The Whiddon Group - Wingham · Home name: The Whiddon Group - Wingham RACS ID: 2632 2 Dates of...

The Whiddon Group - Wingham

RACS ID 2632 Primrose Street

WINGHAM NSW 2429

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 05 February 2018.

We made our decision on 12 December 2014.

The audit was conducted on 17 November 2014 to 20 November 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 - Wingham RACS ID: 2632 2 Dates of audit: 17 November 2014 to 20 November 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 - Wingham 2632


Introduction

This is the report of a re-accreditation audit from 17 November 2014 to 20 November 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 17 November 2014 to 20 November 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: Kay Louise Greentree

Team member/s: Caroline Baker

Approved provider details


Details of home

Name of home: The Whiddon Group - Wingham

RACS ID: 2632

Total number of allocated places:

49

Number of care recipients during audit:

45

Number of care recipients receiving high care during audit:

45

Special needs catered for: N/A

Street/PO Box: Primrose Street

City/Town: WINGHAM

State: NSW

Postcode: 2429

Phone number: 02 6553 4855

Facsimile: 02 6557 0336

E-mail address: Nil


Audit trail

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

Interviews

Category Number

Director of care services 1

General manager, clinical risk 1

Facilities operations manager 1

Deputy director of care services 1

Nurse Unit Manager 1

Catering staff 1

Care recipients/representatives 7

Maintenance officer 1

Lifestyle staff 3

Care staff 4

Physiotherapist Assistant 1

Physiotherapist 1

Sampled documents

Category Number

Resident menu choices and dietary requirement forms 6

Summary/quick reference care plans 4

Medication charts 4

Other documents reviewed

Accountability statements, including police certificates

Activity attendance, description and review records

Annual fire safety statement, emergency warning systems and emergency intercom systems monthly/yearly service record, fire detection and alarm systems monthly/six monthly service reports, fire safety inspection reports, emergency management plan

Appointment reminders, records of attendance to external appointments and hospital discharge summaries

Benchmarking reports, clinical quality data

Care recipient advocacy brochures


Cleaning worksheets

Client death screening tool

Client information handbook

Clinical waste removal notifications

Compliments and complaints register and complaint/comment/ compliment reporting forms, “I have a great idea” forms and “I wanted to say thank you” forms

Consolidated report

Continence care records including orders and pad requirement charts

Contractor register

Daily kitchen charts, menu and dieticians report, temperature and cleaning records

Education attendance records

Electronic record keeping system

Employee handbook

Fluvax register 2014 (care recipients)

Handover records

Incident reports – infections, falls and medication errors

Laundry wash temperature check, main laundry cleaning schedule

Letter sent to care recipients regarding Re-accreditation audit

Main kitchen; kitchen cleaning schedule, daily cleaning chart and daily sanitisation record

Maintenance requests

Mandatory staff education log and compulsory competencies, hazard register and hazard reports, annual employee education assessment, orientation trainers manual, facility induction checklist, letter to staff who haven’t attended compulsory training

Meeting minutes including client meeting minutes, quality/work health and safety/infection control committee terms of reference and meeting records

Mission and values statement

Observation, weight charts and resident of the day forms

Photographs of past activities conducted

Physiotherapy attendance, assessments, referrals and ongoing documentation


Podiatry records and appointment book

Policy and Procedures

Preventative maintenance and routine maintenance planner, pest sighting report, site visit report and treatment reports

Purchase orders

Quality improvement register and continuous improvement logs

Resident newsletter “Manning Valley Muses”

Resident of the day documentation

Resident preferences

Restraint authorisation and release forms

Schedule 4 and 8 medication stock take records

Staff Fluvax register 2014

Staff roster and staff allocation sheets, police certificate register

Staff signature list

Stocktake record

The Whiddon Way “Client First Information and Education Workbook”

“Work.Safe.Whiddon” and work health and safety policy, workplace inspection checklists

Wound care assessments, charts and equipment.

