The Whiddon Group - Glenfield - Easton Park...The Whiddon Group - Glenfield - Easton Park RACS ID...

The Whiddon Group - Glenfield - Easton Park

RACS ID 0243 81 Belmont Road

GLENFIELD NSW 2167

Approved provider: The Frank Whiddon Masonic Homes of New South Wales

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 01 March 2018.

We made our decision on 15 January 2015.

The audit was conducted on 01 December 2014 to 05 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: The Whiddon Group - Glenfield - Easton Park RACS ID: 0243 2 Dates of audit: 01 December 2014 to 05 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

The Whiddon Group - Glenfield - Easton Park 0243


Introduction

This is the report of a re-accreditation audit from 01 December 2014 to 05 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 01 December 2014 to 05 December 2014.

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

Team member/s: Hiltje Miller

Kathryn Mulligan

Margaret Williamson

Approved provider details


Details of home

Name of home: The Whiddon Group - Glenfield - Easton Park

RACS ID: 0243

Total number of allocated places:

198

Number of care recipients during audit:

180

Number of care recipients receiving high care during audit:

89

Special needs catered for: Dementia

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


Street/PO Box: 81 Belmont Road

City/Town: GLENFIELD

State: NSW

Postcode: 2167

Phone number: 02 9827 6666

Facsimile: 02 9829 1516

E-mail address: Nil


Audit trail

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

Interviews

Category Number

Director of care services 1

Assistant director of care services/quality and risk 1

Assistant director of care services /Infection control manager 1

Assistant director of care services 1

General manager clinical and risk 1

Senior nurse educator 1

Registered nurses 4

Clinical nurse specialist – mental health 1

Clinical nurse specialist 2

Registered nurse/ staff vaccination 1

Care staff 14

Certificate IV care staff 1

People and culture advisor Easton Park 1

Osteopath 1

Lifestyle manager 1

Lifestyle officer 5

IT applications support 1

Admissions and client liaison officer 1

Medical officers 2

Endorsed enrolled nurses 3

Care recipients/representatives 32

Food and beverage manager (corporate) 1

Hotel services supervisor 1

Cleaning staff 6

Head chef 1

Catering staff 4

Office coordinator 1

Admissions clerk 1


Category Number

Roster clerk 1

Administration clerk 1

Stores personnel (corporate) 1

Medical stores staff 1

Facilities services manager corporate 1

Maintenance coordinator 1

Maintenance staff 1

Laundry manager 1

Laundry consultant 1

Laundry staff 5

Handy person 1

Therapy aide 1

Sampled documents

Category Number

Care recipients’ files 25

Summary/quick reference care plans 8

Client agreements 12

Medication charts 11

Personnel files 13

Other documents reviewed

The team also reviewed:

Catering, cleaning and laundry: NSW Food Authority License, food safety folder, menus, menu feedback diary, food storage and food temperature records, dishwasher temperature records, instrument calibration records, audits, delivery temperature records, kitchen inspection check lists, certificates of food analysis, kitchen cleaning records, cleaning schedules/duty lists, goods supply ordering records, laundry manual and cleaning schedules

Clinical care: advanced health directives/palliation, behaviour monitoring and management, restraint authority, bowel records, blood glucose level monitoring, dietary needs/preferences, continence management, meals and drinks, weight monitoring, wound management/dressings, dietitian and speech therapist reviews, osteopath documentation including assessments, care plans, manual handling guides, treatment sheets, incident reports, pain assessments and pain strategy evaluation forms

Comments and complaints: comments and complaints forms and register


Continuous improvement: Easton Park projects data base plan, clinical indicator reports, internal and external audits, benchmarking and trending, electronic quality and risk management tool, strategic business plan

Education and staff development: mandatory education tracker, annual employee education assessment, education calendar, education evaluations, orientation program, attendance records

Fire, security and other emergencies: fire alarm register, evacuation plans, emergency manual, emergency flip charts

Human resource management: duty lists, employee orientation pack and handbook, clinical and student placement handbook, relieving sheets, rosters, position statements, appraisal schedule, staffing level monitoring documents, duty lists

Infection control documentation: clinical indicator data, benchmarking performance data, infection lists and surveillance reports, pest control records

Information systems: policies, procedures, newsletters, meeting minutes, memo register, memoranda, meeting schedule, corporate documentation register, surveys, phone lists, doctors book, handover sheets, communication books

Inventory and equipment and external services: contractor handbook, contractors electronic data base and service agreements

Leisure and lifestyle: lifestyle assessments and care plans, activity evaluations, monthly activity calendar, schedule of special events, photographs of activities

Living environment: preventative maintenance work order schedule, work orders, service reports, legionella testing, mixing valve temperature records

