Uniting Care Mirinjani Retirement Village - Eabrai …...Home name: Uniting Care Mirinjani...

Uniting Care Mirinjani Retirement Village - Eabrai Lodge Special Care Hostel

RACS ID 2915 12 Namatjira Drive

WESTON ACT 2611

Approved provider: The Uniting Church in Australia Property Trust (NSW)

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 26 June 2015.

We made our decision on 23 May 2012.

The audit was conducted on 16 April 2012 to 20 April 2012. The assessment team’s report is attached.

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

Home name: Uniting Care Mirinjani Retirement Village - Eabrai Lodge Special Care HostelDate/s of audit: 16 April 2012 to 20 April 2012 RACS ID: 2915

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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 Accreditation 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.

Expected outcome Accreditation Agency decision




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


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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.


decision




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.


decision




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


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Audit Report

Uniting Care Mirinjani Retirement Village - Eabrai Lodge Special Care Hostel 2915


Introduction This is the report of a re-accreditation audit from 16 April 2012 to 20 April 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 Accreditation 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


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 16 April 2012 to 20 April 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. 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 1997. Assessment team

Team leader: Judith Roach

Team member/s: Hiltje Miller

Approved provider details


Details of home

Name of home: Uniting Care Mirinjani Retirement Village - Eabrai Lodge Special Care Hostel

RACS ID: 2915

Total number of allocated places:

21

Number of residents during audit:

20

Number of high care residents during audit:

18

Special needs catered for:

Dementia

Street/PO Box: 12 Namatjira Drive State: ACT

City/Town: WESTON Postcode: 2611

Phone number: 02 6288 4799 Facsimile: 02 6288 4278

E-mail address: Nil


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Audit trail The assessment team spent five days on-site and gathered information from the following: Interviews

Number Number

Executive manager - property and housing

1 Residents/representatives 5

Regional operations manager - property and housing

1 Medical officer 1

Regional operations manager 1 Village liaison officer 1

Regional learning and development manager

1 Acting lifestyle manager 1

Area manager 1 Recreational activity officer 1

Senior clinical manager - regional

1 Chaplain - regional 1

Service manager - site 1 Chaplain - site 1

Nurse practitioner/clinical nurse consultant/infection control coordinator - site

1 Team leader - support services 1

Learning and development coordinator - site

1 Cleaning staff 1

Health safety and welfare coordinator/fire safety officer

1 Maintenance supervisor 1

Multiskilled care service employees

5 Maintenance staff 1

Physiotherapist 1

Sampled documents

Number Number

Residents’ files 6 Medication charts 20

Wound charts 3 Personnel files 2

Other documents reviewed The team also reviewed:

Accident, incident and hazard reports, risk assessment records

Aged Care Complaints Scheme information

Approved providers lists, contracts, agreements and service schedules

Audit schedule, summary reports, benchmarking data

Catering service records including menus, dietician review, resident diet forms

Cleaning and laundry schedules and manuals

Clinical and care assessment documentation: resident dietary and observation charts including weights, continence, behaviours, sleep, skin integrity, pain, mobility, falls risk, toileting, wound assessments, authorisation for restraint forms, leisure and lifestyle


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Comments, complaints and compliments documents

Computer based information systems

Continuous improvement (CI) records including CI plan and register

Criminal history record checks - registers for staff, volunteers, contractors

Daily care plans

Emergency procedure flip charts, disaster management and emergency evacuation plans

Fire safety inspection logs, annual fire safety statement

General practitioner, physiotherapist registration records

Health safety and wellbeing committee records including plan

Human resources records including ‘Aspire to Inspire’ staff recognition and service awards, rosters and allocation lists, position descriptions and duty lists, information handbook, enterprise agreement

Infection control documents/records including outbreak management, surveillance data, temperature records equipment and food, pest inspection records, vaccination records - residents and staff

Notices advising residents/representatives and visitors of the Re-accreditation Audit

Physiotherapy care plans/assessment forms

Planned preventative and corrective maintenance records including schedules, repair and maintenance logs

Podiatry records

Policies, procedures, flowcharts and reference manuals - various

Reportable incidents register

Resident agreement, handbook, information pack, newsletters

Resident and staff surveys - reports and action plans

Resident/representative communication documents - various other

Self assessment report for re-accreditation and associated documentation

Staff communication records including handover sheets, diaries, memorandum, newsletters

Staff education, orientation, induction and mandatory training records

Various meetings - schedules, agendas, minutes Observations The team observed the following:

Accreditation Agency re-accreditation audit notices on display

Brochures - external complaints scheme, advocacy services, food safety, various other

Catering service including food safety program and monitoring records

Charter of Residents Rights and Responsibilities on display

Cleaning and laundry service - systems and processes

Emergency evacuation kit including resident lists

Emergency exits and fire safety equipment, fire panel and location maps


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Equipment in use, supplies and storage areas - various

Feedback forms, suggestion box

Infection control resources - hand wash basins, hand sanitiser, personal protective equipment, colour coded equipment, sharps container, outbreak management kit, spill kit

Interactions between multiskilled care service employees and medical and other health related services personnel