Observations

The team observed the following:

Activities being conducted such as singing, exercises, ball throwing, “play up” and hand massages

Breakfast preferences displayed on a white board in the kitchen

Chapel

Charter of care recipients rights and responsibilities displayed

Daily clinical care meeting

Emergency equipment

Emergency infectious outbreak box


Equipment and supply storage areas including dressing materials, personal care products, oral swabs, continence aids, drugs of addiction and other medications and stock

Evacuation pack

Exercise equipment

Fire detection and fire fighting equipment

Food Authority licence displayed

Hair dressing room

Hand washing facilities

Infection control information displayed

Interactions between staff and care recipients

Internal and external living areas including resident’s rooms which have been personalised

Lifting equipment

Living environment

Meals and drinks being served

Medication round

Menu displayed

Mission and values statement displayed

Post box

Resident advocacy brochures displayed.

Residents daily care needs being attended

The use of mobility and equipment and other daily living aids

Water coolers


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’s continuous improvement system incorporates a range of activities driven by stakeholder feedback and a system of assessing, monitoring and evaluating across the four Accreditation Standards. The quality program incorporates the use of continuous improvement forms, client surveys, audits, reviews, benchmarking of performance indicators, and a comments and complaints system. Formal review of the results of these activities occurs, trends are identified and improvement strategies are planned and implemented as required. Care recipients/representatives and staff interviewed indicated that the home is generally responsive to the issues they raise through the consultation processes available to them. A review of the results of quality activities undertaken pertaining to Standard One reveals actions are taken that have resulted in improvement. For example:

The director of care services noted that the client’s meetings were not being regularly held and were not focused enough on receiving feedback from care recipients and their representatives. The meetings are now held regularly and either the director of care services or deputy directors of care services attend the meetings so they are able to respond to care recipients/representatives questions and suggestions at that time. Care recipients/representatives interviewed were satisfied with the meetings held.

Comments had been received from care recipients saying they did not always know about what was happening within the home and any changes being made. With the support of the corporate communications team, the home’s management have introduced a newsletter that is distributed to care recipients. Care recipients confirmed that this provides them with valuable information about what’s happening within the home.

A review of the availability and currency of policies and procedures has occurred. The home has a combination of organisational and site specific policies and procedures however some site specific policies were out of date and were covered by more up to date organisational wide policies. The policies and procedures folders have been updated and out dated information removed and archived so that all information available is current. Staff report using the folders to access appropriate information.


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 organisation has an effective system to manage regulatory compliance. The results of observations, interviews and document review revealed that policies and procedures have been developed by the organisation to ensure they embrace regulatory compliance. The home is notified of change through alerts provided by the parent organisation’s corporate roles and action is taken as required to ensure the home remains compliant with legislation. Monitoring of quality indicators, audits of compliance, service reviews, and education and competency assessments are assisting management and staff to ensure that required standards are maintained.

Examples of responsiveness to a change in legislation are that the organisation considered the implications of the Aged Care Amendment (Security and Protection) Bill 2007 and implemented the necessary changes. For example, the introduction of police certificates for staff/volunteers and contractors. In addition, The Whiddon Group’s policies and procedures were reviewed and amended in light of the introduction of the Quality of Care Principles 2013 and the Quality Agency Principles 2013. Information provided to care recipients/representatives and staff has been amended to reflect the legislative changes.

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’s system has ensured management and staff have the knowledge and skills to perform their roles effectively. The results of our observations, interviews and document review reveal that staff knowledge and skills begins through staff orientation and ongoing education programs. These programs familiarise new staff with the home’s policy and procedures and provide all staff disciplines with education on a range of relevant aged care issues. The internal education programs, together with the external education available, support staff to provide care and services in accordance with the requirements of the four Accreditation Standards. The effectiveness of the training provided is being measured through audit results, observation, and various competency skills tests.

Education sessions and/or courses that relate to this Accreditation Standard that have been attended by management and/or staff include policies and procedures, elder abuse/mandatory reporting, effective workplace relationships, assessing the Standards, Accreditation roles and responsibilities and relevant computer based systems.