Medication management: drugs of addiction register, medication care plans, medication incidents, self-administration assessment, medication advisory committee meeting minutes, medication refrigerator temperature records

Occupational health and safety: material safety data sheets, safety /compliance requirements matrix, hazard register and report, staff injury data base, risk management process tools, WHS system compliance internal audit report, asbestos register/reports, safe work practice documents

Planning and leadership: organisational chart, philosophy of care, Whiddon Group vision and annual plan, organisational mission and values, strategic plan

Regulatory compliance: reaccreditation self-assessment, register of alleged or suspected assaults, missing resident register, criminal record checks, criminal record check accountability agreements, professional registrations, letter notification of reaccreditation audit for residents and representatives

Security of tenure: client information welcome to Whiddon folder, welcome packs, pre- admission client agreements


Observations

The team observed the following:

Activity program on display; residents participating in activities and activity resources

Archive storage

Cleaning equipment colour coded, chemicals in use and storage

Complaints, comments and compliments forms, suggestion boxes, poster and brochures external advocacy services

Emergency evacuation back packs, first aid boxes, emergency torches

Equipment and supply storage areas

Equipment available and in use for manual handling such as lifters, hand rails, ramps, walk belts, pressure relieving, limb protecting and mobility equipment

Fire safety equipment, fire boards and pre shift evacuation board, exit lights, fire procedures on the back of resident doors, evacuation plans and emergency signage

Interactions between staff, residents and representatives

Laundry equipment including, soiled linen and clothing bins specific to Easton Park, resident’s laundry

Living environment and staff work areas

Menu displayed

Mission, values and the Charter of Residents’ Rights and Responsibilities displayed

Notice boards for staff and residents, information brochures on display for residents, visitors and staff

Outbreak supplies, outbreak management kits and personal protective equipment (PPE)

Safety data sheets, spills kits

Secure storage of medications, locked medication trolleys, medication refrigerators and medication rounds, emergency medications

Short small group observation in Coates and shift handover

Staff implementing hot weather safety strategies

Visitors sign in/out books


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

The home has a quality framework which assists them to actively pursue continuous improvement across all four Accreditation Standards. The quality framework supports the identification, implementation and evaluation of improvement opportunities and activities. Processes used to identify improvement opportunities and to review performance include scheduled regular audits, analysis of incidents and clinical indicators and stakeholder input through the comments and complaints system. Surveys and direct feedback from residents, relatives and staff also contribute to the home’s quality framework. Information about improvements is communicated to stakeholders through meetings and associated minutes, newsletter and notices. Residents, representatives and staff reported the home’s management is responsive to their suggestions for improvement.

Recent improvements relating to Accreditation Standard One-- Management systems, staffing and organisational development include:

In July 2014, the management team identified the need for an onsite human resource manager as a majority of their time was taken addressing human resource issues. A new position was created for human resource management which encompasses people and culture. In October 2014, the director of care services recruited and appointed a staff member to this position. Management advised there has been an improvement in the support departmental leaders receive in relation to developing and empowering staff.

The director of care services identified the need to improve the home’s management of continuous improvement to ensure a centralised approach that included accessibility for all managers. A project management data base tool was developed in August 2014 as part of the home’s quality framework. The director of care services is responsible for the overall data base management. All managers are responsible for the continuous improvement project in their area and for meeting set time lines. The feedback from management has been positive and documentation demonstrates time lines are met and improvements and evaluations are ongoing.

Feedback from staff, particularly new clinical staff, indicated there was a fragmented information system relating to the availability of the resources at the home. In December 2013 management developed a quick reference resource tool folder communicating the resources available for residents and clinical staff. The tool was so successful and well


received department managers requested one for their areas. Management have developed resource tool folders for catering and laundry staff which have been well received.

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


There are systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The organisation’s corporate management team monitors legislation, regulations and guidelines and updates and issues policies in response to changes. The director of care services has access to information directly from an industry peak body and through subscriptions to a variety of information services. The home's management team monitors the implementation of regulatory changes and adherence to regulatory requirements through audit processes and observation of staff practice. Communication to staff about changes in policy and procedure occurs through electronic notifications, meetings, memoranda and staff education programs.

Examples of compliance with regulatory requirements specific to Accreditation Standard One

- Management systems, staffing and organisational development include:

Systems and processes are in place to ensure all staff, allied health professionals, contractors and volunteers have current criminal history certificates.

The provision of information to residents and stakeholders about internal and external complaint mechanisms.

Notification of the re-accreditation audit to residents and their representatives occurred via notices in the home, meetings and letters.

