arcare sydenham

Arcare Sydenham

RACS ID 3578 31-51 Trickey Avenue SYDENHAM VIC 3037

Approved provider: Arcare Pty Ltd

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 17 November 2019.

We made our decision on 26 September 2016.

The audit was conducted on 23 August 2016 to 24 August 2016. The assessment team’s report is attached.

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

Home name: Arcare Sydenham RACS ID: 3578 2 Dates of audit: 23 August 2016 to 24 August 2016

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 care recipients, 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:

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





2.4 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: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care 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 Care recipient security of tenure and responsibilities

Met

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.





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

Arcare Sydenham 3578


Introduction

This is the report of a re-accreditation audit from 23 August 2016 to 24 August 2016 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 23 August 2016 to 24 August 2016.

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

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

Assessment team

Team leader: Mary Murray

Team member/s: Cheryl Conder

Doris Hamilton

Approved provider details


Details of home

Name of home: Arcare Sydenham

RACS ID: 3578

Total number of allocated places:

120

Number of care recipients during audit:

114

Number of care recipients receiving high care during audit:

114

Special needs catered for: Care recipients living with dementia

Street/PO Box: 31-51 Trickey Avenue

City/Town: SYDENHAM

State: VIC

Postcode: 3037

Phone number: 03 9449 6100

Facsimile: 03 9390 1453

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Facility manager 1

State manager 1

General services manager 1

Nursing staff 7

Care staff 14

Lifestyle staff 3

Catering staff 3

Care recipients 15

Representatives 9

Dietitian 1

Physiotherapist 1

Cleaning staff 3

Laundry staff 2

Maintenance staff 1

Sampled documents

Category Number

Care recipients’ files 20

Medication charts 16

Human resource files 5

Other documents reviewed

The team also reviewed:

Activity calendars

Arcare magazine

Assessments, charts and clinical monitoring documentation

Care recipients’ agreements

Care recipient information package including handbook


Catering records

Comments, complaints and associated documents

Continuous improvement records and documents

Controlled substances register

Education calendar and records

Emergency management records

‘ESIS’ general services management system

General practitioner and allied health directives

Independent medication review reports

Leisure and lifestyle records and documents

Meeting schedule and meeting minutes

Policies and procedures

Quality system monitoring documentation

Observations

The team observed the following:

Activities in progress

Café area

Camera security

Daily menu displayed

Drug administration in progress

External complaints and advocacy brochures on display

Fire and safety equipment and signage

Interactions between staff and care recipients

Living environment

Short group observation in sensitive care lounge.


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 actively pursues continuous improvement. The quality system is underpinned by policies and procedures for all functions against which staff practice is measured.

Management seek feedback from care recipients, representatives and staff using multiple mechanisms including forms, meetings and opportunities for individual discussions.

Management and staff gather information about the quality of care and services provided by performing audits, interviews and documenting incident reports. Audit results can trigger reviews of care recipients’ care plans, revision of procedures, additional staff training and education. The home has the support of regional management, a quality support team and a clinical governance committee. Results of the continuous improvement system are communicated to all stakeholders and overseen by the executive level of the organisation.

Examples of improvement activities implemented by the home in relation to Standard 1 - Management systems, staffing and organisational development include:

Management identified the format of policies and procedures lacked sufficient detail to adequately clarify the roles and responsibilities of staff and management. Management allocated resources to redevelop policies and procedures from a flow chart model to a narrative form. Procedures outline clear instructions for staff and have hyperlinks to relevant legislation, guidelines and best practise information. As a result, staff and management have access to information to guide their practice.

Care recipient and representative feedback indicated the format and frequency of their meetings were not effective. Management revised the format of meetings to entertaining and educational short videos and a set agenda within a specified time frame. After the meeting, care recipients and representatives are encouraged to remain for a meal and informal chats with the manager of the home. Management has received positive feedback and has scheduled care recipient and representative meetings to occur more frequently using the new format.

Staff identified the processes for archiving documents could be improved. Management purchased and installed large compactors and revised position descriptions to improve


administration support. Management and staff said archived material is readily accessible and superfluous documents are disposed of in a more timely manner.