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 provides a choice of well-publicised complaint mechanisms that can be used by stakeholders including care recipients, representatives and staff. The results of observations, interviews and document review reveal that stakeholders are aware of and feel comfortable to use these mechanisms, which include both internal and external complaint mechanisms. For example, the clients’ meetings, staff meetings, use of the staff grievance procedure, use of the “I have a great idea” forms and “I wanted to say thank you” forms and external complaints bodies including the Aged Care Complaints Scheme are available. Complaints received are assessed and documented together with details of the investigations conducted. High level complaints are managed external to the home by senior corporate staff. Action is taken to resolve concerns and complaints in a timely manner.

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 has documented the home’s mission and values and commitment to excellence within their services. The results of observations, interviews and document review revealed these statements are communicated to all stakeholders. They are posted on the walls of the home and are included in the home’s key documentation including care recipients and staff information handbooks.

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 appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the needs of care recipients. The results observations, document review and interviews revealed that the home achieves this through the implementation of its organisational human resource policies and procedures. These handle staff recruitment, orientation, staff performance and competency assessment. The staffing budget has been formulated to meet the specific needs of the site, but staffing levels are monitored and adjusted on an ongoing basis in accordance with the care recipients’ needs. The management team demonstrated examples where staffing hours were increased to support particular care recipients’ needs and a system to relief staff on planned and unplanned leave.


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 has systems to ensure that appropriate stocks of goods and equipment are available at all times. The results of observations, interviews and document review reveal that appropriate stocks of goods and equipment such as medical supplies, food, furniture and linen are available and maintained. This is achieved through the utilisation of effective policies and procedures for budgeting, purchasing, inventory control, assets management and maintenance.

1.8 Information systems

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

Team’s findings


There are systems in place that effectively manage the creation, usage, storage and destruction of records, including electronic records. The results of observations, interviews and document review revealed that the organisation effectively disseminates information to management, staff and care recipients/representatives relating to legislation, care, organisational issues and other matters that are of interest to them. This is achieved through intranet, e-mail, electronic data management and reporting applications, memos, noticeboards, meetings, a clinical record system, information packages (including care recipient and staff handbooks), education sessions, meeting minutes and policy and procedure manuals. Information is managed in accordance with the organisation’s privacy policy.

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


All externally sourced services are provided in a way that meets the home’s needs and quality goals. The results of observations, interviews and document review revealed that the home has an effective system to identify preferred and major suppliers of goods, equipment and services. Contracts and/or service agreements are in place with suppliers of services such as maintenance of the fire system, and the supply of pharmaceuticals or continence aids. In addition, the performance of major or regular suppliers is measured against agreed objectives contained in documented service agreements or contracts. Contracts are centrally managed by the parent organisation in consultation with the home and there are mechanisms to track and resolve ongoing problems with suppliers and contractors. All approved supplies and contractors must complete accountability statements which include information on required police certificates, insurances and professional registrations and certifications.


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


The results of observations, interviews and document review reveal the home actively pursues continuous improvement through a program, which is consultative and responsive to feedback from its stakeholders. For comments relating to the home’s overarching quality system see expected outcome 1.1 Continuous improvement.

A range of quality activities including stakeholder surveys, reviews, audits and quality indicators measure performance in relation to all expected outcomes in Standard Two. Improvements are implemented based on the information obtained. Examples of improvements include:

The director of care services identified that case conferences and evaluations of care plans was not occurring to the standard expected. In response the “resident of the day” program was introduced. Each resident is “resident of the day” once every month and this is overseen by the registered nurse. The resident of the day is a system of evaluating their care plan in a meaningful and systematic way. Personal care tasks are checked and attended to such as fingernail care, changing of hearing aid batteries, checking glasses, and cleaning of personal living environment (according to the care recipient’s needs and preferences). Health monitoring activities occur such as urine testing, temperature, pulse and blood pressures. Care reviews are based on the information collected through the monitoring and activities to determine if the care recipients care goals are being met. The management team stated they are receiving positive comments regarding this process and they are observing more attention to detail regarding personal care tasks.