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


There are processes to ensure management and staff have the appropriate knowledge and skills to perform their roles effectively. The review of documentation and interviews with management and staff demonstrate training needs are identified. Compulsory education, programmed training opportunities and competency and skill testing ensure staff have the necessary knowledge and skills to meet the needs of the residents in their care. Guest speakers, qualified staff, televised training and external education opportunities are used to ensure a variety of training is provided. Staff are encouraged to pursue further education through in-house and external training opportunities and completing tertiary qualifications with options for support available through the provision of scholarships. There is a recruitment procedure and orientation process for new staff. All staff interviewed reported they have


access to education on a regular basis. Review of the education documentation and interviews confirmed education has been provided in relation to Accreditation Standard One. Examples include orientation of new staff, compulsory education for all staff, critical incident training for assistant directors of care services, using a new glucometer, new processes for recycling, structure and organisational design, coping with change and lifting sling care and management.

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


Residents/representatives have access to internal and external complaints mechanisms at Easton Park. Information regarding the comments and complaints processes is provided in the resident handbook and the resident agreement. Suggestion boxes and comments and complaints forms are located throughout the home. Residents/ representatives are also encouraged to make verbal complaints and suggestions through the management team’s ‘open door policy’. Further opportunities for feedback are provided to residents and representatives at meeting forums, care consultations and surveys. A comment and complaint register is maintained and regularly reviewed by management.

Residents/representatives and staff indicate they are aware of the home’s complaints mechanisms and that complaints are addressed by management.

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 organisation’s mission, values and philosophy of care are documented. The Whiddon Group strategic plan works towards achieving the Whiddon mission through strategic planning processes. Observations and document review demonstrates the organisation’s mission and values are available to all stakeholders in printed format and are displayed in the home. Interviews with residents/representatives and our observations showed management and staff model behaviours consistent with the organisation’s mission and values.


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


There are systems and processes for the provision of appropriately skilled and qualified staff, sufficient to provide services in accordance with the Accreditation Standards and the organisation’s mission and values. There are processes for recruitment, orientation and ensuring staff are eligible to work in aged care. Rostering processes ensure shifts are filled with suitably qualified staff. Management report they adjust staffing levels based upon resident care needs, clinical data and staff and resident feedback and the carrying out of staffing studies to achieve the best outcomes. Staff are encouraged to pursue further education through in-house and external training opportunities and completing tertiary qualifications. Staff state they are confident they have the relevant knowledge and skills to carry out their work. Residents/representatives are satisfied with the staff and the skill they demonstrate in the provision of care. They state staff are attentive to residents’ needs and are responsive to their requests for assistance.

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


The home’s corporate asset management team oversee purchasing of major equipment items. Management and designated staff have the responsibility for ensuring that appropriate goods and equipment are available on site to provide day to day quality care and service the needs of residents. The home has an impress system to monitor and order stocks of goods such as clinical and general supplies, food and beverages. New equipment is trialled and feedback from staff and residents is sought prior to any purchase. There are systems to manage routine, preventative and corrective maintenance. Equipment is monitored to ensure replacement needs are identified. The home uses external contractors for equipment service and repair. Residents, representatives and staff said there are adequate supplies of goods and equipment available for use in the home.

1.8 Information systems

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

Team’s findings


There are systems for the creation, storage, archiving and destruction of documentation within the home. We observed that confidential information such as resident and staff files is stored securely. Processes are in place to consult with residents and/or their representatives and to keep them informed of activities within the home. Information is disseminated through information technology systems, meetings, notice boards, memoranda, communication books


and diaries, handover reports, newsletters and informal lines of communication. The computers at the home are secure and the corporate office oversees the management and backup systems. There is a system of surveys and audits to identify the need to review policies, procedures and staff work practices. Residents/representatives and staff state they are kept informed and are consulted about matters that may impact them. This occurs through the display of information such as minutes of meetings, newsletters, notices, documentation including policies and procedures and at various meetings and informal discussions.

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


The home’s corporate office has systems in place to ensure all externally sourced services are provided in a way that meets the home’s needs and the organisational values. The home’s corporate facility services manager maintains comprehensive and current information about external services and contractors. This includes appropriate registrations/licences, insurance and contact details. Residents, management and staff said they are satisfied with the provision of external services 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


Refer to expected outcome 1.1 Continuous improvement for a description of the overall system of continuous improvement. In relation to Accreditation Standard Two - Health and personal care the system is monitored through audits, clinical indicator results and feedback from residents/representatives, health professionals and staff.

