RFBI Bellorana Hostel - Quality Agency Bellorana Hostel RACS ID 0019 ... partnership between each...

RFBI Bellorana Hostel

RACS ID 0019 15-23 Watson Street

BELLINGEN NSW 2454

Approved provider: Royal Freemasons' Benevolent Institution

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 19 February 2018.

We made our decision on 06 January 2015.

The audit was conducted on 02 December 2014 to 04 December 2014. The assessment team’s report is attached.

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

Home name: RFBI Bellorana Hostel RACS ID: 0019 2 Dates of audit: 02 December 2014 to 04 December 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision

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 care

Principle:

Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.





2.4 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 Met


Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service 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 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, 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


Audit Report

RFBI Bellorana Hostel 0019


Introduction

This is the report of a re-accreditation audit from 02 December 2014 to 04 December 2014 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.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 02 December 2014 to 04 December 2014.

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

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

Assessment team

Team leader: Christine Logan

Team member/s: Shirley Beaumont Owles

Approved provider details


Details of home

Name of home: RFBI Bellorana Hostel

RACS ID: 0019

Total number of allocated places:

63

Number of care recipients during audit:

44

Number of care recipients receiving high care during audit:

23

Special needs catered for: N/A

Street/PO Box: 15-23 Watson Street

City/Town: BELLINGEN

State: NSW

Postcode: 2454

Phone number: 02 6655 2777

Facsimile: 02 6655 2999

E-mail address: [email protected]

http://www.comlaw.gov.au/Details/F2011L00821

mailto:[email protected]


Audit trail

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

Interviews

Category Number

General manager 1

Care manager 1

Clinical supervisor 1

Team leaders 2

Care staff 6

Acting quality officer 1

Administration staff 1

Physiotherapist 1

Care recipients/representatives 11

Maintenance manager 1

Recreational activity officers 2

Catering supervisor 1

Hotel services manager 1

Cleaner 1

Catering assistant 1

Sampled documents

Category Number

Care recipients’ files 5

Accident/incident forms 6

Palliative care wishes 7

Primary medication charts 8

Nurse initiated medication charts 14

Care recipients’ administration files 4

Personnel files 5


Other documents reviewed

The team also reviewed:

Activity program documentation - assessments, care plans, programs, attendance lists and evaluations

Care recipients’ administration files including resident agreements, enduring power of attorney and guardianship, advanced health care directives, consent for photos, consent to exchange health information, palliative care program, smoking policy, consent for bed rails

Care recipients’ and family survey results

Care recipients’, staff and volunteers’ handbook

Catering documentation including NSW food authority certificate, dietary preference forms, events calendar, approved suppliers, care recipient birthday list, communication book, temperature monitoring chart, 24 hr cook/chill records, catering action sheet, mealtime management plan, information folder

Cleaning documentation including duties checklist, guidelines, vacated room checklist, curtain cleaning schedule

Clinical care documentation including assessments, care plans, progress and medical officers notes, behaviour, wound and pain management; nutrition and hydration preferences, requirements and weight monitoring; diabetic management including blood glucose level parameters; observation charts and case conference records

Communication systems including intranet (P-drive), newsletters, communication books, handover sheets and memoranda

Education documentation including calendar, attendance register, competency training database, evaluations

Fire and emergency documentation including emergency operating procedures, care recipient evacuation folder, flood folder, detection system, fire safety statement, testing and work reports, fire extinguisher replacement schedule

Infection control manual, outbreak register

Laundry documentation including cleaning duties, checklist, linen imprest table

Maintenance documentation including preventative maintenance schedule, service register, inspection reports, electrical equipment tagging and testing, residual current device testing, legionella testing, lanyard and call bell testing, maintenance request book, daily, weekly and monthly checklists, inventory log, safe work method statements, risk assessments, competencies

Material safety data sheets

Medication management documentation including; controlled drug registers, pharmaceutical review’s, electronic medication management tablet with medication profile’s, medication charts and administration records, and resident’s self-administration assessments


Meeting calendar and minutes including residents’, recreational activity officers’, medication advisory committee, registered nurses, care staff, manual handling action team, infection control, work health and safety, supervisors

Organisational chart

Personnel files including orientation audit, pre-employment requirements, confidentiality agreements, code of conduct, national police certificates, performance feedback and development

Physiotherapy assessments and care plans

Police certificate registers for staff, volunteers and contractors

Policies and procedures

Position descriptions and duty lists

Priority action plan

Professional registrations

Quality and clinical indicator documentation including quality register, compulsory reporting and non-reportable registers, comments/complaints register, confidential register, audit schedule, audits, accident/incident reports, aggressive incidents, medication incidents, hazards, infection register

RFBI Bellorana Hostel self-assessment

Staff orientation pack including vision, mission and values, checklist, confidentiality agreement, code of conduct acknowledgement, police record check, statutory declaration, email and internet usage policy, flood relief availability

Strategies to support care and communication.