1.2 Regulatory compliance

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

Team’s findings


The home has a system to ensure management receive and disseminate information regarding relevant legislation, regulations and professional guidelines and monitor compliance with them. Corporate management receive notifications of legislative changes through membership of peak bodies, legislative update services and professional organisations. Corporate management liaise with legal services to identify any impact on the policies and procedures of the home. Policies and procedures are revised accordingly and notification is sent to the home’s manager. Management of the home inform staff, care recipients and representatives of legislative changes. Management and staff have access to relevant legislation on the home’s intranet. Staff are aware of their responsibilities in relation to regulatory compliance and confirmed management inform them of changes.

Examples of regulatory compliance in relation to Standard 1 - Management systems, staffing and organisational development include:

Policies and procedures are referenced to relevant legislation.

Management ensure the currency of staff, volunteer and external contractors’ criminal history checks and professional registrations.

Notification to staff, care recipients and representatives of reaccreditation site audits.

Information is available to care recipients and representatives on external complaints and advocacy services.


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


Management and staff have appropriate knowledge and skills to perform their roles effectively. Prior to commencement of employment, management confirm each candidate’s experience, skills, qualifications and registration if appropriate. New staff participate in training during orientation and undertake ongoing mandatory education relevant to their role. A calendar sets out upcoming training opportunities and staff can access online training modules. Management implement additional training activities based on training needs identified from meetings, audits, incident reports and performance appraisals. Attendance and evaluation records monitor participation in and the effectiveness of the training.

Management encourage staff to attend further education for their professional development. Staff said they are satisfied with education opportunities provided.

Examples of education in relation to Standard 1 - Management systems, staffing and organisational development include:

Arcare values

effective orientation

information management.

1.4 Comments and complaints

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

Team’s findings


The home has a system to ensure each care recipient, their representatives and other interested parties have access to internal and external complaints mechanisms. The home informs stakeholders of internal and external complaints mechanisms through information displays, brochures and handbooks. The home has suggestion boxes for anonymous and confidential feedback. Management record all comments and complaints and actions taken in response on a database. Comments and complaints data is analysed and trended and results are reported through quality reports to the organisation’s executive. Care recipients, representatives and staff said they are aware of comments and complaints mechanisms.


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 has documented the organisation’s vision and commitment to quality.

1.6 Human resource management

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

Team’s findings


There is a system to ensure appropriately qualified and skilled staff are available to provide care and services to care recipients. A dedicated staffing model seeks to promote and facilitate the building of relationships between the care recipient and allocated staff member. There are processes to ensure appropriate coverage for periods of staff leave, unplanned absences, or increasing care recipient needs. The ongoing skill mix of the staff is reviewed to ensure it is in line with care recipients’ requirements. A roster is developed and reviewed on an ongoing basis to ensure appropriate coverage for the care recipient mix. The home’s quality system monitors human resources to ensure compliance via audits and quality reports. Care recipients and representatives are satisfied staff have the skills to meet identified care and lifestyle needs and generally satisfied with the availability of staff.

1.7 Inventory and equipment

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

Team’s findings


The home has a system to ensure equipment and consumables are available for quality service delivery. Key personnel monitor stock levels and the home has stock rotation and re- ordering processes. Staff monitor equipment for its safety and undertake regular maintenance and cleaning of items to ensure they remain fit for purpose. There is a maintenance program to support both planned and reactive maintenance processes. An electronic program assists staff with the scheduling of maintenance processes and management of external contracting staff. Purchase of additional equipment is from preferred suppliers and according to care recipients’ needs. Equipment, supplies, medications, chemicals and perishable goods are stored appropriately and securely. Staff and care recipients said there are sufficient supplies and equipment for their needs.