The organisation has implemented a program to review care recipients files after care recipients have passed away. The program was introduced as another method of identifying areas to improve and is called “death screening”. The director of care services conducts a review of the care of every care recipient when they pass away and check to ensure there are no contentious issues regarding their care or areas that could have been improved. If there are concerns, the care is reviewed in detail by the general manager, clinical risk. Whilst there has not been an occasion to have the file of a care recipient who has passed away reviewed by the general manager of clinical risk at this time within this home, the management team stated this organisational wide program has provided opportunities to improve care systems across all homes within the organisation.

In response to the increased care recipient care acuity, the management team purchased additional clinical equipment to support the care of care recipients. Equipment including specialised chairs, syringe pumps and equipment to assist the


transfer of care recipients. Staff interviewed stated this equipment has enhanced care provided to care recipients.


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


The results of observations, interviews and document review revealed that the home has adopted an effective system to manage regulatory compliance pertaining to Health and Personal Care. For comments regarding the system see expected outcome 1.2 Regulatory compliance.

An example of responsiveness to change in practice guidelines was the review of the use of bed poles and lap belt usage and associated risk assessments completed.



Team’s findings


For details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively please refer to expected outcome 1.3 Education and staff development.

Education sessions and courses that relate to this Accreditation Standard that have been attended by staff include urinary catheter care, dysphagia, medication management and the use of the syringe pump, wound care, dementia, sensory loss, palliative care and depression in the elderly.

2.4 Clinical care

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

Team’s findings


The home has systems to provide care recipients with appropriate clinical care. Care recipients are assessed for their clinical care needs on entering the home and care plans developed from this information. Registered nurses and enrolled nurses provide clinical care to care recipients under the supervision of the deputy care services manager. Case conferences with the family occur to ensure the care is meeting the needs and preferences of care recipients. Formal review of the care plans occurs third monthly. Daily clinical meetings involving the home’s management and registered nurses ensures care recipients are receiving appropriate clinical care. The provision of care is monitored with the use of audits, surveys, investigation of clinical incidents and the comments and complaints mechanisms. Care


recipients/representatives express satisfaction with the clinical care that care recipients receive.

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 systems to meet the needs of care recipients who require specialised nursing care. The home employs registered nurses across all shifts who provide specialised nursing care to care recipients. The current care recipients specialised nursing needs are the management of Type 1(insulin dependent diabetes), and urinary catheters. Care plans document specialised nursing care and demonstrate regular evaluation and review in consultation with the care recipient/representative and medical officer. Care recipients/representatives generally expressed satisfaction with the provision of specialised nursing care.

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


The home has systems to provide referral to appropriate health care specialists. A review of care recipients’ clinical documentation shows assessments and reviews have occurred by various health specialists. Care plans include directives and recommendations made by external health professionals including geriatricians, physiotherapist, podiatrist and dietician. Care plans are evaluated on a regular basis to ensure the home is meeting the needs and preferences of the care recipients. Care recipients/representatives are generally aware of the availability of other health specialists if needed.

2.7 Medication management

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

Team’s findings


The home has systems and processes to guide staff in the management of care recipients’ medication. Medication administration is via a blister pack system and administered by registered nurses and endorsed enrolled nurses. Medication is stored within locked trolleys in a secured storage room and the drugs of addiction are stored in the same room in a double locked medication cupboard. A medication incident reporting and auditing process forms part of the home’s system of monitoring the safety of medication management. The medication management system is subjected to regular internal auditing to identify any issues within the system. The home conducts a medication advisory committee meeting which consist of management, registered nurses, medical officers and two pharmacists. Care recipients say


they receive their medication in a timely manner and feel confident in the knowledge and skills of the registered nurses.