Observations

The team observed the following:

Activities and exercise class in progress

Archive storage

Care recipients’ and staff notice boards

Catering information boards

CCTV security camera at Joyce Jarrett

Charter of care recipients’ rights and responsibilities, vision, mission and values displayed

Cleaning trolleys and cleaning in progress


Comments and complaints forms (internal and external) and advocacy brochures readily available

Dining room during lunch service, morning and afternoon tea

Equipment and supply storage areas

Fire and emergency equipment including emergency charts displayed, exit lights, evacuation maps, evacuation kit, power generators, fire extinguishers, hoses and sprinkler system at Joyce Jarrett, emergency assembly points

First aid kits located around the home

Hairdresser

Infection control resources including: hand washing facilities and instructions, spills kits, sharps containers, clinical waste, outbreak kit, supplies of personal protective equipment

Interactions between staff and care recipients, and medical and other health and related services personnel

Laundry labelling machine

Library with large print books

Living environment – internal and external

Medications (including storage, controlled drug cupboard, medication trolley, medication blister packs, medication refrigerators and medication round)

Mobility aids and care recipients being assisted with mobility

Nurses stations and work areas

Outbreak kit

Palliative care box

Photos of care recipients

Posters displayed advising of dates of site audit

Safe chemical storage

Secure storage of care recipient information

Short group observation

Sleepover room in Watson Street

Spring-loaded laundry trolleys

Staff practices

Suggestion box


Visitor/contractor sign in/out books

Waste disposal including contaminated waste

Worm farm.


Assessment information

This 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 development

Principle: 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

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

Bellorana Nursing Home is owned and operated by The Royal Freemasons Benevolent Institution (RFBI) and has a framework to actively pursue continuous improvement across all Accreditation Standards. The general manager and quality officer coordinate an improvement log embracing input from audits, surveys, meetings, comments and complaints and the analysis of incidents and accidents. Areas of improvement and ideas for solutions are discussed at management and committee meetings with input from staff, allied health and care recipients/representatives. Feedback is provided through meetings, notices, newsletters, education and memoranda. Staff and care recipients/representatives state management are responsive to their comments and suggestions for improvement and this was evident in documentation.

Examples of recent improvements in relation to Accreditation Standard One – Management systems, staffing and organisational development include:

The general manager is planning to retire in 2015 and identified the importance of succession planning not only for her role but across all areas of the facility. Supervisors were asked to identify a person in their team to upskill and prepare them to assume responsibility if they are on leave, resign or retire. The care manager is being trained to take over the role of general manager. The general manager said having staff skilled to take over leadership roles ensures continuity of quality care for care recipients.

The registered nurse/educator recognised it was often difficult for staff to attend scheduled education sessions. More topics have been included in the ‘spot’ education programs and are offered to staff at meetings, handovers or individually. Records are kept to monitor staff attendance or completion of units using DVDs and written material. The educator notes staff have responded well to this change in format with more staff completing education units.

To formalise and capture the vision and values of the home the educator has introduced a ‘Code of Conduct’ document and education module for new employees. This emphasises the importance of professional boundaries and the collaborative staff ethos that is expected of all staff throughout the home.

All staff are required to complete a course in elder abuse. The educator wanted to include a more positive aspect to this course and has included ‘customer care’ in the session. This is designed to make staff more aware of the importance of positive interactions with care recipients and emphasises the importance of respecting individual differences.

Family members who did not live locally commented to the general manager at an afternoon tea that they would like more information on news and events within the home. An attractive seasonal newsletter has been created which is emailed or posted to families. There has been a positive and appreciative response to this initiative.

The administration staff consulted with the general manager to develop a system to prioritise and organise incoming documentation and correspondence. Colour-coded


plastic folders are now used to identify the subject matter such as red for hazards, blue for police checks, green for quality forms, purple for invoices and accounts and orange for care recipient documents. The general manager and maintenance manager said this has helped them identify and prioritise their correspondence.

1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings


The home has a system for identifying relevant legislation, regulatory requirements, professional standards and guidelines and has mechanisms for monitoring compliance. Bellorana is a member of a peak body who keep the home informed about any changes to legislation related to approved providers of aged care services. Notifications of directives and changes in policy are received from NSW Health, the Department of Social Services and other related government and non-government agencies through subscriptions and automated e-mailing advice. Relevant information is communicated from the home’s management to staff through meetings, education, memoranda and staff notice boards.

Policies and procedures are reviewed and modified in line with legislative changes. Documentation, management and staff confirmed policies, procedures, relevant legislation, regulations and standards are available and easily accessible for staff.

Examples of responsiveness to regulatory compliance relating to Accreditation Standard One Management systems, staffing and organisational development include:

A system to ensure all staff, volunteers and contractors have national criminal history checks and these are monitored for renewal.

Care recipients/representatives were advised of the accreditation site audit visit as per requirements under the Aged Care Act.

The home maintains records to ensure compliance with the compulsory reporting requirements of the Aged Care Act.

1.3 Education and staff development

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

Team’s findings


The home has a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. Bellorana has been actively involved in the NSW new entrant traineeship program to support trainees through the Certificate III in Aged Care. All new staff complete an orientation program which includes a ‘buddy’ system to ensure duty of care obligations are met and key information relating to policies, legislation and communication processes are covered. Staff are expected to attend compulsory education sessions covering topics such as fire safety, elder abuse and customer care, manual handling


and infection control. There is a system to follow up non-attendance at these sessions. A registered nurse/educator monitors and reviews staff education and the approved provider financially supports internal and external education. Staff training needs are reviewed annually and on a needs basis. Staff stated they are encouraged and supported to attend education and training courses and attendance records are maintained.