1.8 Information systems

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

Team’s findings


The organisation’s information management system ensures all interested parties are kept up to date on events at the home. Care recipients, families and visitors are made aware of what is happening at the home via meetings, activity calendars, notices and the Arcare ‘Connecting’ quarterly newsletter. Management, care and hospitality staff have access to accurate information regarding care recipients’ needs via an online care documentation system, memos, handovers, meetings, minutes, registers and reports. Systems to update and evaluate clinical information ensure there is clear information to guide staff in their practices. Information is stored and retained in line with legislative requirements. Computers are password protected and storage of clinical information is secure. Care recipients and representatives said they can readily access information.

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


External service providers work with the organisation to deliver services consistent with the needs of the organisation. A centralised procurement department manages contractor arrangements, appointing preferred suppliers via service agreements. Agreements outline the scope and standard of work and regulatory compliance requirements. Current external services include allied health, catering, cleaning, laundry, and specialised maintenance providers. All contractors receive an orientation to the site in line with the scope of their work. Management regularly review the ability of external suppliers to deliver on the home’s requirements and quality expectations. A process exists to monitor non-conformance with contractual arrangements or any poor performance identified. Staff and care recipients are satisfied with the products and services currently supplied to the home by external providers.


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 home has a continuous improvement system that demonstrates ongoing improvement in care recipient health and personal care. For a description of the system, refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvements over the last 12 months relating to Standard 2 - Health and personal care include:

Staff identified an opportunity to use electronic care management tools to improve communication of changes to care recipients’ weights. An automatic alert is now sent when there are alterations in a care recipient’s weight of over two kilograms. Management said the initiative has resulted in more timely communication of changes in condition to nurse unit managers and referrals to allied health professionals.

In response to the results of clinical audits, registered and enrolled nurses participated in an interactive training day to enhance clinical knowledge and skills. The full day of training included guest speakers offering opportunities for “hands on learning”. Clinical staff said the training had improved their confidence in delivering quality care.

Management identified an opportunity to expand clinical care auditing. Auditing processes have been modified to include interviews with staff and care recipients. The enhanced audit methodology has resulted in improvements to clinical documentation and staff knowledge.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines in relation to health and personal care.

Examples of regulatory compliance relating to Standard 2 - Health and personal care include:

Registered nurses manage medications and specialised nursing care.

Medication administration and storage is in accordance with legislative requirements and staff’s scope of practice.

There is a system for recording, reporting and managing unexplained care recipient absences.



Team’s findings


The organisation has an education and staff development system. Refer to expected outcome 1.3 Education and staff development for details of the home’s education and staff development system.

Examples of education and staff development relating to Standard 2 - Health and personal care include:

dementia and distressed behaviours

falls prevention

wound care and nutrition.


2.4 Clinical care

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

Team’s findings


There are processes to ensure care recipients receive appropriate clinical care. Staff conduct assessments according to an electronic schedule and determine each care recipient’s needs and preferences. Assessments, care plans and handovers inform staff of individual care needs. There is a three monthly, or sooner if required, process to evaluate care recipients’ needs and staff maintain records of care. Regular medical reviews and increased monitoring occurs when needed. Care recipients and representatives are complimentary of the care provided by the staff.

2.5 Specialised nursing care needs

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

Team’s findings


The home has a system to ensure appropriately qualified staff identify and meet care recipients’ specialised nursing care needs. Education is provided to ensure staff knowledge in these areas. Complex care plans detail instructions from doctors and health professionals for care recipients with dysphagia or reportable blood sugar parameters. Review of the care plan is every three months or when care needs alter. Referrals to appropriate health specialists occur as required and instructions from these specialists are noted in care plans. There is access to appropriate equipment and supplies to deliver specialised care. Care recipients and their representatives are satisfied with the ability of staff to attend to their specialised nursing care needs.

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


There are processes in place to identify care recipients’ care needs in relation to allied and other health professionals. After entry, a history of previous visits to health professionals such as physiotherapists, podiatrists, dieticians, optometrists, speech pathologist, dentists and medical specialists is taken. Care plans, allied health notes and progress notes show input and recommendations from appropriate health specialists. Staff were able to demonstrate knowledge of care recipients’ needs from other health and related services. Care recipients and representatives confirmed their access to medical and other health care services as required.