Interactions between staff, residents and relatives/representatives, visitors

Living environment - internal and external

Manual handling system and processes

Material safety data sheets (MSDS), chemical storage area

Meal service and staff assisting residents

Medication administration round and medication storage area

Mobility and manual handling equipment including shower chairs, wheel chairs and walkers

Notices, pamphlets, forms and other information on display for staff, residents, representatives, visitors

Photographs of resident activities on display

Principles, philosophy, vision and values statements on display

Residents leisure and lifestyle activities in progress

Residents leisure and lifestyle calendar, resources

Security system including nurse call system

Staff access to information systems

Staff work practices and work areas

Storage of resident and staff files

Treatment room, clinical supplies and trolleys

Visitor/contractor sign in/out books


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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 residents, 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 continuous improvement system to identify improvement opportunities and monitor performance against the Accreditation Standards. At the organisation level of UnitingCare Ageing South Eastern region, there is a range of management services that provide overall direction, support and coordination of quality activities. At the local level, continuous improvement opportunity forms are used to identify and/or evaluate improvements and provide a mechanism for staff and residents/representatives to provide input and feedback. Other mechanisms used include internal and external audits, satisfaction surveys, benchmarking reports, and training and incidents analysis. The home uses a continuous improvement data entry system whereby improvement opportunities are logged into a service specific database. This process generates a register, plan and summary of achievements through tracking identified continuous improvement opportunities. Representatives and staff interviewed are satisfied that the home actively pursues continuous improvement. Examples of improvement initiatives either in progress or implemented by the home in relation to Standard 1 Management systems, staffing and organisational development include:

UnitingCare Ageing has developed an ‘Inspired Care’ framework to guide a person centred approach to care and service delivery. The person centred model has been widely adopted within UnitingCare Ageing South Eastern region over the past three years. The framework includes the UnitingCare Ageing ‘Aspire to Inspire’ model which was developed in response to the organisation identifying a need to foster and nurture a person centred culture with staff as well as with the residents. The home has commenced implementing the model to assist staff’s understanding of the principles of the Inspired Care framework and has identified a number of positive outcomes. For example, management has identified an increase in the provision of holistic resident care through the creation of a therapeutic culture of care. Other identified outcomes include increased staff participation in quality improvement activities, education and training, and more effective staff relationships.

UnitingCare Ageing South Eastern region has commenced a staged introduction of an electronic learning management system in 2011. Staff have been provided with designated learning spaces, laptops and monitors and access to an on-site learning and development coordinator as required. Management said the initiative is being implemented following the organisation identifying a need to provide all staff with a user-friendly, flexible elearning platform. Other objectives include increasing staff knowledge and compliance supported by increased monitoring of staff education and training. The initial role out of the elearning packages comprised mandatory topics including fire safety, manual handling and infection control. Management advised and staff interviewed confirmed that staff are being rostered extra time on duty to undertake the mandatory


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topics, or they can complete them at home. The learning management system automatically records all completed learning activities and once the staff have successfully completed a mandatory topic they receive a certificate of completion. Staff said they are finding the receipt of certificates very satisfying and encouraging.

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The home has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home is advised of any changes in regulatory requirements and professional standards by the UnitingCare Ageing South Eastern region. The organisation monitors the regulatory environment through updates from government and industry bodies, an aged care specific legislation service and other mechanisms. Changes to legislation are disseminated to the home’s management and staff via emails, memos, meetings and education sessions. Policies and procedures are reviewed and updated in line with new legislation. Audits, surveys, quality improvement activities, staff supervision and support ensure that work practices are consistent and compliant with legislative requirements. Interviews with staff demonstrated their awareness of regulatory compliance. Examples of the home’s response to meeting regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

Residents and other stakeholders having access to complaints mechanisms, and monitoring professional registrations of relevant staff and contractors.

Current criminal history record checks have been carried out for staff, volunteers and relevant contractors commencing 2007 in line with the Accountability Principles 1988.

Residents/representatives were notified of the re-accreditation audit and their right to speak with the assessment team as required by the Accreditation Grant Principles 2011.

A system is in use for the secure storage, archiving and destruction of personal information in accordance with privacy legislation and regulations relating to residents’ records.

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 meets this expected outcome There is a system to ensure that management and staff have appropriate knowledge and skills to perform their roles effectively. Maintenance of staff knowledge and skills is underpinned by a staff orientation program that familiarises new staff with the home’s policies and procedures. UnitingCare Ageing South Eastern region mandatory education program supports all staff disciplines in providing care and services in accordance with the requirements of the four Accreditation Standards. The home’s internal education programs together with the external education available provide staff with education and training on a range of issues relevant to aged care. The effectiveness of the training provided is being


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measured through resident and staff feedback, audit results, observation, staff appraisal and competency assessments. Management and staff said they are supported to attend relevant internal and external education and training. Representatives interviewed are of the view staff have the skills and knowledge to perform their roles effectively. Examples of education and training relating to Standard 1 Management systems, staffing and organisational development that has been provided for management and staff include:

The Accreditation Standards, continuous improvement, inspired management training; aspire to inspire sessions, the aged care funding instrument (ACFI), comments and complaints management, compulsory reporting, information technology including care documentation processes, mentoring, and policy and procedures. In addition, a number of management and administration personnel have or are obtaining certificate IV or higher qualifications, in management or related business administration courses.