Examples of education sessions and activities relating to Accreditation Standard One include:

Certificate IV in training and development

Reviewing the admission process

Advocacy services

Registered nurse responsibilities.

1.4 Comments and complaints

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

Team’s findings


The home’s complaints management process and external mechanisms for complaints are well documented and communicated through the care recipient’s handbook and information and displays. Information regarding external complaints processes is also displayed.

Comments/complaints forms are used to gather feedback and are widely available and used by care recipients, representatives and staff. All care recipients/representatives we interviewed could describe their approach to raising complaints should they have one, usually through direct contact with staff and management. Complaints and comments are logged along with the actions taken and follow up feedback, all of which is regularly reported to management and staff committees. The home demonstrated its responsiveness to any complaints received and its approach to close off any issues or complaints identified. We noted that feedback had driven several improvement initiatives in the home.

1.5 Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings


The home’s vision, mission and values are well documented and this information is published in the care recipient and staff handbooks, the policy manual and is reflected in notices placed around the home. A Board of Directors oversees and supports the commitment to quality throughout the home. To reflect their mission and values the organisation monitors, values and supports appropriately qualified and skilled management staff. The Board believes a positive work environment is the basis for providing an efficient and effective service for all care recipients, staff, visitors and the local community.


1.6 Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".

Team’s findings


The home has systems to ensure there are appropriately qualified and skilled staff sufficient to provide services in accordance with the Accreditation Standards and the home’s mission and values. Staff are provided with position descriptions and guidelines to duties that clearly define positions, roles and responsibilities. Staffing requirements are rostered in accordance with care recipient needs and staff input and are amended as needs change. Staffing at all levels and from all service areas are monitored through meeting outcomes, comments and complaints and workplace inspections. Care recipients/representatives interviewed reported care was delivered competently in a happy, supportive atmosphere by dedicated, caring staff. Staff expressed satisfaction with their employment and skill development in the home. Care recipients/representatives commented on the positive attitude of staff and several commented on the warmth and respect shown to them by staff.

1.7 Inventory and equipment

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

Team’s findings


Stocks of appropriate goods and equipment are available for the delivery of quality services. The home’s system includes effective purchasing and assets management procedures with a maintenance program to ensure equipment is safe for use and a system to ensure appropriate storage and timely use of perishable items to avoid spoilage and/or contamination. New equipment is researched and purchased as required. Staff and care recipients/representatives stated there are satisfactory stocks of goods and equipment available at all times to enable quality service delivery. Particular emphasis is placed on keeping sufficient supplies in case of flood. Employees appreciate the prompt response from management when requests are made for extra supplies or equipment.

1.8 Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings


There are information management systems to provide management and staff with information to perform their roles effectively and keep care recipients/representatives well informed. Assessments and clinical care notes are documented in a password protected electronic software system. They are regularly reviewed and provide the necessary information for appropriate care. Policy and procedure manuals and job descriptions clearly outline correct work practices and responsibilities for staff. Information is distributed to management and staff through handbooks, the intranet program, memorandums, noticeboards, clinical records,


communication books, meetings and associated minutes, education and training and policy and procedure manuals. Care recipients/representatives receive information when they move into the home and ongoing through meetings, handbooks, notice boards, case conferencing and newsletters. Care, staff and archived files are securely stored and in accordance with privacy legislation. All staff sign confidentiality agreements. Staff and care recipients/representatives report they are kept well informed and consulted about matters that impact on them.

1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings


Externally sourced services are provided in a way that meets the home’s needs and service quality goals. Contractors are selected according to the needs of the home and in keeping with the organisation’s philosophies. All contractors are expected to have current police certificates. Service agreements are entered into with contractors for the provision of services and external service providers are required to have current licences, insurances, professional registrations, and comply with relevant legislation and regulatory requirements. Any non-compliance identified is acted upon. Care recipients/representatives and staff have opportunities to provide feedback and indicated satisfaction with the quality of external services provided to the home.


Standard 2 – Health and personal care

Principle: 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.



Team’s findings


Information about the home’s continuous improvement system is provided under expected outcome 1.1 Continuous improvement. Examples of improvements relating to Standard Two include:

The organisation introduced electronic clinical and care management software in 2012 with all care recipients’ records now stored securely in this system. As an extension to this program an electronic medication management system was introduced in 2014. Care staff believe this has simplified and improved the administration of medications. Management continue to monitor the system and errors are discussed at the medication advisory committee.

Following pain assessments for the aged care funding instrument, the care manager identified the services of a registered nurse could be utilised one day per week to provide massage and specialised pain relief to care recipients. This treatment has proven very beneficial and care recipients said they look forward to these massages. Trained care staff also provide light massage as part of their activities of daily living. The care manager is trialling chair massage cushions with heat inserts to provide relaxation and pain relief for care recipients.