2.7 Medication management

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

Team’s findings


Registered nurses oversee medication management at the home with medications administered by both registered nurses and endorsed enrolled nurses. Policies and resources are available to guide staff in medication administration. Care recipients who wish to self-administer medications are assessed for their ongoing capacity and supported in their wish to do so. Medications are appropriately stored in lockable trolleys within medication rooms. Medication incidents are tabled at the three monthly medication advisory committee meetings. Medication charts have clearly defined allergies and current care recipient photographs. Medication reviews occur by an accredited pharmacist on regular basis and a pharmacist caters for urgent and out-of-hours orders. Care recipients and representatives are happy with the way staff manage their medication.

2.8 Pain management

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

Team’s findings


All care recipients have assessments for any presence of pain and its history on entry to the home. Pain assessments occur for those who are unable to communicate their pain levels and care plans show strategies such as pillow support, massage, and repositioning in addition to analgesia. There is a dedicated allied health assistant who administers heat packs to those who require them, and care recipients with severe intractable pain can have access to a syringe driver. Care recipients and representatives said they are happy with the way staff manage pain.

2.9 Palliative care

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

Team’s findings


There is a process to ensure the comfort and dignity of the terminally ill care recipient. Identification of palliative care wishes occurs on entry to the home or during the care recipient’s stay with expressed wishes used to enhance end of life care. Regular conferences with families ensure terminal wishes are adhered to and the care recipient’s comfort is maintained. Syringe drivers in addition to assistance from local palliative care specialists are available if required.


2.10 Nutrition and hydration

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

Team’s findings


Identification of care recipients’ likes, dislikes, allergies, meal choices and meal texture occurs on admission and a copy of the assessment is delivered to the kitchen. Referrals to a speech pathologist or dietitian occur when necessary for ongoing reviews. If a care recipient experiences unplanned weight loss of more than two kilograms in three months they are closely monitored, referrals initiated and kitchen staff informed of any additional requirements. Care plans detail assistive devices required to maintain independence and dignity such as lipped plates or spouted cups. Staff assist care recipients with their meals in a respectful manner and without rushing. Care recipients and representatives report they are happy with the meals and choices offered.

2.11 Skin care

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

Team’s findings


Registered and enrolled nursing staff assess care recipients’ skin integrity on entry to the home and identify any risks to optimal skin integrity such as diabetes. Care plans outline care recipients’ personal preferences in relation to skin care. Dedicated registers detail wounds and skin tears and incident forms are completed for all wounds and skin tears. There are adequate resources available for ongoing skin care needs including sheepskins and specialised cushions. Care plans note devices and interventions in place for care recipients prone to skin breakdown. Care recipients and representatives said they are satisfied with skin care and said staff were aware of their skin care needs.

2.12 Continence management

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

Team’s findings


The home has a system to ensure continence management is effective for care recipients. After a settling in period, a continence history is taken and charting commenced. Health aspects which may affect continence, such as medications, or fluid intake are noted and voiding patterns identified. Voiding schedules are trialled using specialised continence aids, which record when a care recipient requires toileting and the trial establishes the level of staff assistance required. Staff report they use the recorded plans to assist care recipients with their toileting needs. Care recipients are representatives are satisfied continence needs are managed.


2.13 Behavioural management

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

Team’s findings


The home has processes to ensure the effective management of the needs of care recipients with challenging behaviours. Pre and post entry information is collected in which triggers are investigated and interventions are devised and trialled. Information gathered formulates an individualised care plan and details successful interventions used. A range of therapies and strategies are in place to provide care recipients the freedom to move around whilst remaining in a safe environment. Staff are able to describe appropriate actions when dealing with challenging behaviours such as encouraging friendships between like-minded care recipients to reduce wandering behaviour. Information shows the home accesses external assistance when required and improvement in the management of challenging behaviour is evident. Care recipients and representatives felt challenging behaviours were appropriately managed.

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


There is a system to support care recipients to maintain optimum mobility and dexterity levels including assessment, care planning and exercise programs. Physiotherapists, an allied health assistant and care staff assess each care recipient’s mobility, strength and transfer requirements in detail on entry to the home. The physiotherapist devises an exercise plan for each care recipient. Staff record falls on incident forms for discussion and collation.