The home has implemented improvements in Accreditation Standard Two - Health and personal care including:

Management identified inconsistencies in the home’s approach in the documenting of care consultations with residents/representatives. Staff were not using a standardised approach in documenting each care consultation. This made it difficult to monitor and ensure communications with resident/representatives is reflected in a resident’s care plan. Management reviewed the process utilised when documenting a care consultation and standardised the home’s approach. As a result staff document using the appropriate form in their electronic clinical system. This has facilitated a process ensuring care information discussed with residents/representatives is captured within a resident’s ongoing assessment and care plan review. Feedback from staff indicates there has been an increase in communication with residents/representatives and improved quality of a resident’s care plan.

Data indicated there was a higher than average number of unplanned hospital admissions over the last six months. Management reviewed the reasons for the hospital transfers and medical officers out of hours support. They identified the need to improve the home’s management of residents prior to unplanned hospital admissions together with reducing the number of unplanned admissions. Management also identified the care needs of residents were increasing. Education regarding managing the deterioration of a resident was provided to the registered staff. A new position was created, recruited and appointed for a registered nurse. This position provides a communication link between the hospital, the home and the resident’s representatives. The home has also linked in with the clinical services of the NSW Ambulance service. Together they have commenced a research project/action plan to further review reasons for unplanned admissions to hospital.

In August 2014, the home’s data indicated there had been a slow increase in the number of falls residents’ were experiencing. A comprehensive education program relating to fall prevention was conducted for staff. Management reviewed the data, the residents having frequent falls, the environment and equipment in use. As a result 18 new floor line beds were purchased and distributed according to resident needs across the Glenfield site. This has resulted in a major decrease in falls for these residents in particular and all


residents in general. The clinical nurse specialists have been made responsible for monitoring the ongoing data and the review of residents who fall.


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


Refer to expected outcome 1.2 Regulatory compliance for a description of the overall system related to this expected outcome. Examples of regulatory compliance with regulations specific to Accreditation Standard Two - Health and personal care include:

There is a system to ensure that professional registrations for registered nurses, endorsed enrolled nurses and physiotherapists are monitored and maintained.

Registered nurses initially assess and plan care and provide ongoing management and evaluation of residents as specified.

Medications are stored and managed in line with NSW state legislation requirements.

2.3 Education and staff development


Team’s findings


Refer to expected outcome 1.3 Education and staff development for a description of how the home monitors and provides education to ensure management and staff have appropriate skills and knowledge. Review of the education documentation and interviews confirmed education relating to Accreditation Standard Two - Health and personal care has been provided for management and staff. Examples include continence management, pain management, providing assistance with medications, behaviour management, first aid, cardio pulmonary resuscitation, heat awareness preparedness, oral hygiene and managing a deteriorating resident.

2.4 Clinical care

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

Team’s findings


The home provides residents with appropriate clinical care through initial and ongoing assessments, care planning and evaluation processes. The home has processes that enable residents/representative to exercise control regarding the care they receive and to provide input into residents' care planning. The assistant director of care services (ADCS), clinical nurse specialists and registered nurses review and evaluate residents’ individual plans of care


every three months or when required. Resident care needs are communicated to staff electronically, verbally and via handover sheets. Residents’ weights, vital signs and urinalysis results are recorded monthly or as ordered by the medical officer. An accident and incident reporting system is in place for the reporting of resident incidents, such as falls, skin tears and behaviours of concern. Staff demonstrate knowledge of residents’ care needs ensuring that residents’ clinical care are met. All residents/representatives interviewed are satisfied with the timely and appropriate assistance given to residents by care staff.

2.5 Specialised nursing care needs

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

Team’s findings


Residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officer input when required. This includes registered nurse input into assessment, management and care planning for residents. The home currently provides specialised nursing care for residents requiring diabetic management, wound care, catheter care and pain management. Staff are provided with education in specialised nursing procedures with competency/skills based assessments in place. Staff confirmed they have access to adequate supplies of equipment for the provision of residents’ specialised nursing care needs. Residents/representatives are satisfied with the level of specialised nursing care offered to residents by nursing, medical and/or other health professionals and related service teams.

2.6 Other health and related services

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

Team’s findings


Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates timely referrals for residents are arranged with appropriate health specialists as required. Management and the clinical team are able to refer residents to psycho geriatricians, physiotherapist, podiatrist, speech pathologist, wound and continence clinical nurse consultants and palliative care. Regular review and evaluation of residents’ health and well-being and referrals are carried out by the ADCS, clinical nurse specialists and registered nurses in collaboration with care staff and doctors. Effective monitoring is achieved through handover of key resident information between relevant staff. When required, residents’ medical officers are alerted and consulted.

Residents/representatives stated residents are referred to the appropriate health specialists in accordance with residents’ needs and preferences.