The general manager keeps informed of any grants and special funding projects offered by the State and Federal governments. She accessed a NSW Government initiative to improve dental hygiene in regional areas and a dental health van now visits the home annually. The visiting professionals also provide education to staff and at the last visit offered suggestions to improve the oral assessments. While improving the dental health for care recipients who take advantage of this service, the general manager is also pleased with the improvement in dental hygiene throughout the home. A system of replacing all toothbrushes each season has also been introduced.

After reviewing palliative care procedures the care manager has modified the palliative care form to include more specific reasons for transferring care recipients to hospital. This provides clearer instructions for registered nurses when they are assessing whether to send a care recipient to hospital during palliation. A palliative care box made by the ‘mens’ shed’ has been created which includes a quilt made by a local community group, bible, reflective texts and a CD player with appropriate CDs.



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

Team’s findings


Information about the home’s system for identifying and ensuring compliance with regulatory requirements is provided under expected outcome 1.2 Regulatory compliance. Examples of the home’s monitoring and compliance with regulatory requirements relevant to Accreditation Standard Two are:

The home has a system to monitor and record registered nurses, allied health professionals and medical practitioners have current authorities to practice.

Registered nurses are responsible for the care planning and assessment processes and specialised nursing services implemented for care recipients.

The home ensures residents are provided with services, supplies and equipment as required under the Quality of Care Principles.



Team’s findings


Information about the home’s system for education and staff development is provided under expected outcome 1.3. Education sessions management and staff attended relating to Accreditation Standard Two include:

Massage for registered nurses

Hand-washing

Medication management

Drug calculations

Clinical competencies.


2.4 Clinical care

This expected outcome requires that “care recipients receive appropriate clinical care”.

Team’s findings


Care recipients conveyed to the team that they are satisfied with the care provided by the home. There are systems in place to ensure that each care recipient receives appropriate clinical care; this includes assessment of care recipients’ individual needs carried out by the multi-disciplinary team following moving into the home. Care plans are developed with information collected from the assessments, goals are set and interventions documented with strategies for meeting the individual needs of the care recipient. Care plans are reviewed, updated and evaluated three monthly by care staff and when a change in the care recipient’s condition is identified. Registered nurses oversee the review of care plans and all care provision. Consultation with care recipients and their representatives is undertaken in relation to their care including case conferences which are conducted following moving into the home and annually. Consultation with the care recipient’s medical officer of choice and other relevant health care specialists ensures that ongoing needs are met. Relevant documents, care recipients and staff confirmed the above.

2.5 Specialised nursing care needs

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

Team’s findings


The home has a system to ensure that care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. When a care recipient is identified as requiring specialised nursing care the registered nurses and care manager oversee all aspects of assessment, care planning, provision and review. Links have been established to specialists and specialist advisers within the extended health care team who provide support, equipment and training when required. Observations revealed that there is sufficient equipment and supplies to provide specialised nursing care. Staff, care recipients/representatives and documentation confirmed that care recipients’ specialised nursing care needs are met.

2.6 Other health and related services

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

Team’s findings


A system is in place to ensure that care recipients are referred to appropriate health specialists in accordance with their needs and preferences. The need for referral is identified by the registered nurses in consultation with the medical practitioner and/or care recipients/representatives. A podiatrist, optometrist, dietician and speech pathologist visit care recipients in the home as required. The physiotherapist attends the home weekly to assess care recipients, develop care plans and provide 1:1 therapy as required. Care recipient/representatives and staff and clinical documentation confirmed the home has an


efficient and effective system for referral of care recipients to appropriate health specialists. There is a procedure in place for the home to obtain information from the consultation with health specialists to enable actions to be taken in relation to any recommendations made.

Staff advised and care recipients confirmed that the home arranges referrals and transportation with escorts (where required) to appointments as necessary.

2.7 Medication management

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

Team’s findings


The home has an efficient and effective system which ensures that care recipients’ medication is managed safely and correctly. Care recipients/representatives reported to us that they are satisfactorily assisted with their medication requirements. The system includes assessing care recipients’ medication needs following admission, consultation with care recipients and/or their representatives, liaising with the medical officer to arrange for medications to be ordered and regularly reviewed, and liaising with the pharmacist for the supply of medications. Medication is administered by medication trained care staff from individual single dose blister packs. A consultant pharmacist regularly reviews care recipients’ medication and a medication advisory committee meets quarterly. The team observed all medications to be safely stored. Policies and procedures and a system for reporting medication incidents are in place and medication audits are conducted. Care staff are assessed annually for competency in the administration of medications. This was confirmed by care staff and documentation.

2.8 Pain management

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

Team’s findings


The home has an effective system to assess and manage care recipients’ pain. Staff and clinical documentation confirm that a pain management assessment and history of pain is carried out on all care recipients on moving into the home and as necessary, a pain management plan is implemented, documented and regularly reviewed. Further assessments are undertaken as required when the level of pain changes or strategies are no longer effective. The registered nurses oversee the assessment and management of care recipients’ pain and provide regular massage treatment. Both pharmaceutical and non- pharmaceutical pain relief is considered when planning pain management. Non- pharmaceutical strategies include repositioning, massage and heat. The physiotherapist also assists in the management of pain and has access to a TENS (Transcutaneous Electronic Nerve Stimulation) machine for use when required. Care recipients are referred to pain management specialists and clinics as necessary. Care recipients/representatives confirm that they are maintained as free from pain as possible.


