer to expected outcome 1.2 Regulatory compliance for information regarding the system to ensure the home complies with legislation and regulations relevant to care recipients’ health and personal care. Administration staff are able to access the Australian Health Practitioner Regulatory Agency (AHPRA) website to verify current registrations for registered nursing staff if required.



Whilst the home has an overarching education program for staff (refer to expected outcome 1.3 Education and staff development regarding the education system) the program for clinical education is not being managed effectively. Deficiencies in staff practices regarding clinical


care were identified in relation to clinical care, medication management, pain management, skin care and behaviour management which indicates they do not have the appropriate knowledge and skills to perform their roles effectively.

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


The home does not have effective systems to ensure care recipients receive appropriate clinical care. Responsibility for clinical governance has recently been established after a period of vacancies in key positions including service manager, clinical care coordinator and registered nurse positions. Oversight of the new clinical documentation system is yet to be achieved by the new clinical management team. The system for assessing, reviewing, evaluating and updating care recipients’ care is ineffective. Information on care plans is inconsistent and incomplete and there is a breakdown in the oversight of accident and incidents involving care recipients resulting in appropriate clinical care not being provided. Care notes do not consistently show care that is being delivered or exceptions to planned care.

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 care charts are used to assist in monitoring specialised needs. Registered nurses liaise with external health professionals including the local hospitals and outreach teams to ensure care recipients’ specialised nursing care needs are met. Registered nurses said they have access to resources and 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”.


Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates referrals for care recipients are arranged with appropriate health specialists. The service manager/clinical care co-ordinator/registered nurse has regular access to a physiotherapist, podiatrist, speech pathologist, optometrist and community clinical nurse consultants. Monitoring is achieved through the handover of key care recipient information to relevant staff. When required, care recipients’ medical officers are alerted and consulted. Care recipients/representatives stated referrals are generally made to the appropriate health specialists in accordance with care recipients’ needs and preferences.


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


Management is not able to demonstrate care recipients’ medication is managed safely and correctly. Medication auditing does not include the home’s computerised medication record system. Staff practices are consistent with the home’s policy but alerting systems are not in place to prevent incorrect administration related to missed medications.

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


The home does not have an effective system to ensure all care recipients are as free as possible from pain. Care recipients pain is not regularly monitored; regular pain assessments are not completed. Pain management plans are generic or non-existent and not specific to individually identified needs. There are no systems to ensure care plans are regularly reviewed, evaluated or updated. Care recipients reported they are in pain and observations made by the team indicate some of them have pain that is not managed effectively.

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


The home has a suitable environment and culture to ensure the comfort and dignity of terminally ill care recipients is maintained. Where possible, care recipients' end of life wishes are identified and documented on entry to the home or at an appropriate time thereafter, through the assessment process. The home has specialised clinical and comfort devices to ensure and maintain care recipient palliation needs and preferences. The local clergy visit and are available to provide emotional and spiritual support. The home has a variety of resources and equipment that families, friends and staff can use for the benefit of the care recipient. Staff receive ongoing education and describe practices appropriate to the effective provision of palliative care. Care recipients/representatives said the home’s practices maintain the comfort of terminally-ill care recipients.

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


The home has processes to provide care recipients with adequate nourishment and hydration. Care recipients are assessed for swallowing deficits and other medical disorders, allergies, intolerances, food likes and dislikes, as well as cultural or religious aspects relating to diet. Provision is made for care recipients who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information on care recipient’s nutrition and hydration is recorded and sent to the central kitchen. Care


recipients are provided with assistance at meal times and assistive cutlery and crockery are available. The home monitors nutrition and hydration status through staff observations and recording of care recipients’ weights with variations assessed, actioned and monitored. Care recipients are referred to a dietician and/or speech pathologist when problems arise with nutrition. Care recipients/representatives are satisfied they are able to have input into menus and care recipients’ meals.

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


Management cannot demonstrate care recipients’ skin integrity is consistent with their general health. While staff monitor care recipients’ skin as part of daily care, changes in skin integrity are not always identified and/or referred to their medical practitioner or allied health services for review. Registered nurses oversee all wound dressings however wound charts are not effectively evaluated and updated. There is not an effective system to identify and manage changes in care recipients wound care needs. Wounds are monitored but information to objectively track wound improvement or deterioration is not recorded. Assessment processes do not provide information used in the development of a care plan. Care recipients and representatives are not satisfied with the manner in which staff manage skin and wound care.