Strategies for care recipients’ falls management include completion of falls risk assessments, physiotherapy referral, use of sensor mats, floor level beds, and hip protectors. The living environment is clutter free and care recipients are satisfied with the support provided to optimise their mobility and dexterity levels.

2.15 Oral and dental care

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

Team’s findings


There is a system to ensure maintenance of care recipients’ oral and dental health. Assessment of oral and dental needs occur on admission with information detailing assistance required and previous visits to a dentist or dental technician. Staff formulate a care plan with this information and refer to it when assisting care recipients with their oral and dental care. Care plans show the person’s ability to clean their own teeth and level of assistance required from staff. Following consultation, staff organise dental service appointments or dental technician visits. Care recipient feedback indicates a high level of satisfaction with the maintenance of their oral and dental care.


2.16 Sensory loss

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

Team’s findings


After entry, staff assess each care recipient’s sensory needs to identify any decline or loss, coordinate management strategies and identify the need for referrals to specialist service providers. Following the development of a care plan, regular evaluation of the effectiveness of strategies and interventions occur with changes made to the care plan as required. A health specialist company visits on a regular basis to conduct formal assessments for those who require them. Care recipients and representatives report staff assist them with their sensory loss in a satisfactory manner.

2.17 Sleep

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

Team’s findings


A sleep assessment occurs for each care recipient on arrival at the home. Preferred settling and rising times, any particular routines and environmental preferences are identified and inform the care plan. Specific strategies and interventions are followed to encourage a natural sleep pattern. Staff evaluate the effectiveness of these measures every three months. Care recipients have their own bedrooms and where appropriate, sensor mats are provided to alert staff if assistance is required overnight. Care recipients and representatives said staff are helpful in assisting the care recipients to achieve a natural sleep pattern.


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 home has a continuous improvement system that demonstrates ongoing improvement in care recipient lifestyle. For a description of the system refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvements over the last 12 months relating to Standard 3 - Care recipient lifestyle include:

Following a literature review of best practice in promoting care recipients’ lifestyle, management undertook a variety of quality activities to increase natural light, beautify and improve access to gardens, provide individualised music and welcome pets into the home. Management said care recipients and representatives have provided positive feedback.

Care recipients requested more bus trips. Management facilitated the redesign of the leisure and lifestyle program. Bus trips have increased in number, are more responsive to individual care recipient’s preferences and are of longer duration. Management have provided increased human resources to allow greater participation by care recipients with complex needs. Care recipients have expressed their satisfaction.

Management identified an opportunity to improve communication of care recipients’ lifestyle preferences. Care recipient lifestyle assessments were expanded to capture more information. Care plans are now actively shared with dedicated staff. There is a clearer understanding of care recipients’ choices and greater participation in the lifestyle program.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines in relation to care recipient lifestyle.

Examples of regulatory compliance relating to Standard 3 - Care recipient lifestyle include:

Management maintain a register for incidents of elder abuse and compulsory reporting.

Care recipients’ agreements include information regarding privacy and confidentiality, specified care and services, rights and responsibilities and security of tenure.

Care recipients’ rights and responsibilities are on display and included in the care recipient and staff handbooks.

There is a system to ensure the security and privacy of confidential information.



Team’s findings



Examples of education and staff development relating to Standard 3 - Care recipient lifestyle include:

privacy and dignity

identifying elder abuse

care recipients’ rights and responsibilities.


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 have processes to support care recipients adjust to life in the home and provide ongoing emotional support. Management provide prospective care recipients and their representatives with a tour of the home and information regarding the care and services provided. Care recipients and representatives receive information on entry and ongoing. Staff orientate care recipients to the home and introduce them to care recipients who share common cultures, languages or interests. Clinical staff assess care recipient’s mood, gather information regarding preferences and relationships and regularly review plans of care. Staff provide one on one social and emotional support and refer to pastoral carers, community visitors, medical practitioners and psychiatric services as required. Care recipients and representatives said staff are kind and welcoming.