1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome The home has policies, procedures and processes to ensure that each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Brochures and information explaining the internal and external complaints mechanisms are on display in the foyer of the home. The processes for feedback are discussed with residents/representatives as part of the resident entry process and at resident and staff meetings. A review of comments and complaints records and residents/representatives interviewed confirmed that issues are investigated, analysed and responded to in timely manner. General surveys of customer satisfaction and surveys of specific services, such as catering, are conducted and the results used as a basis for quality improvements. Representatives are aware of the mechanisms by which they may make complaints on behalf of residents, and comment on or compliment management and staff for excellence in service provision. Staff interviewed outlined the processes for management of complaints for residents/representatives and ways in which they can personally raise issues of concern. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The home is a part of the UnitingCare Ageing organisation and as such comes under its overall vision, values, philosophy, objectives and commitment to quality. These are encapsulated in its vision, mission and values statements that have been documented and communicated to all stakeholders in the home. These statements are published in the home’s key documentation including the resident handbook which is given to all residents/representatives on a resident’s entry to the home. All staff receive a copy of the staff handbook which includes these statements on commencement of their employment. The statements are displayed throughout the home and are available on the UnitingCare Ageing website. In addition, staff are made aware of the home’s vision, mission and values


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through its staff recruitment, orientation and education processes, staff meetings and other communication. 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 meets this expected outcome UnitingCare Ageing South Eastern region and the home have effective human resource management systems and processes in place. These systems and processes ensure the home has appropriately skilled and qualified staff sufficient to provide services in accordance with the accreditation standards and the home’s philosophy and objectives. Policies and procedures that guide the human resources practices are accessible to all staff in hard and electronic copy. Staff recruitment includes criminal record checks, reference checks, an orientation program and buddy shifts. Performance reviews through an appraisal and competency assessment program are in place. Position descriptions have been developed for all positions and are regularly reviewed. Staff interviewed said they are satisfied with their rosters and sufficient time to meet residents’ needs. Staff confirmed that staffing levels are flexible and monitored in line with residents’ specific care needs and related dependencies. Skills mix review, observation of work practices, auditing processes, clinical indicators and stakeholder feedback inform this process. Representatives interviewed are of the view that staff are skilled and knowledgeable about their work and that staffing levels are adequate. 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 meets this expected outcome The home has policies and procedures for ensuring there are adequate supplies of inventory and equipment available for quality service delivery. UnitingCare Ageing South Eastern region has developed an overall purchasing system of preferred suppliers designed to ensure that desired standards are met. A stock control and ordering system is in operation with particular staff roles having responsibility for specific areas of inventory monitoring and ordering. Storerooms and service areas such as clinical rooms, the kitchen, and housekeeping areas were observed to be well equipped, well stocked, and well maintained. Staff interviewed advised there are adequate supplies of inventory and equipment for them to perform their job roles effectively. Representatives interviewed said the home provides sufficient stocks of appropriate equipment and supplies to meet changing resident care needs and preferences. A planned preventive and corrective maintenance program is in place to ensure that equipment is well maintained and fit for purpose. Staff and representatives said that maintenance is prioritised and responded to in a timely manner.


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1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome UnitingCare Ageing South Eastern region and the home have effective information management systems in place to support the operation and function of the home. The resident information system includes a resident handbook, resident agreements, residents’ meetings, newsletters, resident assessments, care plans and clinical records. Staff communication systems are in place to ensure relevant information provision to and between staff. These systems include a range of meetings, access to computers, distribution of hardcopy materials, staff noticeboards, and induction and training. Resident and staff records were observed to be kept in secured areas to ensure appropriate security and confidentiality of information. Staff interviewed confirmed their satisfaction with the home’s information management systems. Representatives interviewed are satisfied with their access to information and said it assists them to make decisions about the delivery of care and services to residents. 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 meets this expected outcome UnitingCare Ageing South Eastern region has a contract management system to ensure that externally sourced services are provided in a way that meets the home’s needs and service quality goals. A range of contractors and external service providers operate within contracts and service agreements including resident and care related services, fire systems and various building maintenance and services. Contracts and/or service agreements encompass the home’s requirements/expectations for quality service provision, professional qualifications and certifications, relevant insurances and police checks. Contractors and tradespeople entering the home are required to comply with the organisation’s health and safety requirements. The quality of external services is monitored at both the organisation and local level by reporting through the home’s continuous improvement system. Other avenues include staff and resident feedback, one-to-one interaction, and observation of work practices. Representatives and staff interviewed confirmed their satisfaction with the quality of services provided by approved external providers including the quality of residents’ food supplies and fire safety services.