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 systems for assessing, monitoring, evaluating and treating residents’ pain. Care plans are formulated with individual pain management strategies. The home offers a combination of treatment options to manage care recipients’ pain, which includes heat, transcutaneous electrical nerve stimulation (TENS), massage and exercise. The physiotherapist also offers a pain management program. Care recipient/representatives express satisfaction with pain management and staff response to care recipients’ needs.

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 demonstrates capacity to provide palliative care, based on individual resident needs and ensure the comfort and dignity of terminally ill care recipients is maintained. The home establishes care recipients’ wishes with regard to end of life care in consultation with care recipients/representatives on entry to the home, and whilst the utmost will be done to support them there is no guarantee that a single room will be available. The end of life care needs are also discussed again at family conferences or at other times throughout their stay. One of the home’s registered nurses has a history of working in a palliative care unit; this nurse is the “go to person” for staff to get advice on palliation. The home’s consultant supports the staff to provide a palliative care pathway in consultation with the local medical officers. The home has equipment and supplies to ensure they meet the needs of care recipients receiving end of life care.


2.10 Nutrition and hydration

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

Team’s findings


The home has systems to ensure care recipients receive adequate nourishment and hydration. Assessment is undertaken on entry to the home and as needed. Relevant information regarding nutrition and hydration is provided to the kitchen. Staff are aware of care recipients’ individual special diets and fluid requirements and preferences. Care recipients’ weights are recorded monthly and in line with the individual resident’s assessed need. The advice of a dietician is sought when significant or ongoing weight loss occurs.

Nutritional supplements are available for care recipients who require extra nutritional support. Specialised eating equipment is used on an individual basis to help promote independence. Staff were observed to promote consumption of fluids throughout the day. Care recipients/representatives said they are satisfied with most meals and the support they are given to eat and drink.

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 systems to assess, monitor and maintain care recipients’ skin integrity. Care recipients are assessed on entry to the home and care plans developed to meet their needs. Staff monitor care recipients skin integrity daily during care. The home uses the incident reporting system to report any breaches in skin integrity and wound charts are maintained to document progress towards wound healing. The registered nurses conduct wound dressing and review the effectiveness of wound management strategies. The home has a range of dressing products available and there are pressure relieving aids to assist in maintaining and promoting care recipients’ skin integrity. Care recipients’ nutritional status is examined as part of the wound healing process and supplements provided that aid wound healing. Care recipients/representatives are generally satisfied with the way staff maintain care recipients’ skin integrity.

2.12 Continence management

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

Team’s findings


The home has systems to ensure care recipients’ continence needs are managed effectively. Continence management strategies are developed by staff for each resident following an initial assessment of urinary and bowel patterns. Care staff assist care recipients with their continence programs as required and care recipients’ bowel management programs are monitored daily. Care staff stated there is a sufficient supply of continence aids to meet care


recipients’ needs. Care recipients/representatives said they are satisfied with the support provided.

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 the needs of care recipients with challenging behaviours are managed. All care recipients are assessed on their entry to the home, behaviours identified and strategies are developed to manage each individual care recipient. Episodes of challenging behaviour are recorded in the resident’s notes and behaviour logs. Care and lifestyle staff are aware of care recipients’ individual needs and management strategies. Care recipient/representatives are generally satisfied with the manner in which staff manage those care recipients with challenging behaviour.

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 processes to optimise care recipients’ levels of mobility and dexterity. Care recipients’ mobility and dexterity is assessed on arrival at the home and on a regular basis. A physiotherapist attends each week and the home employs a physiotherapy aide once a week. The physiotherapist reviews and provides assessment and treatment of care recipients post falls. The incident reporting system includes analysis of falls to identify trends and implementation of strategies to reduce reoccurrence. Care staff showed an understanding of their responsibilities in relation to optimising care recipients’ mobility and dexterity. Care recipient/representatives expressed satisfaction with the home’s resident mobility program.