2.7 Medication management

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

Team’s findings


There are systems and processes in place to ensure residents’ medication is managed safely and correctly. The home uses a pre-packed system of medications supplied by the pharmacy. Staff administering medications have undertaken training. Observation showed staff undertook to administer medications safely and correctly. Audits of the medication system are undertaken to ensure safe and correct administration and a medication advisory committee meets regularly. Medications are secured in a medication trolley kept in a locked room when not in use. There is a medication incident reporting system and staff are aware of when and how to use it. Residents/representatives interviewed said they are satisfied with the way medications are being managed.

2.8 Pain management

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

Team’s findings


All residents are assessed to identify their pain history and the presence of pain. Interventions to minimise and manage pain levels are documented in the resident’s care plan and are provided by staff. Pain reassessments are completed to determine the effectiveness of interventions and care plans are updated as required. A multidisciplinary approach involving nursing staff and osteopaths supports a resident’s pain management program. Staff are knowledgeable about the many ways of identifying residents who are experiencing pain. Pain management strategies include regular repositioning, the administration of pain relieving medications, the use of slow release narcotic patches, gentle exercises, heat and massage. Residents say the care provided at the home relieves their pain or it is managed so they are comfortable.

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 suitable environment and culture to ensure the comfort and dignity of terminally ill residents is maintained. Where possible, residents' end of life wishes (advance care plans) are identified and documented on entry to the home in consultation with residents/representatives. The home has access to an external palliative care community team which provide specialised care planning when required to ensure resident comfort. The home has specialised clinical and comfort devices to ensure and maintain resident palliation needs and preferences. Staff receive ongoing education and described practices appropriate to the effective provision of palliative care. Residents/representatives said the home’s practices maintain the comfort of terminally-ill residents.


2.10 Nutrition and hydration

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

Team’s findings


The home has processes to provide residents with adequate nourishment and hydration. Residents are assessed for swallowing deficits and other medical disorders, allergies, intolerance, like and dislikes and cultural or religious aspects relating to diet. Provision is made for residents who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information is recorded on a resident’s dietary needs form and sent to the kitchen. Residents are provided with assistance at meal times and dietary assistive devices are available when required. When changing needs of a resident’s dietary requirements are identified, the resident is re-assessed with care plans being updated and information forwarded to the catering staff. The home monitors nutrition and hydration status through staff observations and recording residents’ weights with variations assessed, actioned and monitored. Residents are referred to a dietician and/or speech pathologist when problems arise with residents’ nutrition. Residents have input into the menus, which allow for alternative choices at each meal. Residents/ representatives are generally satisfied with the meals.

2.11 Skin care

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

Team’s findings


The home has a system to ensure residents’ skin integrity is consistent with their general health. Initial assessment of the resident’s skin condition is carried out along with other assessments which relate to and influence skin integrity. Residents have nutritional support, podiatry, hairdressing and nail care provided according to their individual needs and choices. Maintenance of skin tears, skin breakdown and required treatments are documented, reviewed and noted on wound care charts. The home’s reporting system for accidents and incidents affecting skin integrity is monitored monthly and is included in the audit system. The home has a variety of equipment in use to maintain residents’ skin integrity. Care staff help to maintain the residents’ skin integrity by providing regular pressure area care, the application of skin guards and correct manual handling practices. Residents/representatives are satisfied with the skin care provided to residents and report staff are careful when assisting residents with their personal care activities.

2.12 Continence management

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

Team’s findings


The home has a system for identifying, assessing, monitoring and evaluating residents’ continence needs to ensure their continence is managed effectively. Processes are in place for the distribution of residents’ continence aids and informing staff of residents’ continence aid


needs. Residents are assisted and encouraged to maintain or improve their continence level in a dignified and supportive manner. Care staff have access to adequate supplies of continence aids to meet residents’ needs and they provide residents with regular toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies. These include regular fluids, aperient medications if necessary and a menu that contains high fibre foods such as fresh fruit and vegetables and a variety of fruit juices. Infection data, including urinary tract infections, is regularly collected, collated and analysed. The home’s continence supplier provides ongoing advice and education for staff and residents. Feedback from residents/representatives shows satisfaction with the continence care provided to residents.

2.13 Behavioural management

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

Team’s findings


The needs of residents with challenging behaviours are managed through consultation between the resident/representative, staff, medical officers and allied health professionals to identify any behavioural issues. Care staff and the lifestyle officer implement a range of strategies to effectively manage residents with challenging behaviours. Residents’ behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate. Staff are able to recognise the triggers and early warning signs exhibited by some residents and put in place appropriate strategies to manage residents. The team observed the environment to be calm and residents well groomed.

Residents/representatives said staff manage residents’ challenging behaviours well.