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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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 2 Health and personal care, staff record information on resident falls, skin tears, medication incidents, behaviours and absconding residents and this information is then collated and analysed for trends. Residents and staff are satisfied that the organisation actively promotes and improves residents’ physical and mental health. Examples of improvement initiatives the home has implemented or that are in progress in relation to Standard 2 Health and personal care include:

The home has introduced a ‘comfort clinic’ which is managed and supervised by a physiotherapist. Management advised the initiative is part of the home’s aspire to inspire model of care which is resulting in the creation of a therapeutic culture. The comfort clinic is held twice a week and focuses on older people with identified chronic pain to ensure they are as free as possible from pain. To support the establishment of the clinic the home has purchased specialised pain relief equipment including an ultrasound machine, a specialised massage support head rest, and a transcutaneous electrical nerve stimulation (TENS) machine. Residents interviewed expressed their gratitude and satisfaction with the initiative.

The home has introduced a home-based palliative care model in liaison with and support from the palliative care team based at a local area hospital. The initiative has been implemented following the home receiving feedback from residents/representatives who wished for residents receiving palliative care to remain at the home. Management has purchased clinical equipment and supplies to enable appropriate provision of palliative care to relevant residents at the home. Results include residents being able to choose appropriate home-based palliative care services that are fully supported by a hospital based palliative care team. Advance care directives and a palliative care policy have been introduced in line with the initiative.

2.2 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 about health and personal care”. Team’s findings The home meets this expected outcome The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Accreditation Standard 2.


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Examples of the home’s response to meeting regulatory compliance relating to Standard 2 Health and personal care include:

The home ensures that specialised nursing procedures as defined by the Quality of Care Principles 1997 are managed and supervised by registered nurses, and carried out only by staff qualified and trained to do so. Relevant registrations of nursing staff are monitored.

Policies and procedures are in place to ensure the correct management and administration of medications in line with legislative guidelines.

Policies and procedures are in place to ensure the Department of Health and Ageing is notified in line with Accountability Amendment Principles 2011 when residents are reported missing without explanation.

2.3 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 meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Accreditation Standard 2. The education program includes an extensive range of subjects specific to residents’ health and personal care, and is reinforced by competency assessments in related areas. Examples of education and training relating to Standard 2 Health and personal care that has been provided for management and staff include:

Core clinical skills for care staff, challenging behaviours, dementia care, diabetes, falls prevention, oral and dental care, medication management, nutrition and hydration, resident assessment and documentation and various other aspects of resident care. In addition, the majority of care staff have or are obtaining their certificate III or IV in aged care or higher qualifications.

2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home provides residents with appropriate clinical care through initial and ongoing assessments, care planning and evaluation processes. The home has processes that put the residents/representatives in control of residents’ care and to provide opportunities to have input into residents' care planning. The nurse practitioner and registered nurses review and evaluate residents’ personalised plans of care every three months or when required. Resident care needs are communicated to staff verbally, via handover sheets and the electronic communication system. 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. Arrangements are in place to contact medical officers after hours ensuring that residents’ ongoing needs are met. Staff demonstrate knowledge of residents’ care needs ensuring that residents’ clinical care is being met. All residents/representatives


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expressed satisfaction 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 The home meets this expected outcome Residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officer input when required. This includes nurse practitioner and registered nurse input into the assessment, management and care planning for residents. The home currently provides specialised nursing care for residents requiring: diabetic management, pain management regimes, palliative care, and wound care. Trained and qualified care staff are provided with education in specialised nursing procedures with competency/skills audits based assessments in place. Staff demonstrate knowledge and understanding of residents’ specialised nursing care needs. Staff confirmed they have access to adequate supplies of equipment for the provision of residents’ specialised nursing care needs. Representatives are satisfied with the level of specialised nursing care offered to relevant 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 The home meets this expected outcome The home has systems to identify residents’ needs and preferences in relation to other health and related services and for making referrals. Management advised that internal and external other health and related services are available to residents. Examples include: audiology, continence management support, dental service, dermatologists, dietician, optometry, physiotherapy, podiatry, psycho geriatrician, radiology, speech pathology, massage, pathology, palliative care, psychiatric services and wound care specialist. Care plans and progress notes are reflective of specialist health care practitioners’ recommendations and ongoing care interventions. Residents have pathology testing when ordered by their medical officer including checks for therapeutic medication levels. Representatives are satisfied with the access and availability of other health and related services for residents. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome The home has processes to ensure residents’ medication is managed safely and correctly through policies and procedures, regular pharmacy deliveries, the secure storage of medications, and internal and external audits. Qualified and trained staff administer medication from packaged medications packs and the nurse practitioner oversee the home’s medication management system and processes. Review of residents’ medication charts