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


There are systems to ensure care recipients’ continence is managed. Documentation and discussions with staff show continence management strategies are developed for each care recipient. Care staff report they assist care recipients with their continence programs and monitor care recipients’ hygiene and skin care needs. Care staff said they are trained in continence management including the use of continence aids and the assessment and management of urinary tract infections. Bowel management strategies include daily monitoring. There are generally supplies of continence aids to meet the individual care recipient’s needs. Care recipients said they are generally satisfied with the continence care provided to meet their needs.

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


Management is not able to demonstrate care recipients with responsive behaviours are managed effectively. The home’s systems for behaviour assessment, development of behaviour management plans and review are ad hoc. These processes are not ensuring the care recipients’ behaviours are identified, evaluated or clinically reviewed. Referral to behaviour specialist occurs but recommendations are often not implemented or implemented and not evaluated for effectiveness. While some behavioural assessments are attended, and some behaviour charts are used incident management strategies do not always result in timely review and referral for treatment recommendations. Care planning processes related


to behaviour management are not effective and information recorded on them when they are completed is generic. Care recipients and representatives are not satisfied with the manner in which staff manage other care recipient’s behaviours to reduce the impact on them

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


Care recipients are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by care recipients for transferring and mobility. A care recipient’s mobility status and falls risk are assessed by a registered nurse/physiotherapist/occupational therapist when the care recipient moves into the home and as their needs change. Individual treatments include massage, heat treatments and exercises. Falls prevention strategies include the completion of risk assessments. Interventions noted include group exercises and the provision of specialised equipment such as mobility aids, ramps and handrails. Staff are able to discuss an individual care recipient’s needs and were seen assisting care recipients to mobilise within the home. Care recipients said they are satisfied with the program and assistance they receive from staff.

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


The home has systems to ensure care recipients’ oral and dental health is maintained. Care recipients’ dental needs are identified through consultation with the care recipient and representative on a care recipient’s entry to the home and as their needs change. Appropriate dental health is planned and staff are informed of the care recipients’ needs. The care recipient’s medical officer is consulted if there are any needs and a referral may be made to a specialist and/or a dentist for further assessment or treatment. Ongoing care needs are identified through care recipients’ feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Care recipients are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Care recipients/representatives said they are satisfied with the oral and dental care provided to them.

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


The home’s staff identify care recipients sensory losses on entry and assist them in managing devices use to minimise the loss. The home’s activity program features activities to stimulate care recipients’ sensory functions. Staff described types of group and individual activities which encourage active participation from care recipients with sensory deficits. Staff said they employ various strategies to assist care recipients with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance care recipients’ participation, adapting the environment to ensure it is conducive to maximising care recipients’ enjoyment and participation in the chosen activity. Care


recipients/representatives said they are satisfied with the home’s approach to managing care recipients’ sensory losses.

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


The home assists care recipients to achieve natural sleep patterns through choice of time for going to bed and rising, and staff support at night. Staff are able to explain the various strategies used to support care recipients sleep. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, repositioning and night sedation if ordered by the medical officer. Care recipients can use the nurse call system to alert the night staff if they have difficulties in sleeping. Care recipients stated they sleep well at night. Care recipients/representatives said they are satisfied with the home’s approach to care recipients’ sleep management.


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



Refer to expected outcome 1.1 Continuous improvement regarding the continuous improvement system which exists in the home. Examples of recent improvements in relation to Standard Three include the following:

‘Changing Seasons’ and ‘Looking Forward Looking Back” programs – these programs are providing care recipients and their representatives with opportunities to reflect on the move into aged care and reminisce about their life. Part of the program (Changing Seasons) links three care recipients with three Fine Arts students from Newcastle University. The students work with the care recipients on art projects which are incorporated into a printed book which includes stories from various periods in their life. The ‘Looking Forward Looking Back” program runs with four care recipients and their representatives. These sessions run over a ten week period with each week allocated to a particular stage in a care recipient’s life. Nine weeks are allocated to the care recipient with only the representative attending week ten. Art work and a life story are also produced from these sessions. The sessions are held in the chapel. These programs have had positive feedback from representatives and care recipients and a good participation rate by care recipients.

The home has introduced changes to the dining experience as a result of changes in care recipients weight, nutrition and behaviours. An initial trial was undertaken in September 2016 in Camellia and Gumnut cottages to improve the environment and meal focus and make the dining experience better for care recipients. Stackable stools were purchased to provide seating for staff when they are assisting care recipients with their meals. Suitable music is played during the meal service to enhance the atmosphere. Bain maries were also installed to enable hot meals to be plated in the cottage and improve the presentation as well as extend the meal service period if needed. Improvements included weight being maintained or increased for some care recipients. As a result of the trial the program has been extended into Daffodil cottages and is being progressively extended into the other cottages. In the Daffodil cottages changes were also made to the size of the dining tables to seat four people at each table.