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


Residents are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by residents for transferring and mobility. Osteopaths assess new residents and review residents on a regular basis, including after a fall. Therapy aides implement the program developed by the osteopaths. Individual treatments include massage, heat treatments and exercises.

Falls prevention strategies include the completion of risk assessments and interventions noted include group exercises and the provision of specialised equipment such as mobility aids, bed sensors, ramps and handrails. Staff were able to discuss individual residents needs and were seen assisting residents to mobilise within the home. Residents said they are satisfied with the program and assistance they receive from staff.


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 systems to ensure residents’ oral and dental health is maintained. Residents’ dental needs are identified through assessment and consultation with the resident/representative on a resident’s entry to the home and as their needs change.

Appropriate dental health is planned and staff are informed of residents’ needs. Dental consultations are arranged as required either to the resident’s dentist of choice, or by referral to the mobile dental clinic. Ongoing care needs are identified through resident feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Residents are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Residents/representatives said they are satisfied with the oral and dental care provided to residents.

2.16 Sensory loss

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

Team’s findings


The home assesses residents’ eyesight and hearing initially on entry and on an ongoing basis. Other sensory assessments for touch, smell and taste are undertaken when assessing residents’ nutrition, activities and dexterity. These are documented on residents’ care plans/summary care plans to prompt and instruct staff on how to care and engage residents appropriately. The home’s leisure program features activities to stimulate residents’ sensory functions. Staff described types of group as well as individual activities which encourage active participation from residents with sensory deficits. Staff said they employ various strategies to assist residents with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance resident participation, adapting the environment to suit to ensure it is conducive to maximising residents’ enjoyment and participation in the chosen activity. Residents/representatives said they are satisfied with the home’s approach to managing residents’ sensory losses.

2.17 Sleep

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

Team’s findings


The home assists residents to achieve natural sleep patterns through a sleep assessment, care planning, 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 residents’ sleep. Such as offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, positioning and night sedation if ordered by the doctor. Residents use the nurse call system to alert the night staff if they have difficulties in sleeping. Residents state they sleep well at night.


Residents/representatives are satisfied with the home’s approach to residents’ sleep management.


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


Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Accreditation Standard

Three- Care recipient lifestyle: resident meetings, the comment and complaint system, verbal comments and surveys are used to gather suggestions and feedback on the lifestyle systems of the home.

The home has implemented improvements in relation to Accreditation Standard Three- Care recipient lifestyle including:

Lifestyle staff requested resource material is made available in order to provide emotional support to residents/representatives at a time of grief and loss. They identified the need to improve their skills in this area. Lifestyle staff report they have used the resource material effectively. They also report feeling they have improved their skills and knowledge in providing support to residents/representatives as needed.

The activity plan has been redesigned to clearly communicate the activities available for residents to attend. This was in response to resident feedback. The residents felt the previous activity plan was circulated monthly and was too cluttered and difficult to read. The new activity plan is circulated fortnightly, is written in larger print and clearly communicates what activity is occurring, when and where. Resident feedback is positive indicating they can now read the plan and understand what is available.

Responding to resident feedback regarding the repetitiveness of the activities within the activity plan, the program was reviewed in August 2014. New activities have been added to the plan in response to resident suggestions. Each new activity has been evaluated to identify resident satisfaction. Resident feedback has been positive.



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 care recipient lifestyle”.

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for a description of the overall system related to this expected outcome. Examples of regulatory compliance with regulations specific to Accreditation Standard Three – Care recipient lifestyle include:

Resident and staff information is stored in a manner that meets privacy legislation requirements.

There is a policy, procedure and staff training for the reporting of alleged or suspected resident assault.

The organisation’s privacy policy has been reviewed and updated in line with the changes to relevant legislation.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for a description of how the home monitors and provides education to ensure management and staff have appropriate skills and knowledge. Review of the education documentation and interviews confirmed education relating to Accreditation Standard Three – Care recipient has been provided for staff. Examples include leisure workshop-where to now, leisure documentation, resident respect and dignity, play-up program, obligations regarding the mandatory reporting of elder abuse and clinical pastoral care.

3.4 Emotional support

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

Team’s findings


Residents and their representatives are provided with information prior to and on arrival at the home to assist in adjusting to life in the home. Staff ensure residents are introduced to each other and other staff and explain daily happenings at the home. Staff encourage residents to join in with social activities as they feel comfortable. Residents are able to bring in personal items to decorate their rooms. Family members are encouraged to visit whenever they wish and say they feel welcomed by staff. Staff were knowledgeable about strategies used for individual residents’ emotional needs. Residents say they are happy living at the home and the


staff are kind and caring. Observations of staff interactions with residents during the re-accreditation audit showed warmth, respect and laughter.