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revealed current general practitioners’ orders are recorded and filed with medication identification sheets. These documents are filed along with information including residents’ photographic identification, allergies, how to take the medication, staff signature and medication allergy status. Controlled drugs are administered by registered nursing staff according to legislated guidelines and regulatory compliance. The home has a medication error reporting system with additional monitoring provided by the home’s medication advisory committee. All staff who administer medications are assessed according to the home’s medication policy through competency based assessments on an annual basis or as required. Residents/representatives said they are satisfied with the home’s management of the residents’ medication. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome The home ensures all residents are as free as possible from pain through the initial assessment of residents, care planning, evaluation processes, and accessing advice on pain management from medical officers. Interventions are detailed in residents’ care plans and on-going assessments documented. There are various pain control methods used in the home. The individual resident’s needs are considered to ensure the most appropriate method of pain relief is used for each resident. Effective pain control methods used are pharmacologic, music and relaxation, physical therapies (massage, repositioning and gentle exercise), provision of pressure relieving equipment and emotional support. Pain relief measures are followed up for effectiveness and referral to the resident’s medical officer and other services organised as needed. Residents/representatives expressed satisfaction with management of residents’ pain states and indicated that staff respond in a timely manner to residents’ requests for pain control. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome The home has processes to maintain the comfort and dignity of terminally ill residents. Discussions are held with the relevant resident’s medical officer, family and staff. Care plans for palliative care are developed and implemented as required. Support is provided for terminally ill residents including pressure relief care, oral care, and pain relief. Preferences relating to the spiritual, physical, cultural, psychological and emotional needs of the residents are considered in care planning, and pastoral care is provided as requested. Staff demonstrate an understanding of the needs of a terminally ill resident and their families, including a peaceful and supportive environment. The palliative care plan is reflective of resident/representative feedback during the assessment process.


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2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome The home has processes to provide residents with adequate nourishment and hydration. The resident’s special dietary needs are assessed at the time of admission on a resident’s dietary needs form and sent to the kitchen. Provision is made for residents who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. 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/representatives expressed satisfaction with residents’ meals, which allow residents to have an alternative choice and that they are able to have input into menus. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome 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 such as air flow and overlay mattresses, and protective coverings for limbs. Care staff help to maintain the residents’ skin integrity by providing regular pressure care, the application of skin guards and correct manual handling practices. Representatives are satisfied with the skin care provided to residents. Residents indicated that 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 meets this expected outcome 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. Care staff have access to adequate supplies of continence aids to meet resident’s needs and they provide residents with regular toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies.


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For example: regular drinks, aperients medication 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 indicated general satisfaction with residents’ continence care, inclusive of continence. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The needs of residents with challenging behaviours are managed through consultation between the resident/representative, staff, general practitioners and allied health professionals to identify any behavioural issues. The home practices a restraint free environment for residents. Care staff, recreational activity officers, and the pastoral care team implement a range of strategies to effectively manage residents with challenging behaviours. The residents’ behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate for review. The specialist mental health services for older people provide guidance and education to staff in identifying and managing residents’ challenging behaviour. Staff are able to recognise the triggers and early warning signs exhibited by some residents and put in place appropriate strategies to calm and distract residents. The team observed the environment to be calm, residents well groomed, and residents happily participating in activities of interest to them. Resident’s representatives confirmed that staff manage residents’ challenging behaviour well. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome Residents are supported to achieve optimum levels of mobility and dexterity through assessments completed on entry to the home, care planning and exercise programs provided. A registered physiotherapist is employed by the home and is available to assess those residents who have identified needs. Based on the assessment a plan of care is developed and evaluated for effectiveness. Individual and group exercise programs are recorded in the residents’ plans of care and staff are informed verbally, visually and electronically. Re-assessment of residents occurs: following falls, when there is a change in their condition and on return from hospital. Strategies for residents’ falls prevention include: physiotherapy; provision of mobility aids; medication reviews; the use of hip protectors when indicated, and exercises. The physiotherapist gives education on manual handling to staff on a yearly basis or when necessary.


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2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome 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 and as their needs change. Appropriate dental health is planned and staff are informed of the residents’ needs. Specific care plans including any treatments for teeth and gums are recorded on individual resident’s medication charts and plans of care as necessary. Dental consultations are arranged as required either to the resident’s dentist of choice, or by referral to a 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. Representatives stated 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 meets this expected outcome Residents’ sensory losses are identified and managed effectively through assessments, development of a plan of care, documentation, monitoring and evaluation. Residents’ sensory losses are recorded on their care plans which are evaluated three monthly or when required. The home’s recreational activity officers have implemented a variety of programs and resources to assist residents with sensory loss. These programs are designed to promote independence, sensory stimulation and interaction with others. Staff recognise that a loss of taste may be associated with medications, disease, and ageing processes that result in a decrease in appetite and nutritional issues. Residents can access large print books through the home or from a local library if required. Residents have access to specialist services, for example referral to optometrists, and a local acoustic hearing centre. Representatives said staff are supportive of residents with sensory loss and promote their independence. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome 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. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, positioning and night sedation if ordered by the medical officer. Residents use the nurse call system to alert the night staff if they have difficulties in sleeping. Most residents state they sleep well at night. Residents/representatives interviewed did not identify any problems with residents achieving natural sleep patterns and indicated satisfaction with the home’s approach to sleep management.