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 care recipients’ oral and dental health is maintained. This includes initial and ongoing assessment of care recipients’ oral and dental needs. Care recipients’ daily oral care is attended in line with individual care plans. The home has a system in place to ensure that all care recipients are offered access to a dentist annually and when needed. Care staff demonstrated an understanding of oral and dental care practices used in residential care. Care recipients/representatives expressed satisfaction with the way in which care recipients’ oral health is maintained.


2.16 Sensory loss

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

Team’s findings


Care recipients’ sensory losses are identified and managed by staff at the home. The home’s assessment process ensures any sensory loss is identified and referrals to appropriate specialists are made where required. The activity program incorporates activities that promote stimulation of the senses such as gardening and aromatic hand massages. Staff demonstrates an understanding of individual care recipients’ sensory needs. Care recipient/representatives report satisfaction with the assistance provided by the staff in managing resident sensory loss.

2.17 Sleep

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

Team’s findings


The home has systems to assist care recipients achieve their natural sleep pattern. On entry to the home a resident’s sleep pattern is assessed. Strategies include a quiet environment at night, settling routines, a warm drink, repositioning, optimisation of continence care and pain management. Care recipients stated the home is generally quiet at night and they are able to 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


The results of our observations, interviews and document review revealed that the home actively pursues continuous improvement through a program, which is consultative and responsive to feedback from its stakeholders. For comments regarding care recipient and staff feedback and details of the system see expected outcome 1.1 Continuous improvement.

The home uses a range of quality activities including stakeholder surveys, reviews and audits to measure its performance in relation to all expected outcomes in Standard Three of the Accreditation Standards. Improvements are implemented based on the information obtained. Examples of improvements include:

As a way of enhancing the social engagement of care recipients, a supper dance was held. The supper dance will now be a regular activity on the home’s activity calendar. Photographs show care recipients dressed up and enjoying the dancing and engagement with others. Care recipients stated it was a very pleasant activity.

The home has commenced a program of visiting dogs on a weekly basis. Staff and care recipients stated this is a much anticipated activity on the calendar and care recipients look forward to the visits.


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


The results of observations, interviews and document review revealed that the home has an effective system to manage regulatory compliance pertaining to Care recipients’ Lifestyle.

For comments regarding the system see expected outcome 1.2 Regulatory compliance.

An example of responsiveness to a change in legislation is the action taken by the home to implement policy and procedures to manage mandatory reporting and investigation of care recipient abuse in line with changes to the Aged Care Act 1997. In addition, care recipient agreements and handbooks were reviewed and amended in light of the introduction of the Quality of Care Principles 2013 and the Quality Agency Principles 2013.




Team’s findings


For details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively please refer to expected outcome 1.3 Education and staff development.

Education sessions attended by staff that relate to this standard include but are not limited to client rights, privacy and dignity, and responding to alleged and/or suspected elder abuse.

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


Management and staff of the home recognise the importance of providing emotional support for new and existing care recipients. Emotional needs are identified through the care recipients’ care plan, consultation with families and one-to-one meetings. On entry to the home lifestyle staff meets new care recipients and assist with the settling in process by orientating them to their new home and introducing them to other care recipients and staff. Staff provided examples of individualised strategies to meet care recipients’ emotional needs on entry and on an ongoing basis. Care recipients/representatives stated that the staff are warm and caring, making the facility their home.

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


Care recipients are assisted to achieve independence, maintain friendships and participate in community life within and outside the home according to their preference. Lifestyle staff described bus outings and provided examples of care recipients who attend social outings and family outings. A range of activities are available at the home to support resident’s independence including exercise programs, mobility programs and assessments. Care recipients are supported to remain on the electoral roll and to vote. Care recipient/representatives advised care recipients are encouraged to be independent in all aspects of life according to their preferences.


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 demonstrates each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Care recipients are accommodated in shared rooms which has privacy screening used at times of bereavement or when clinical care is provided. Resident information is securely stored in locked rooms. Consent is sought from care recipients for their photographs to be displayed and information to be shared with other service providers. Staff described strategies for maintaining care recipients’ privacy, dignity and confidentiality including; doors being closed during care delivery, discrete notices to identify special care needs and addressing care recipients by their preferred name. Care recipient/representatives interviewed are satisfied with how staff promotes care recipients’ privacy and dignity.