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 systems to assist residents to achieve maximum independence, maintain friendships and participation in the community. The home-like environment provides residents with opportunities to exercise independence and choice on a daily basis. A range of individual and general strategies are implemented to promote independence, including the provision of services and equipment for resident use, a leisure activity program and regular mobility and exercise regimens. Participation In the local community is promoted through outings and visiting entertainers. Staff describe strategies to maintain residents’ independence in accordance with individual abilities. Residents say they are encouraged to maintain their independence and contact with the local community.

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


Management and staff of the home protect the privacy and dignity of residents and ensure the confidentiality of residents’ personal information. Residents or their representative, sign consent forms for the release of information to appropriate parties and staff sign confidentiality agreements. The home’s environment promotes privacy, through the provision of single rooms and outdoor areas for residents. Shift handovers are conducted away from the hearing of residents and visitors to the home. Staff demonstrate an awareness of practices which promote the privacy and dignity of residents. These include closing resident doors and window blinds or curtains when providing personal care. Residents say staff are polite, respect their privacy, knock on doors prior to entering and close doors during care provision.

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


The home has systems to ensure residents are encouraged and supported to participate in interests and activities of their choice. The individual interests and preferred activities of residents are identified on entry. Each resident has an individualised care plan that identifies specific resident care needs. Information obtained from resident meetings and one-on-one discussions is also used to plan suitable group and individual activities. A monthly activity


program is displayed and includes a wide range of activities. Activities include physical exercise, mental stimulation and general social interaction. Activity programs are evaluated via resident feedback, meetings and review of activity attendance records. Residents told us there are a variety of activities provided and whilst they are encouraged to participate their decision not to do so is respected.

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 cultural and spiritual lives of residents are acknowledged and celebrated by the home. The home identifies information related to residents’ cultural and spiritual background when they first move into the home which is incorporated into care planning where appropriate.

Church services are held by religious representatives from a range of denominations. Specific cultural days and multicultural ‘theme’ days are celebrated with appropriate festivities. Residents’ birthdays are celebrated and involvement from families and friends is encouraged. Communication cards are available for use by residents and support from cultural community associations can be accessed.

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


The home encourages residents to exercise choice and control over their lifestyle through participation in decisions about the services each resident receives. Residents are able to describe many examples of where they are encouraged by staff to make their own decisions. This includes use of preferred name, personal care regimes and diet preferences, bed times and whether to participate in activities. Staff were observed providing residents with choice in a range of activities of daily living. There are mechanisms for residents/representatives to participate in decisions about services including, access to management, resident/relative meetings, care consultations and complaint processes. Where residents are unable to make choices for themselves, management said an authorised decision maker is identified for the resident. Residents/representatives say they speak up without hesitation and the home enables residents to make choices of importance to them.


3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


There are processes to ensure residents have secure tenure within the residential care service and understand their rights and responsibilities. The admissions and client liaison officer discusses relevant information about security of tenure, fees, care, services and residents’ rights with residents and their representatives prior to and on entering the home. Prospective residents and/or their representatives are provided with a tour to select a suitable room and are offered a pre-admission client agreement. On entry residents receive a client agreement and resident handbook which outline care and services, residents’ rights and complaints resolution processes. New residents are orientated to the home and ongoing communication with residents/representatives is encouraged through scheduled and individual meetings. Management advised if the need arises residents and their representatives are consulted and consent is gained prior to residents moving rooms and/or buildings.


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


The home is actively pursuing continuous improvement in relation to the physical environment and safe systems. This was confirmed through observations, interviews and review of documentation. For a description regarding the continuous improvement system see expected outcome 1.1 Continuous improvement.

Examples of improvement activities in relation to Accreditation Standard Four- Physical environment and safe systems include:

Management observed residents were not utilising the common area in Easton Park units’ level two. They met with the residents in August 2014 and identified residents did not like the area set up and felt it was bland and uninviting. Residents were consulted in regards to what they would like to see improved. This resulted in new furnishings being purchased and the area rearranged. Since this has occurred staff have noticed residents are socialising more and the area is used on a daily basis.

In November 2013, the corporate office, responding to the changes in the weather pattern developed a ‘staying healthy in the heat’ service plan. In October each year the director of care services is responsible for commencing the heat preparedness program. This consists of an audit of the environment, air conditioners and stock level of bottled water. Also included is the circulation of the ‘staying healthy in the heat’ flyers for staff and stakeholders. The flyers identify each department’s role and responsibility in relation to managing the heat for all stakeholders. We observed staff implementing strategies to manage the hot weather such as extra fluids for both residents and staff. Residents said they are comfortable in their environment.