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Standard 3 – Resident lifestyle Principle: Residents 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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 3 Resident lifestyle, resident/representative meetings and resident/representative surveys are used to gather suggestions. Feedback is regularly recorded and evaluated from all lifestyle and care activities. Staff also contribute to improvements to resident lifestyle through surveys, training and networking. Staff encourage and support residents and others to provide feedback and suggestions. Examples of improvement initiatives the home has implemented or that are in progress in relation to Standard 3 Resident lifestyle include:

The home has recently established a ‘Tea and Tales’ leisure activity to enhance spirituality and meaning for residents, and to encourage their conversations around life matters. The initiative was implemented following feedback from the chaplaincy team about a need to promote interactions and community life to enrich the lives of residents who are restricted in outside access. Representatives interviewed expressed their gratitude and satisfaction with the resident focused initiative.

Person centred lifestyle activities are being increased following staff feedback on observation of the residents. For example, staff identified that a resident did not know what a compact disc is or how to effectively use it. As a result of the feedback management has purchased two record players and old style records. Staff are reporting good outcomes for residents including positive reminiscence in response to hearing music and songs from their past.

Examples of other person centred lifestyle activities being increased include weekly bus trips. An extra bus trip each week has been initiated following resident/representative and management and staff feedback. Examples of extra trip venues and bus trip activities include scenic drives and ‘stop-offs’ for ice cream. An extra volunteer bus driver has been sourced by the home to assist with the extra bus trips. Resident/representative feedback reveals increased levels of resident satisfaction are being expressed.

3.2 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, about resident lifestyle”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring regulatory compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.


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Examples of the home’s response to meeting regulatory compliance relating to Standard 3 Resident lifestyle include:

Management has mechanisms in place to ensure the home meets the provisions of the Aged Care Act 1997 including privacy provisions for staff and residents’ confidential information. Other examples include mechanisms in place to provide residents’ security of tenure, and to ensure the appropriate reporting of suspected or alleged incidents of elder abuse.

Management has mechanisms in place as at 1 February 2012 in line with the User Rights

Amendment Principles 2011 to ensure the home meets the regulatory requirements of the Governance Standard for prudential requirements.

3.3 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 meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Accreditation Standard 3. Examples of education and training relating to Standard 3 resident lifestyle that has been provided for management and staff include:

Orientation and induction related to resident lifestyle; grief and loss; residents’ privacy, dignity and respect, and elder abuse. Other examples include resident rights, staff responsibilities in relation to the confidentiality of residents’ personal information, and dementia workshops.

3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home has a system to ensure residents receive support in adjusting to life in their new home environment and on an-ongoing basis. Residents’ records show that residents’ individual social, emotional, cultural and spiritual history details are recorded shortly after their entry to the home. The information is used to formulate the residents’ personalised care plans that are reviewed three monthly. Management, care staff and recreational activity staff demonstrated ways they provide new and ongoing residents with emotional support. Examples include: welcoming new residents, providing new residents with an orientation to the home, introducing new residents to other residents, reassurance by staff, and one-to-one support. Residents/representatives and staff are provided with support from the homes’ chaplaincy team as requested. Residents are able to have familiar and treasured items in their rooms which contribute to their overall health and wellbeing. The team observed staff showing respect to and interacting with residents in an understanding and caring manner.


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3.5 Independence This expected outcome requires that "residents 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 meets this expected outcome Residents’ abilities and preferences in relation to independence and lifestyle needs are assessed on their entry to the home. The information is documented in their care plans and evaluated three monthly. The home provides an environment in which community groups are welcome to visit the home. The residents visit other aged care homes in the local area and participate in joint activities. Residents’ representatives are also welcome to visit and the home provides a room which residents can use for special celebrations with their families. Residents can choose to continue to participate in local community activities and to go on outings as their condition allows. Residents’ independence is enhanced through various activities and areas of decision-making. These include personal hygiene, attendance at activities, the use of specialised equipment and assistive devices such as hearing aids, rollator frames, raised toilet chairs, and shower chairs. Communication and feedback is available through resident meetings, newsletters and personal discussion. Residents/ representatives expressed satisfaction with how the residents are encouraged by the home to maintain their independence and friendships. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome The home recognises and respects each resident’s right to privacy and dignity through the identification of residents’ care needs, care planning and staff practices. New residents/representatives are provided with the home’s privacy policy and are requested to sign a privacy agreement and a form giving consent for the use and display of resident photographs. Care staff demonstrate they maintain the confidentiality of resident information and are aware of strategies for maintaining respect for residents’ privacy and dignity. Resident’s records and personal information are securely stored. Observations confirmed that residents’ personal care is provided in a manner that protects their dignity and privacy. Residents/representative expressed satisfaction with the way residents’ privacy and dignity is recognised and respected by staff in the home. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome The home has systems to encourage and support residents to participate in leisure interest and activities of interest to them. An activities plan of care is developed for each resident on entry to the home which outlines the resident’s previous and current interests and preferences. The residents’ involvement in activities is recorded and changes are made to their individual care plans when needed. Lifestyle programs are developed with many group activities and entertainments shared with all residents. Recognition of residents’ individual