2.9 Palliative care

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

Team’s findings


The home has a system in place to provide and maintain the comfort and dignity of terminally ill care recipients. Identification of palliative care wishes are recorded on entry to the home and reviewed at an appropriate stage. Decisions regarding the management of the terminally ill are made in consultation with the care recipient, their family and medical officer. End of life care is provided by appropriately trained staff and the home has access to the community palliative care service for clinical support as needed. A palliative care box has been put together containing equipment and materials to enable care to be provided in a sensitive manner. Relatives are kept informed of the care recipient’s condition and family are welcome to stay with the care recipient. Ministers of religion regularly visit the home and are contacted on the request of care recipients and/or their families. Staff demonstrated an awareness of the needs and requirements of terminally ill.

2.10 Nutrition and hydration

This expected outcome requires that “care recipients receive adequate nourishment and hydration”.

Team’s findings


There are systems to ensure care recipients receive adequate levels of nourishment and hydration. Care recipients’ nutritional and hydration needs, preferences and allergies are recorded and passed to the kitchen. Care recipients’ weight is monitored regularly.

Monitoring is increased and the care recipient is referred to a dietician if there are nutritional concerns. Special diets and varied consistency of meals, including thickened fluids, are available as required. Nutritional drinks are provided as a dietary supplement to assist in reversing weight loss. Care recipients’ swallowing ability is assessed by a speech pathologist if there are concerns. Staff supervise and assist care recipients’ with their meals as necessary and adapted crockery and cutlery is also available. Care recipients, staff and review of documentation confirmed that care recipients’ nutrition and hydration needs are assessed, documented and regularly reviewed and acted upon.

2.11 Skin care

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

Team’s findings


The home has a system to ensure that care recipients’ skin integrity is consistent with their general health. Staff and clinical documentation confirm that care recipients have a skin assessment completed after moving into the home. Care recipients identified at risk have skin integrity care plans with management strategies outlined. Care recipients’ skin integrity is


monitored daily by staff who report any abrasions, rashes or abnormality to the registered nurses. A range of equipment and practices is utilised to assist in the maintenance of care recipients’ skin integrity such as special mattresses and pressure relieving devices, pressure area care, repositioning, protective bandaging and equipment and moisturising creams. A wound management chart that documents the dressings required, frequency of treatment, evaluation and progress of healing is commenced for care recipients who have skin tears or wounds. The management of complex wounds is undertaken by the registered nurses. Skin tears and simple wounds are managed by care staff under the supervision of registered nurses. Care recipients/representatives are satisfied with care provided to maintain skin integrity.

2.12 Continence management

This expected outcome requires that “care recipients’ continence is managed effectively”.

Team’s findings


The home has a comprehensive system to ensure that care recipients’ continence is managed effectively. Clinical documentation showed that the system includes an individual continence assessment when the care recipient moves into the home, and the development of a care plan and where needed a toileting program which is regularly reviewed and evaluated. Toileting regimes are maintained for as long as possible. A disposable continence aid system is used for care recipients with intractable incontinence and staff confirm there are always adequate supplies of continence aids of varying sizes available for care recipients. Staff advised that the supplier of continence aids are available for consultation and advice. Care recipients are assisted to maintain their bowel function in a number of ways, such as through high fibre diet, fresh fruit, exercise and medications, bowel movements are monitored to ensure these interventions are effective. Care recipients/representatives expressed satisfaction with the way care recipients’ continence is managed.

2.13 Behavioural management

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

Team’s findings


The home has systems to ensure that the needs of care recipients with challenging behaviours are managed effectively. Clinical documentation confirmed that all care recipients receive behavioural assessments following moving into the home and on a regular basis.

Challenging behaviours are identified and management strategies and appropriate programs are implemented and regularly reviewed. Personal alarms are provided for care recipients who have a tendency to wander. We observed that strategies detailed in care plans for specific care recipients are effective. The home has access to specialised services including geriatricians and the mental health team. Observations and talks with care recipients/representatives and staff indicate that care recipients’ behavioural issues are treated with patience and understanding in an effective and efficient manner.


2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings


The home has an effective system in place to ensure that optimum levels of mobility and dexterity are achieved for all care recipients. Staff and documentation reviewed revealed that all new care recipients are assessed by the physiotherapist for mobility, dexterity and manual handling requirements when moving into the home and when necessary. Where indicated, the physiotherapist develops individualised programs which are provided by the care staff and physio aids and are regularly reviewed. An exercise program and daily walks are offered and care recipients are encouraged to attend. There is a range of mobility aids and equipment to assist care recipients to move independently and staff to assist in moving care recipients safely. Care recipients/representatives stated they are satisfied with the assistance they receive to maintain or improve their mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings


The home has strategies in place to ensure that care recipients’ oral and dental health is maintained. Review of clinical documentation showed that care recipients’ oral hygiene is assessed, documented, regularly reviewed and acted upon. Staff are trained to supply ongoing oral and dental hygiene by observation, mouth care, either prompting or assisting care recipients to clean teeth and/or dentures. Care recipients are referred to specialist dental services and technicians as required. Staff demonstrated knowledge on oral care and care of dentures. Care recipients/representatives confirmed that where necessary care recipients’ dentures are checked daily and/or care recipients are assisted to brush their teeth.