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


Management and staff assist care recipients to achieve optimum independence and social connectivity. Clinical staff assess care recipients for cognitive abilities, mobility, sensory loss and communication methods and barriers. Leisure and lifestyle staff discuss with care recipients their preferences for maintaining friendships and links with the community. Staff assist care recipients to maintain independence by facilitating regular shopping trips, providing mobile voting booths and supporting the use of scooters and taxis. The home has a ‘gym’ and daily exercise programs. Care recipients are encouraged to retain independence regarding financial matters and staff liaise with guardians were appropriate. Management monitor the environment for risks. Care recipients expressed satisfaction with the support they receive to maintain independence and community connections.

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 ensures care recipients’ rights to privacy, dignity and confidentiality is recognised and respected. Management provide care recipients with information regarding their rights to privacy. Staff consult care recipients and representatives to ensure care plans are individualised to needs and preferences across all care domains. Staff obtain consent from care recipients to display their photographs and names. Care recipients have single bedrooms with private bathrooms and can receive their guests in well appointed private and communal


areas. Staff sign confidentiality agreements and care recipient information is secure. Care recipients and representatives expressed satisfaction with privacy, dignity and confidentiality.

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


Management and staff support care recipients to participate in a wide range of activities of interest to them. Leisure and lifestyle staff assess care recipients on entry to the home for their interests and the activities they enjoy. Care recipient care plans detail recreational activities in which care recipients participate. Lifestyle staff develop a program that incorporates activities for physical, spiritual, cognitive and social needs and preferences. Staff ensure each care recipient has access to information regarding the program and encourages them to participate to the extent they wish. Staff document care recipients’ engagement in and enjoyment of the program and perform regular reviews. Care recipients and representatives expressed satisfaction with the lifestyle program.

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


Management and staff value and foster the customs and beliefs of care recipients in the home. Staff assess care recipients for their culture, language and spiritual beliefs on entry to the home. Staff develop care plans in consultation with care recipients and representatives to acknowledge culture and spiritual beliefs and assist care recipients to maintain them. Clinical staff support and encourage care recipients to discuss end of life wishes and document them. The home provides religious services for care recipients who wish to participate and a lifestyle program that includes preferred cultural activities. The home maintains a register of the languages spoken by staff and staff said they have access to external interpreter services if required. Care recipients and representatives expressed satisfaction with cultural and spiritual life.


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 has a system to enable and encourage care recipients and representatives to participate in decisions about the home’s services and the care recipient’s lifestyle.

Management foster care recipient feedback by coordinating care recipient and representative meetings. Care recipients have access to comments and complaints forms and advocacy information. Staff assess care recipients for their preferences across all care and lifestyle domains and document their wishes in care plans. Registered nurses hold care planning conferences with care recipients and representatives regularly, and care recipients have the right to refuse treatment. Management collect and record information on powers of attorney. Care recipients and representatives expressed satisfaction with the opportunities for choice and decision making.

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


Management and staff have a system to ensure care recipients have security of tenure in the home and understand their rights and responsibilities. Management provide each care recipient with a residential care agreement and the ‘Charter of care recipients’ rights and responsibilities’. Management communicate changes to fees and charges. Care recipients and representatives said they are satisfied with the information they receive from management.


Standard 4 – Physical environment and safe systems

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



Team’s findings


The home has a continuous improvement system that demonstrates ongoing improvement in physical environment and safe systems. For a description of the system refer to expected outcome 1.1 Continuous improvement.

Examples of recent improvement over the last 12 months relating to Standard 4 - Physical environment and safe systems include:

Care recipients commented there was a considerable amount of lost clothing. Management revised laundry hours so staff could work flexibly in response to changing volumes of laundry. Management raised staff awareness in relation to checking care recipients’ clothing for labels and encouraged representatives to name care recipients’ new clothes. Management said there has been a significant reduction in lost clothing.

A review of the living environment identified the chapel area was underutilised. Management redesigned the space to operate as a home theatre in addition to a place of worship. The room has 16 premium theatre seats, a high technology screen and surround sound with computer interface. Management said care recipients and representatives use the area for movie nights and staff can entertain care recipients with a variety of activities.