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limitations is taken into consideration and assistance is provided to enable them to participate in activities. Group activities include interaction with other local aged care homes, bus trips, music, movies, games, and cultural and birthday celebrations. Residents’ one-on-one activities include: reminiscing, walking, and conversations. The home keeps residents informed of activities via noticeboards, verbal prompts and the home’s newsletters. Residents with short term memory loss and sensory losses are regularly informed/reminded of current activities to enable then to attend if they so desire. Residents/representatives expressed satisfaction with the activities offered to residents and the opportunities to provide suggestions for inclusion. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome The home has systems through which residents’ cultural and spiritual needs are valued and fostered including the identification and documentation of residents’ interests, cultural needs, and religions. The menu is flexible and can accommodate the preferences of residents from culturally and linguistically diverse backgrounds. Specific cultural days such as Australia Day, St Patricks Day, Anzac Day and Christmas and Easter are commemorated with appropriate festivities. Residents’ birthdays are recognised and celebrated. Freedom of choice with religious and cultural beliefs is respected. Pastoral care is delivered by various religious denominations providing services, personalised through one to one visits and weekly services. Debriefing and support for residents, staff and families following a death or personal crises are referred to the homes’ pastoral care team. Residents/representatives expressed their satisfaction with the home’s approach to the cultural and spiritual program and the support provided. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident 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 meets this expected outcome Residents/representatives are enabled and encouraged to participate in choice and decision making about residents’ care needs and services, and to exercise control over residents’ lifestyle. The home informs residents/representatives of choices available to residents and the residents’ rights through the information provided on entry to the home. This includes information in the resident agreement and the resident handbook. Examples of residents’ choices for care and services include: choice of participation in activities, choice of personal items in rooms, input into care delivery, choice of rising and bed times, and a choice from a selection of meals. Residents/representatives can express the residents’ choices and preferences through: access to comments and complaints mechanisms, surveys, and directly to staff or management. The service manager provides an ‘open door’ policy. Residents/representatives expressed their satisfaction that residents are able to exercise choice and control over the care and services provided to them within the home.


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3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome UnitingCare Ageing South Eastern region and the home have policies and procedures in place to ensure that residents have secure tenure within the home, and understand their rights and responsibilities. New residents (and/or their representatives) are provided with comprehensive information on entry to the home that is explained both prior to and during the admission interview. A resident agreement is offered to each resident during this time to formalise residency arrangements. The agreement includes information for residents about their rights and responsibilities, complaints handling, fees and charges, their security of tenure and the process for the termination of the agreement. Representatives interviewed said they are satisfied with the information the home has provided regarding residents’ security of tenure, and their rights and responsibilities.


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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. 4.1 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 well-developed and effective continuous improvement systems and processes are described in detail in expected outcome 1.1 Continuous improvement. These systems and processes operate across the four Accreditation Standards, including Standard 4 Physical environment and safe systems Examples of improvement initiatives the home has implemented or that are in progress in relation to Standard 4 Physical environment and safe systems include:

Cleaning hours at the home have been increased in response to feedback received during a previous assessment contact visit by the Aged Care Standards and Accreditation Agency. Feedback also included staff, representative and management input. Cleaning hours have increased from three to five days per week and outcomes include expressions of satisfaction from residents/representatives. Management and staff interviewed said their daily observations confirm the level of cleanliness at the home has improved and is being sustained.

Management advised that the home has been refurbished in the last two years as a result of management’s ongoing pursuit of continuous improvement. They stated the kitchenette and serving area, and all ensuite bathrooms have been enlarged. Additionally, new furnishings and fittings have been purchased and installed in all common areas. Representatives and staff interviewed expressed satisfaction with the home’s living environment.

The home has formed a health, safety and wellbeing (HSW) committee in response to the new work health and safety legislation. A full time HSW and injury management coordinator has been appointed to the region and a staff member from each discipline has joined the HSW committee. Health, safety and wellbeing outcomes are being achieved and include existing spill kits being replaced with biohazard spill kits. Management said that there is increasing staff engagement in the initiative and expressed their belief that the improvement is attributed to the impact of the home’s aspire to inspire program.

4.2 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, about physical environment and safe systems”. Team’s findings The home meets this expected outcome The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards, including Accreditation Standard 4. Compliance with legislation is ensured through monitoring of staff work practices, risk identification and hazard reporting. Other mechanisms used include incident and accident reporting, environmental audits and routine and preventative maintenance


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systems. To assist further in the monitoring of regulatory compliance in this Accreditation Standard, the home’s Health Safety and Wellbeing committee has specific responsibility for monitoring occupational health and safety. Examples of the home’s response to meeting regulatory compliance relating to Standard 4 Physical environment and safe systems include:

Education and training has been provided to staff on the new work health and safety legislation (Work Health and Safety Act 2011). In response to meeting regulatory requirements the home has formed a health, safety and wellbeing committee.

A review of records and observations confirmed fire safety equipment is being inspected, tested and maintained in accordance with fire safety regulations. The annual fire safety statement is on display in the home. A review of staff training records and staff interviews confirmed that staff have attended mandatory annual fire awareness and evacuation training.