2.16 Sensory loss

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

Team’s findings


The home has a system in place to identify and effectively manage care recipients’ sensory losses. Assessments of care recipients’ sensory needs are undertaken when moving into the home and when there is a change in the care recipient’s condition. Staff and clinical documentation confirm that care recipients are assessed for the identification of their sensory loss and needs. Care recipients who are identified as having sensory deficits, for example, require glasses or hearing devices, have management strategies documented in their care plans and are assisted to access services or equipment that will support them. Clinical documentation reviewed also showed that referrals are made to specialist services as required. Care recipients/representatives reported that staff assist them where necessary, with the care and maintenance of their glasses and hearing devices.


2.17 Sleep

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

Team’s findings


The home has strategies in place to assist care recipients to achieve natural sleep patterns. The home identifies the care recipient’s usual and preferred sleeping patterns on admission and uses this information to assist in supporting the care recipient to develop a regular sleep pattern. Strategies implemented to assist care recipients achieve natural sleep patterns include management of environmental disturbances, continence management programs and pain management programs. Care recipients/representatives advised that the environment is conducive for them to achieve uninterrupted sleep.


Standard 3 – Care recipient lifestyle

Principle: 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.



Team’s findings


Information about the home’s continuous improvement system is provided under expected outcome 1.1 Continuous improvement. Examples of improvements relating to Standard Three include:

Care recipients in the Watson Street building said they would like more variety in their diet and missed not being able to cook. They suggested the kitchen in this area which is no longer used would be suitable. The activity officer consulted with the catering supervisor to establish safe food handling procedures and purchased appropriate equipment such as coloured chopping boards. A recent pizza meal cooked by the care recipients proved very popular. Care recipients are looking forward to making white Christmas and rum balls at their next session.

After seeing a men’s shed at another facility, the activity officer consulted with male care recipients in Watson Street who agreed they’d like to trial the concept. There is an unused shed in the garden that proved suitable. The group meet weekly and are supported by a volunteer and maintenance staff. Projects so far have included renovating a television cabinet, making a box for palliative care and a toy box for visiting children. This was decorated by the female care recipients and toys donated by families. The men look forward to their weekly get-together and are hoping to meet up with a local men’s shed which is being established.

The care manager attended a course about person centred care with a focus on capturing care recipients life experiences. Activity staff received training and developed one-on-one and group activities which allow care recipients to share their memories. Families are enjoying finding out details about their parents’ lives such as when they had their first cigarette, date or alcoholic drink. A family member said it has provided an insight into their parent’s life and they enjoy hearing things they didn’t know or would never think of asking. Care staff said this information helps develop communication with care recipients particularly when providing personal care.

A care recipient commented that it was difficult to continue interpersonal relationships with their spouse or partners. There were few activities that encouraged or involved partners. A Valentine’s Day lunch was organised with decorated tables, wine, flowers and chocolates. Staff dressed as waiters and a special meal was prepared. A care recipient who was in a long-term homosexual relationship asked if their partner would be welcome. The general manager assured them it would not be a problem. After the lunch the care recipient complimented the staff on the acceptance of their partner. This highlighted to the general manager the importance of assuring all care recipients from


the lesbian, gay, bisexual and transgender community are encouraged and supported to continue their relationship after they come to live at the home.


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

Team’s findings


Information about the home’s system for identifying and ensuring compliance with regulatory requirements is provided under expected outcome 1.2 Regulatory compliance. Examples of the home’s monitoring and compliance with regulatory requirements relevant to Accreditation Standard Three are:

All care recipients are offered an accommodation agreement.

Information is provided to care recipients/representatives in the care recipient guide and other material regarding their rights and responsibilities including security of tenure.

The Charter of residents’ rights and responsibilities is displayed in the home and is documented in the care recipient agreement.



Team’s findings


Information about the home’s system for education and staff development is provided under expected outcome 1.3. Education sessions management and staff attended relating to Accreditation Standard Three include:

Privacy, dignity and confidentiality

Dementia, delirium and depression

Life stories.

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".

Team’s findings


The home has a system in place to ensure care recipients receive support in adjusting to life in the home and on an ongoing basis. Staff and documentation demonstrate that support is


provided prior to the care recipient moving into the home by conducting entry consultation with the care recipient and/or their representative. This includes the explanation of services available at the home, provision of an information pack and a tour of the home. Care recipient files confirmed their emotional needs are documented and monitored and that staff provide support to care recipients who require it. Any special needs a care recipient may have are ascertained through the initial assessment and ongoing process. Observations of staff interactions with care recipients showed warmth, respect, empathy and understanding. Care recipients/representatives told us they are satisfied with the way they were assisted to adjust to life in the home and are assisted on an ongoing basis.