Management identified the home’s laundry services needed to improve outcomes for residents and staff in response to feedback from residents/representatives. The home had received complaints regarding the turnaround time for personal clothing. A laundry consultant was employed in July 2014 to review the entire laundry system. As a result of the review a number of changes were implemented in October 2014. Two new smaller washing machines were purchased and installed for personal clothing. Colour coded linen bags were introduced to each area of the home. This has facilitated easier sorting, folding and returning of residents’ personal clothing. Turnaround time has reduced from four days to one or two days. Residents report satisfaction with the improved service. Management has received no further complaints about the service and staff moral in the laundry has greatly improved. Staff said the changes have been wonderful.



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


Refer to expected outcome 1.2 Regulatory compliance for a description of the overall system related to this outcome. Examples of regulatory compliance with regulations specific to Accreditation Standard Four - Physical environment and safe systems include:

There is a system for the regular checking and maintenance of fire safety equipment and a current fire safety statement is on display. The home is fitted with a sprinkler system.

There is a current New South Wales (NSW) Food Authority licence on display. The food safety system is regularly audited by the NSW Food Authority and meets the legislated requirements for food safety.

There are examples of how the organisation complies with work health and safety legislation. For example the provision of staff training and staff involvement in maintaining a safe work place and following documented safe work practices.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for a description of how the home monitors and provides education to ensure management and staff have appropriate skills and knowledge. Review of the education documentation and interviews confirmed that education relating to Accreditation Standard Four - Physical environment and safe systems has been provided for management and staff. Examples include hand hygiene and personal protective equipment competencies, laundry processes, fire safety and evacuation, spill kits, designated smoking areas, chemical safety, food safety, carpet cleaner training, texture modified food service, salad presentation and meal sizing.

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


The home’s management is actively working to provide a safe and comfortable environment consistent with resident care needs. Easton Park units consist of two separate buildings offering a variety of care options. Coates house is a secure unit with a courtyard sensory


garden catering for residents living with dementia. Easton Park hostel is a three storey building. Each resident has a single room with ensuite bathroom and is able to personalise their own room. The team observed the resident’s rooms to be clean and well lit. Communal areas such as dining and lounge rooms are well furnished. The safety and comfort of the living environment is monitored through environmental audits, resident/representative feedback, incident/accident reports, hazard reports, risk minimisation and observations by staff.

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


The home’s management team actively work to provide a safe working environment that meets regulatory requirements. Staff are aware of their obligations to ensure the living environment for residents and the staff work environment is safe and regular meetings provide a forum for discussion and review. Safe work practices are achieved through regular staff education, following documented safe work practices, investigating accidents and incidents and the use of a variety of monitoring processes. The monitoring processes include audits, observation and monitoring of incidents and clinical data. Staff highlight risks and hazards through the maintenance, accident and incident and hazard reporting systems and are aware of safe work practices. Personal protective equipment is readily available for staff. Staff members receive education in manual handling during orientation and annually and we observed staff working safely.

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 home has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire evacuation plans and exit signs are located throughout the home. Monitoring and maintenance of all fire equipment is undertaken and reports are provided. Fire equipment is located throughout the home and there is evidence that this is regularly serviced and tested. Fire safety and evacuation training is included in the orientation program and there are mandatory annual updates. A disaster management kit including, identification tags and a first aid kit is easily accessible in the event of an emergency. There are security procedures to ensure the buildings and grounds are secured at night. Staff interviewed state they are aware of and understand their responsibilities in the case of fire and other emergencies. Residents said they feel safe and secure.


4.7 Infection control

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

Team’s findings


The home has an effective infection control program. The assistant director of care services/ infection control manager is responsible for ensuring the overall infection control surveillance within the home occurs. Infection data is collected by the registered staff and is collated and evaluated by the assistant director of care services/infection control manager. Infection control education forms part of all staff induction and mandatory training. Staff were observed using personal protective equipment and washing hands. Colour coded equipment is used in catering, cleaning and laundry procedures and areas. An outbreak management kit and spill kits are available and the home has a stock of personal protective equipment available. Staff demonstrated knowledge of the home’s infection control practices and outbreak management procedures.

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


The hospitality services provided at the home are meeting the needs of the residents. Meals in the home are provided according to a seasonal four week rotating menu. Special meals are provided to residents with particular requirements. Fluids are thickened as needed and other requirements or preferences are catered for. Cleaning is undertaken by the home’s staff according to schedules. Cleaning staff demonstrated an understanding of the home’s cleaning schedules, infection control practices and safe chemical use. Personal clothing and linen is laundered onsite. The laundry staff explained processes used for the labelling, management and return of laundry to residents. Residents/representatives report general satisfaction with the hospitality services provided.

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