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


Staff support care recipients to participate in a variety of activities of interest to them. On entry to the home an assessment of care recipients’ leisure interests is undertaken and a care plan developed. The activities program is provided six days per week, with visitors encouraged to attend the other day. Lifestyle staff assess and evaluate the activities program and care recipients’ attendance records to ensure care recipients’ preferences are met. The activities program is flexible to meet the daily needs of care recipients. We observed care recipients participating in a range of activities throughout the home including “play up”, music, exercise programs and games. Care recipients/representatives expressed satisfaction with the activities and lifestyle program available 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 cultural and spiritual lives of care recipients are recognised and supported by the home. Care recipients needs and preferences are identified through an assessment and documented on their care plan. Specific cultural and spiritual days such as Australia Day, ANZAC day, Mothers’ Day Christmas and Easter are celebrated. The home provides care to some care recipients with diverse cultural and spiritual backgrounds and gave specific examples on how they meet their individual needs. Care recipients/representatives are complimentary of the staff and home’s approach to their cultural and spiritual needs.


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 supports each care recipient and/or representative to participate in decisions about the services provided and for care recipients to exercise choice and control over their lifestyle. The menu provides choices for each meal and food preferences are recorded and met. Participation in activities is the choice of the care recipient and their right to refuse is respected. The Charter of Residents’ Rights and Responsibilities is displayed in the home. Care recipients/representatives are able to participate in decisions about the care and services provided at the home through resident meetings, family conferences and discussions with registered nurses and management. Care recipients expressed satisfaction with their choices and control over the care and services they receive.

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


The home’s systems provide appropriate and consistent information to care recipients/representatives on entry to the home and when changes occur. A handbook and agreement including information about security of tenure provisions and care recipients’ rights and responsibilities is provided to each new care recipient/representative on entry to the home. Information includes cost of services, services provided included in cost and any additional costs. Room moves occur only after consultation and negotiation with the care recipients/representatives. Care recipient/representatives advise they are provided with information and understand their rights, responsibilities and security of tenure.


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 results of observations, interviews and document review revealed that the home actively pursues continuous improvement through a program that is consultative and responsive to feedback from its stakeholders. For details of the overall system and comments regarding care recipient and staff feedback see expected outcome 1.1 Continuous improvement.

A range of quality activities are used to measure performance in relation to all expected outcomes in Standard Four of the Accreditation Standards. These include reviews and audits in areas covering care recipient satisfaction, the environment, work health and safety and infection control. A review of these activities indicates that actions are carried out that result in improvement. For example:

A dedicated program of review and removing clutter of care recipient spaces within the home has occurred. The emphasis has been about providing a more comfortable, home like environment. Out dated furniture, unused items and equipment have been removed and some new furniture purchased, including visitor seating beside the care recipients’ beds. Care recipients/representatives are satisfied with the changes made.

In response to identified risks, the parent organisation is now taking an organisational approach to testing and tagging of electrical equipment. In the past the task was done by the maintenance staff and/or local providers however the process was inconsistent and time consuming. The organisation has now contracted a provider to provide the service on a scheduled basis and in a consistent manner.


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


Results of observations, interviews and document review revealed that the home has an effective system to manage regulatory compliance. For comments regarding the system see expected outcome 1.2 Regulatory compliance.

Examples of the home’s responsiveness to legislative requirements include the assessment of the building using the 1999 Certification Assessment tool and the implementation of a food safety program that is audited externally in accordance with the Food Safety Act 2010. The home is upgrading its fire safety system equipment including


the retrofitting of a sprinkler system in accordance with the NSW Environmental Planning Policy Amendment (Fire Sprinkler Systems) 2012 under the Environmental Planning and Assessment Act 1979 effective 1 January 2013.



Team’s findings


For details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively, please refer to expected outcome 1.3 Education and staff development.