3.5 Independence

This 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".

Team’s findings


The home has an environment that encourages care recipients to maintain independence and friendships and participate in the life of the community within and outside the home. Care recipients’ independence is also fostered through having personal items and photographs in their rooms, provision of mobility aids and utensils to assist with eating and drinking, a varied activity program and the ability and assistance provided to vote in government elections. Care recipient files showed they are actively encouraged to maintain independence in areas such as decision-making, personal hygiene and attendance at activities. Care recipients/representatives told us they are encouraged by the home to maintain their independence and friendships.

3.6 Privacy and dignity

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

Team’s findings


The home has a comprehensive system that ensures each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Staff, observation of staff practices and interactions with care recipients demonstrates that staff treat care recipients respectfully and with dignity. The home has a system to gain consent from care recipients or their representative in relation to privacy, for example display or publish photographs. We observed care recipients clinical files to be stored securely and no information of a private nature was on display in areas where unauthorised persons could access. Care recipients/representatives confirm that staff treat them in a dignified manner and with respect.


3.7 Leisure interests and activities

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

Team’s findings


There are systems in place that demonstrate care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them. On entry to the home, care recipients/representatives are consulted in relation to their past and current leisure interests and activities which assist in the development of their social history and care plan. Recreational activities staff develop a monthly program of group and individual activities which are evaluated regularly. The program is modified in response to attendance and ongoing care recipient feedback via mechanisms including surveys and care recipient meetings. The program includes regular concerts, craft, happy hour, singing, card bingo, cooking and men’s shed. Celebratory themes are held throughout the year and include Melbourne Cup, Mother’s Day, Father’s Day, Christmas and Easter. The activities program is communicated to care recipients and their representatives in a newsletter and is displayed around the home. Care recipients are satisfied participation is encouraged and supported and the activities offered by the home are of interest to them.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


The home has systems to value and foster residents’ cultural and spiritual needs through the identification and communication of residents’ individual interests, customs, religions and ethnic backgrounds. Significant occasions such as birthdays and anniversaries are acknowledged. Provision is made for the celebration of special cultural and religious days, for example; Christmas, Easter, Mother’s day, Father’s day, Anzac Day, Remembrance Day and Australia Day are celebrated. Religious services are conducted regularly and all denominations are welcome. Various ministers of religion visit the home to meet the individual needs of care recipients. There are no care recipients residing in the home at present with culturally or linguistically diverse needs. Care recipients/representatives stated they are satisfied with the care the home provides to support their cultural and spiritual lives.

3.9 Choice and decision-making

This 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".

Team’s findings


There are systems that ensure each care recipient/representative is able to exercise choice and control over care recipients’ lifestyle. Examples of this are; care recipients being given the


choice of their own medical practitioner, being able to participate in decisions about care and services provided through consultation processes, having diet preferences documented and communicated to the catering staff and what activities they participate in. A care recipients’ meeting is held bi-monthly where care recipient/representatives are encouraged to attend to express views about care and service provision. All care recipients are provided with a care recipient handbook that details their rights and responsibilities. The home provides opportunities and support for care recipients wishing to vote at government elections. Care recipients/representatives confirm they are provided with choice and are able to make decisions about their lifestyle.

3.10 Resident security of tenure and responsibilities

This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities".

Team’s findings


The home has processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Relevant information about security of tenure, fees and care recipients’ rights is discussed with care recipients and/or their representative prior to, when possible, and on entering the home. All care recipients are offered an accommodation agreement and guide which outlines the legislated government financial requirements and the complaints resolution processes. Room moves only occur with prior consultation and consent from the care recipients and/or their representative. The Charter of Residents’ Rights and Responsibilities is on display in the home and included in the resident agreement. The home has an ‘open-door’ policy and ongoing communication with care recipients/representatives is encouraged through scheduled meetings, individual meetings and notices. Care recipients/representatives indicated satisfaction with their security of tenure at the home and an awareness of their rights and responsibilities.


Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Team’s findings


Information about the home’s continuous improvement system is provided under expected outcome 1.1 Continuous improvement. Recent improvements relevant to Accreditation Standard Four are:

The communal sections in the building known as Joyce Jarrett were in need of painting. With new building and renovations planned for the whole facility the cost to have the interior painted by professionals was prohibitive. During discussions at staff meetings it was suggested a working bee be held to complete the painting. Extra activity staff were employed for the planned weekend to provide activities for the care recipients. Fifteen staff members and volunteers completed the painting in one day. New furniture and curtains were purchased for the dining area. Care recipients said they enjoyed watching the painting and thought the dining room looked very attractive.

A family member complained about the difficulty accessing the nursing home and Joyce Jarrett areas after hours or on the weekend when the reception desk was unattended. A security camera and buzzer linked to a speaker have been installed at the entrance. The buzzer is linked to the call bell system. Staff said this has helped security after hours and family members appreciate the improved access.