In response to care recipient feedback that cleaning services were not effective. Management reviewed processes for cleaning. Management liaised with the cleaning team to improve services. Care recipients and representatives were encouraged to discuss with staff their preferences for cleaning personal items. Care recipients and representatives expressed satisfaction with cleaning and said if they want anything additional done they simply ask the staff.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines about physical environment and safe systems.

Examples of regulatory compliance relating to Standard 4 - Physical environment and safe systems include:

The kitchen has a current food safety plan and certifications by external authorities.

External contractors maintain essential services according to legislative requirements and provide appropriate records.

Chemical storage is secure with current material safety data sheets accessible.

Staff attend manual handling training and management ensure the availability of sufficient and well maintained lifting equipment.



Team’s findings



Examples of education and staff development relevant to Standard 4 - Physical environmental and safe systems include:

infection control

fire and evacuation

manual handling.


4.4 Living environment

This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".

Team’s findings


Management are actively working towards providing a safe and comfortable living environment, which meets the needs of care recipients. Living areas are tastefully and appropriately furnished. There are several communal and private places for people to gather or spend some quiet time alone. Facilities at the home include a café, theatre, hairdresser and a gym. Cleaning processes ensure a clean and comfortable environment and maintenance staff address repair needs and undertake preventative maintenance.

Environmental audits, incident reports and maintenance requests provide ongoing review of the living environment. Care recipients and representatives were complimentary of the home’s environment and facilities and said it is a pleasant home to live in or visit.

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


There is a system to provide a safe working environment that meets occupational health and safety requirements. Policies and procedures guide staff in undertaking their role safely and documentation including risk assessments and hazard notifications inform the system. Staff are provided with general and job specific training to ensure they are safe performing their roles. Staff have mandatory training in manual handling and the use of any other applicable equipment. The home’s audit processes include review of occupational health and safety with any deficits referred to the home’s quality team. Incidents and statistics are reviewed on a monthly basis to identify trends. A return to work manager assists staff in returning to work safely. Staff are satisfied with their occupational health and safety.

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


Management and staff are actively working to promote safety and provide a care and work environment that minimises the risk of fire, security breaches and other emergencies. A corporate emergency management plan identifies potential local and external risks and outlines risk mitigation actions. Staff undertake emergency management training and designated ‘wardens’ receive training on coordinating an emergency response. An emergency pack contains essential equipment and information, if an evacuation is required. The home is equipped with security and smoke detection systems, sprinklers and other fire- fighting and


emergency equipment. Scheduled servicing of fire and emergency equipment occurs and chemical substances are stored securely. Management and staff are confident in their ability to handle an emergency.

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. Staff have access to policies and procedures to guide infection control and training occurs on a yearly basis to ensure compliance. Care recipient infections are logged and monitored, with any trends used to identify opportunities for improvement. Specific infections are monitored by the home’s nursing staff, with medical staff referral where required. Audits and quality reports monitor the home’s infection rates to ensure infections are managed appropriately. There is access to equipment including sharps containers, spills kits, personal protective equipment and outbreak kits to promote infection control. Cleaning, laundry and kitchen staff adhere to appropriate infection control processes and pest control and appropriate waste management occurs. Care recipients and staff are encouraged to vaccinate against influenza.

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


Catering staff follow a seasonal menu reviewed by a dietitian for nutritional balance. Care recipients have input into the menu choices provided at the home through meetings and feedback mechanisms. Dietary advices inform catering staff regarding care recipients’ likes, dislikes, allergies and modified food and drink requirements. Cleaners follow a schedule which includes both personal and communal areas. Monitoring of the cleaning services occurs on an ongoing basis with any deficits addressed at a site level. Linen and personal items are laundered on site. Staff have training in laundry processes, chemical handling and actions to take in the event of an infectious outbreak. Washing machines and dryers are maintained to ensure safe equipment and there are processes to minimise lost clothing. Care recipients and representatives are happy with catering, cleaning and laundry services.

arcare sydenham

Documents