Education sessions attended by staff that relate to this standard include but are not limited to manual handling, infection control, and fire safety training. Sessions also provided include dining with dignity, chemical awareness and bullying and harassment.

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 results of observations, interviews and document review revealed that the home generally provides a safe and comfortable environment consistent with care recipients’ needs. For example, care recipient/representative interviews revealed that the majority are satisfied with the living environment. Care recipients reside in predominantly shared rooms with communal bathrooms. There are communal areas including dining, lounge and activity rooms. A comfortable temperature is maintained within the building. Large windows and doors provide care recipients with views of the external environs which include well maintained landscaped gardens and paved garden courtyard areas that are accessible to them. Environmental audits and the planned preventative and corrective maintenance systems ensure that the environment (grounds, building and equipment) are generally well maintained.

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. The results of observations, interviews and document review revealed that this is achieved through a program that incorporates policies and procedures, staff awareness, incident/accident/hazard reporting, risk assessment and a functioning committee that includes work health and safety as part of its role. In addition, the home employs a number of


preventative strategies including education and competency testing, hazard management and the provision of suitable equipment to reduce the risk of manual handling injuries. For example, lifters and trolleys to transport goods are used. Staff confirmed they have access to workplace safety training and have input into the purchase of equipment. Workplace safety inspections/environmental audits are undertaken and where possible remedial action is taken to rectify hazards or risks identified.

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 environment and safe work practices are minimising fire, security and emergency risks. The results of observations, interviews and document review revealed that there are well publicised and clearly understood emergency and fire evacuation procedures. The home has appropriate fire warning and fire fighting equipment that is regularly assessed against the relevant Australian Standard. Clearly marked emergency exits are free from obstruction. Fire prevention measures used include education, environmental safety inspections, safe storage of chemicals, an electrical equipment checking/tagging program, and a smoking policy with designated outdoor areas provided for care recipients and staff who smoke. Security systems include lock up procedures, numeric coded key pad locks, night patrols by external security personnel and appropriate fencing. Emergency contact numbers and phones are available for staff use. All care recipients have access to emergency buzzers in their rooms, bathrooms and communal areas and/or via pendant.

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 in place. The results of observations, interviews and document review revealed this program operates throughout the home. It incorporates infection surveillance and reporting system, a hazard risk management system, a waste management system and outbreak management procedures. A food safety program operates in the kitchen and appropriate laundering techniques are followed by the onsite laundry. Preventative measures include education for all staff disciplines, an effective cleaning program, and a vaccination/immunisation program for care recipients and staff. In addition, appropriate equipment, staff practices and workflows are minimising the risk of cross infection. Staff interviewed demonstrated an awareness of infection control as it pertains to their work area.


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 the care recipients’ quality of life and the staff’s working environment. The results of observations, interviews and document review revealed that:

Care recipients meals are prepared in the onsite kitchen using the fresh cook method and are in accordance with a four-week seasonal rotating menu. The dietician approved menu is providing care recipients with choice and variety. Care recipients have input into menus through meetings and their likes and dislikes are recorded on entry to the home. The comments and complaints system and satisfaction surveys provide further mechanisms for feedback. Care recipients interviewed indicated their likes and dislikes, special dietary needs and expectations re quality and quantity of meals are identified and met.

Planned cleaning programs are ensuring that appropriate cleaning standards are maintained. Care recipient interviews revealed that a clean and hygienic environment is maintained at all times.

The onsite laundry service employs effective systems for the storage, identification, laundering of and delivery of care recipients’ personal clothing. Flat wear including bed linen and towels are provided by an external contractor. Care recipient interviews revealed that they are satisfied with the laundry services provided. Their personal items are returned to them promptly in good condition in a timely manner.

The Whiddon Group - Wingham · Home name: The Whiddon Group - Wingham RACS ID: 2632 2 Dates of...

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Transcript of The Whiddon Group - Wingham · Home name: The Whiddon Group - Wingham RACS ID: 2632 2 Dates of...