The general manager reviewed the system for ensuring care recipients are assisted from their rooms in the event of an emergency. A small blackboard has been fitted on doors and chalk is being attached. If care recipients have to evacuate, staff will mark the board with an ‘x’ to indicate a resident has been safely moved from their room or the room checked for occupancy. This procedure will be included in mandatory fire and emergency training. A care recipient commented they thought this idea was innovative and would help them feel secure in the event of an evacuation.

The catering supervisor recognised significant dietary information was not readily available. She created an information folder with easy to access information about special dietary requirements such as diabetes, low potassium and low sodium diets and vegetarian/vegan diets. A major feature of this folder is the cultural dictionary which provides information about special cultural days and diets. The catering supervisor now works in collaboration with the activity staff to provide food relating to the cultural events or special celebrations. Care recipients appreciate the extra effort catering staff go to for these special occasions.



This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”.

Team’s findings


Information about the home’s system for identifying and ensuring compliance with regulatory requirements is provided under expected outcome 1.2 Regulatory compliance. Examples of the home’s monitoring and compliance with regulatory requirements relevant to Accreditation Standard Four include:

A review of records and observations showed fire safety equipment is being inspected, tested and maintained in accordance with fire safety regulations and the annual fire safety statement is displayed.

A review of staff training records and interviews with staff indicate staff have fulfilled the mandatory fire awareness and evacuation training.

The current NSW Food Authority licence is displayed and a food safety program has been implemented as required by the NSW Food Safety Authority.



Team’s findings


Information about the home’s system for education and staff development is provided under expected outcome 1.3 Education and staff development. Education sessions management and staff attended recently relating to Accreditation Standard Four include:

Safe food handling

Work health and safety

Hedge trimmer, electric soldering iron and ladder use

Outbreak coordinator training

Outbreak management

Chemical handling.


4.4 Living environment

This 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".

Team’s findings


Bellorana hostel is contained in two separate buildings called Watson Street and Joyce Jarrett. Joyce Jarrett is attached to the nursing home. All rooms are single with en-suite bathrooms. Communal areas are attractively furnished and there are landscaped courtyards and gardens with paved walkways. The living environment is clean, well-lit, free of clutter and malodour and there are regular inspections to identify safety risks. Call bells are installed in rooms and living areas. Management is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. Maintenance requests are responded to promptly and a routine maintenance program is implemented. Care recipients and visitors were seen to be enjoying the internal and external communal areas and expressed satisfaction with the living environment.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


Management is actively working to provide a safe working environment that meets regulatory requirements. A Work Health and Safety Committee meets regularly to assist in developing, monitoring and reviewing work health and safety (WH&S) procedures to ensure safe environments and work practices. All staff receive WH&S training. WH&S issues are identified through audits or incident and hazard reports and are addressed through maintenance or risk management processes. Equipment and supplies are available to support safe work practices. Workplace incidents are reported and actioned and a trained staff member is available to support injured staff return to work. Staff said management are responsive to staff suggestions and requests relating to WH&S.

4.6 Fire, security and other emergencies

This 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".

Team’s findings


The fire and safety systems are maintained and monitored to provide an environment and safe systems that minimise fire, security and emergency risks. The system includes regular testing of fire and other emergency equipment and compulsory training at orientation and annually for staff on fire safety procedures, use of equipment and evacuation drills. There is a trained fire safety officer on site. Emergency information notices are easily accessible and include fire and other emergencies such as bomb threats, medical emergency, internal and external emergencies. Emergency exits are clearly marked, well lit and kept free from obstruction.


Evacuation plans are appropriately positioned. Exit doors are secure with key pad entry/exit. There are nurse call activators in care recipients’ rooms and in communal areas which are regularly checked by the maintenance staff. Staff demonstrated knowledge of the location of emergency equipment and emergency procedures and care recipients said they feel safe and secure in the home.

4.7 Infection control

This expected outcome requires that there is "an effective infection control program".

Team’s findings


The home has an effective and efficient infection control program in place. The program includes surveillance and reporting processes, hazard risk management, waste management and a food safety program. Preventative measures include orientation and ongoing training, audits and competencies for staff and the provision of protective personal equipment.

Cleaning, food safety and vaccination/immunisation programs are in place. Infection control indicators are collected and results are monitored for trends then systems and practices reviewed as necessary. The laundry has sanitisers incorporated in the supplied chemicals. An outbreak kit is available and emergency supplies available on-site and sharps and other contaminated waste are disposed of appropriately. Documentation, observations and staff confirm the home has an effective infection control program.

4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment. The home offers a four-week rotating menu of meals cooked on-site. Care recipients’ dietary information and likes and dislikes are recorded on moving into the home and updated regularly. Care recipients/representatives were very satisfied with meals and felt comfortable to complain or request an alternative when necessary. Cleaners follow a set daily schedule which ensures all care recipients’ rooms and common areas are cleaned regularly. All laundry is undertaken in the home’s laundry. Staff are trained in the use and storage of equipment and chemicals and there are procedures for cleaning and laundry management if an outbreak should occur. Care recipients/representatives said the home is always clean, their personal requests are addressed promptly and laundry services are satisfactory.

RFBI Bellorana Hostel - Quality Agency Bellorana Hostel RACS ID 0019 ... partnership between each...

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