The home has a food safety program in line with the Food Act with policies, procedures and practices operating in line with the Vulnerable Persons Food Safety Scheme.

4.3 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 meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Accreditation Standard 4. Examples of education and training relating to Standard 4 Physical environment and safe systems that has been provided for management and staff include:

All staff are required to attend mandatory training in infection control including outbreak management. Additionally, all staff attend annual mandatory training in the use of fire equipment and the processes of emergency evacuation and undergo competencies in manual handling. Other training undertaken by staff includes environmental hazard/incident/accident reporting, chemical safety and usage, and food safety. Staff have attended external training courses related to their specialist roles and responsibilities.

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 residents’ care needs". Team’s findings The home meets this expected outcome UnitingCare Ageing South Eastern region and the home’s management are actively working to provide a safe and comfortable environment consistent with the residents’ care needs. Residents’ needs are identified on entry to the home and residents/representatives are advised of care and services available to residents at the home. The living environment is secure, well furnished, well lit and free of clutter, and has a heating/cooling system to maintain a comfortable temperature. The home promotes a restraint free environment.


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The buildings and grounds are very well maintained with a program of preventative and routine maintenance. The safety and comfort of the living environment is monitored through environmental inspections, resident/representative feedback, incident/accident reports, and audits and observation by staff. Residents/representatives interviewed expressed their satisfaction with the residents’ living environment. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome Management is actively working to provide a safe working environment that meets regulatory requirements. The home has systems and processes that ensure a safe working environment is provided for all members of staff, visitors and residents. Maintenance staff and approved external service personnel provide a regular program of planned preventative and corrective maintenance that assists in ensuring the overall safety of equipment and the environment. The home’s safety system is overseen by its health, safety and wellbeing committee and issues identified are followed up and actioned appropriately and in a timely manner. The safety system includes regular staff training including manual handling, regular safety system audits and inspections, hazard reporting and risk management, and accident and incident reporting. There have been minimal incidents relating to staff safety, thereby indicating the effectiveness of the home’s approach to occupational health and safety. Staff and representatives interviewed said they are supported and encouraged by management to report potential and actual risks within the home. They confirmed all reported health and safety issues are addressed appropriately and in a timely manner. 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 meets this expected outcome Management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. Regular checks of equipment by external contractors, audits, and fire and emergency evacuation procedures are in place. All electrical equipment is tagged and/or tested as required. The home is fitted with emergency warning systems, fire fighting equipment and emergency lighting. Formal contractual arrangements are in place for monitoring and maintaining all fire safety equipment and systems and the home’s annual fire safety statement is displayed along with the home’s emergency evacuation plan. Emergency evacuation maps are correctly orientated and emergency procedure folders are located at strategic points throughout the home. An emergency evacuation kit is in place and contains an occupancy list with current residents’ names, tags and other relevant information. Staff wear identification badges and there is a sign in and sign out register for residents and visitors. Staff training records and staff interviewed confirmed their attendance at compulsory fire safety training and demonstrated and understanding of evacuation procedures and use of fire fighting equipment. Residents interviewed expressed feelings of safety when talking about their life at the home.


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4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has an effective infection control program that includes infection policies, practices and guidelines. The nurse practitioner/infection control coordinator ensures the operation and effectiveness of the infection control program through clear policies and procedures, education and an infection surveillance program. The program is monitored through reporting of all infections, trend analysis, audits, benchmarking and managerial review. The home has mandatory training in infection control and hand washing competencies are assessed. Hand washing facilities, personal protective equipment and other equipment is available to enable staff to carry out infection control procedures. The infection control program also includes an outbreak management policy, a food safety program, a vaccination program for residents and staff, pest control and waste management. Staff interviewed demonstrated they have a sound knowledge and understanding of infection control and were observed implementing the program. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome Catering There is a system to identify residents’ dietary requirements and preferences on entry to the home and as their needs change. A four week rotating menu is offered and food is cooked on site. Representatives interviewed said there is an adequate quantity and variety of food available for residents and that residents are provided with a number of alternatives if the menu is not to their liking on the day. The home also provides residents with a choice of in-between meals and snacks throughout the day and evening including but not limited to soup, a variety of egg dishes, salads and sandwiches. Residents interviewed expressed satisfaction with the food provided to them at the home. Cleaning The living environment was observed to be clean and fresh. Cleaning schedules guide the cleaning staff who demonstrated a comprehensive knowledge of the home’s cleaning requirements, infection control practices and safe chemical use. Representatives interviewed said they are very satisfied with the level of cleanliness of residents’ rooms and other areas of the home. Laundry A co-located, on-site laundry provides services for residents’ clothing and linen. Laundry clean and dirty areas are maintained and there is a system for the collection and identification, laundering and delivery of residents’ personal clothing and linen. Representatives interviewed said they are satisfied with the laundry services at the home. They confirmed that all personal clothing is being cared for and returned to them in a timely manner.

Uniting Care Mirinjani Retirement Village - Eabrai …...Home name: Uniting Care Mirinjani...

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Transcript of Uniting Care Mirinjani Retirement Village - Eabrai …...Home name: Uniting Care Mirinjani...