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”.


Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s system to ensure compliance with legislation and regulations relevant to care recipients’ lifestyle. The home maintains relevant registers such as a mandatory reporting register. The organisation subscribes to a service which provides an up to date version of the residential


care agreement to ensure new care recipients or their representatives are provided with the most current version when required.



Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Education sessions provided via the mandatory education program include the topic of compulsory reporting, confidentiality and dignity, privacy and cultural awareness.

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".


The home has programs designed to support care recipients to adjust to life in a new environment and meet their on-going emotional needs. The home’s creative therapy team runs a new admission program called ‘Changing Seasons’. The program is delivered in small group sessions over several weeks and care recipient’s family and relatives are encouraged to participate in the program. Care recipients are encouraged to reflect on their lives, likes and passions and to create a memory book to capture pivotal moments in their lives. The program is designed to help build and strengthen care recipient relationships with partners, relatives and fellow residents. The program addresses grief, loss and change and helps relatives gain an understanding of the nature of their relationships with loved ones now and into the future. Staff said that they are seeing real break-throughs with care recipients allowing their emotions to show through.

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 makes provision for and encourages care recipients’ to live as independently as possible and participate in community life. Care recipient’s life history, level of independence and their need for assistance is assessed on entry to the home. The home facilitates care recipients’ links with the community through bus trips, shopping, art exhibitions, ‘mums and bubs’ visits, pet therapy etc. and by providing opportunities for care recipients to interact with volunteers and other visitors. Care recipients and representatives said they are satisfied with opportunities to participate in community life and exercise independence.

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



The home manages care recipients confidentiality through ensuring pertinent information is kept secure either in a locked office or within the home’s electronic care management system. Each care recipient has their own room with an ensuite bathroom which assists in maintaining their privacy. However some staff members work practices with regard to the management of continence do not ensure that care recipients’ right to dignity is recognised and respected.

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 are encouraged and supported to participate in a wide range of activities of interest to them. The home’s leisure and lifestyle staff plan and deliver a wide variety of programs and activities to cater to the interests of care recipients. The home’s activities include large and small group activities such as bingo, games, musical concerts, reminiscing sessions, poetry and story-telling, pet therapy and outdoor walks. Staff also engage care recipients in sensory-based activities including taste and touch activities. The home’s creative therapy team provide hand massage and aromatherapy designed to relax and calm care recipients’ mood. They also run a drumming circle, open studio art-based program and small group emotive programs namely ‘Looking Forward, Looking Back’ and ‘Changing Seasons’. Care recipients and representatives were satisfied with the range of activities and programs available at the home. Staff were observed supporting care recipients to attend music sessions and small group concerts.

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


The home endeavours to foster care recipients’ interests, customs, beliefs, cultural and ethnic backgrounds. Church services are held in the home’s chapel several times each month for care recipients wanting to attend regular Christian services. A variety of culturally themed morning and afternoon teas, namely Polish and Italian, are hosted to cater to the home’s culturally diverse care recipients. Each month the home runs a culturally themed lunch menu and activities including Italian Day, Hawaiian, Chinese, Indian, English and Scottish days etc. Staff dress in culturally appropriate attire and actively participate with care recipients and relatives in cultural dance, singing and ritual activities in the home’s recreation centre. Staff said that themed events are generally well patronised and provides an opportunity for care recipients, relatives and staff to interact. Care recipients and representatives said they enjoy the special events each month.

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 provides care recipients and their representatives with an information pack on entry to the home informing them about their rights and responsibilities as residents of Tinonee Gardens. The home’s initial assessment includes care recipient's ability to make decisions and identifies authorised representatives, in the case that decisions need to be made on the care recipient’s behalf. Care recipient’s choice on the timing, delivery and need for assistance with personal hygiene is accommodated as much as possible in their activities of daily living. The home uses several methods to foster care recipient participation in decision making including resident meetings, newsletters, a complaints process, surveys and feedback forms. Care recipients said they are generally satisfied with the way they are consulted and able to participate in decisions about the care and services they receive, and 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 endeavours to ensure care recipients have secure tenure within the residential care service, and understand their rights and responsibilities. On entering the home, care recipients and their representatives are provided with a resident’s handbook that outlines their rights and responsibilities whilst living at the home. Care recipients enter into an agreement to formalise their occupancy in the home. Copies of the care recipients charter of rights was observed throughout the home. Care recipients and their representatives said they are satisfied with the information provided regarding their 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.



Refer to expected outcome 1.1 Continuous improvement for information regarding the continuous improvement system which exists in the home. Examples of recent improvements in relation to Standard Four include the following:

Improvements have been made to the sensory gardens in Daffodil, HoneyGem and the upstairs area in Grevillea. Previously there had been limited external areas for care recipients to use. Work was undertaken to extend some garden areas and improve the landscaping to improve access for care recipients. Improvements were also undertaken with the plants used in the new garden areas. On the first floor in Grevillea improvements were made to enable care recipients to access an external area.

In response to severe storms which had occurred in the Newcastle area the home purchased three small portable generators. In the event of a power outage staff can access the generators to run key medical equipment such as oxygen concentrators. The home has laminated several copies of the operating instructions and these are stored with the generators. Maintenance staff run a regular program to test the generators are operating effectively and ensure no old fuel is in the tanks.

The home has improved the trending of staff incidents since the introduction of the new computerised documentation system. The work health and safety representative advised the organisation had identified an improvement in the number of staff incidents being recorded since the introduction of the system.

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”.


Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s system to ensure compliance with legislation and regulations relevant to the physical environment and safe systems. This regulatory system includes compliance with legislation regarding environmental and fire safety systems and the NSW Food Authority requirements.




Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Staff advised the home conducts a series of mandatory education sessions on manual handling, fire safety and infection control. The new members of the work, health and safety committee have also attended committee 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".


Management is working to provide a safe and comfortable environment consistent with the care recipients’ care needs. Care recipients and their representatives expressed satisfaction with the living environment and said care recipients can personalise their rooms with personal belongings, mementoes and furnishings. The home has three sections (Daffodil which consists of five single storey cottages (Buttercup, Jonquil, Minnow, Gumnut and Camellia), Willow, which consists of four single storey cottages (Blue Gum, Bottlebrush, Wattle and Lilly Pilly) and Grevillea with five cottages (the main Grevillea building is a two storey structure with Rosemary and Lavender on the first floor and HoneyGem and Juniper on the ground floor and a stand-alone cottage Palmcourt). Each cottage has its own lounge and dining areas as well as outdoor areas. Care recipients representatives said the home is well maintained and free of clutter. The home has a maintenance program to ensure the home is well maintained. The safety and comfort of the living environment is monitored through feedback as well as incident/accident reports, hazard reports and ongoing observations by staff.

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 and staff are active in providing a safe working environment that meets regulatory requirements. Staff members are provided with information on workplace safety including manual handling and fire safety as part of the orientation program and ongoing education program. Work health and safety issues are discussed when needed at meetings. The home has a system which manages workplace safety including the identification of hazards. Staff members interviewed on this topic explained their knowledge on safe work practices and said they receive training to support them in ensuring a safe working environment.

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


The home has systems to minimise fire, security and emergency risks in the home. As part of the home’s safety system there are external contractual arrangements for the routine checking and maintenance of the fire-fighting equipment, including a sprinkler system and internal fire alarm system. Staff advised fire safety is included as part of the orientation


sessions for new staff members as well as part of the compulsory education program. Key staff members were able to explain the procedures to be followed in the event of a fire or storm damage to the building. The home has access to three small portable generators which can be used to keep equipment, such as oxygen concentrators, operating. Key information on a range of other emergency situations is located in emergency procedure flip charts which are located near the telephones.

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


The home has an established infection control system. Service managers’ are responsible for implementing monitoring infection control procedures within their respective clusters. On induction, staff are given a full day of training that includes infection control. Staff are aware of and were observed implementing practices to minimise the incidence and impact infectious disease. Care recipients and representatives said that they are advised of and kept informed about actual and potential outbreaks. 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 and monitors laundry and cleaning practices.

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 the hospitality services provided to care recipients. Information on food preferences as well as dietary needs is obtained on entry to the home and referred to the central kitchen. The catering manager advised the registered nurses provide information to alert them to any changes to care recipients’ dietary requirements. A food safety system provides ongoing monitoring of food through the delivery, storage, cooking and serving processes. There is a program for the routine cleaning of all areas of the home to ensure the home is well maintained. Linen as well as care recipients clothing are washed on-site. Staff said they have adequate stocks on hand and additional supplies can be sourced when needed. Care recipients and their representatives spoke favourably about the catering and laundry services. Care recipients and their representatives generally spoke favourably about the cleaning services.


Documents

Published_decision_(SA_and_RA) · Web viewThe home has laminated several copies of the operating instructions and these are stored with the generators. Maintenance staff run a regular