mt providence village - aacqa.gov.au · pdf filewe made our decision on 05 february ......

Mt Providence Village

RACS ID 0120 59 Tindale Street

MUSWELLBROOK NSW 2333

Approved provider: Calvary Retirement Communities Hunter- Manning 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 25 March 2018.

We made our decision on 05 February 2015.

The audit was conducted on 13 January 2015 to 14 January 2015. The assessment team’s report is attached.

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

Home name: Mt Providence Village RACS ID: 0120 2 Dates of audit: 13 January 2015 to 14 January 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Mt Providence Village 0120

Approved provider: Calvary Retirement Communities Hunter-Manning Ltd

Introduction

This is the report of a re-accreditation audit from 13 January 2015 to 14 January 2015 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 13 January 2015 to 14 January 2015.

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

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

Assessment team

Team leader: Hiltje Miller

Team member/s: Sally Cox

Approved provider details

Approved provider: Calvary Retirement Communities Hunter-Manning Ltd

Details of home

Name of home: Mt Providence Village

RACS ID: 0120

Total number of allocated places:

36

Number of care recipients during audit:

34

Number of care recipients receiving high care during audit:

22

Special needs catered for: n/a

Street/PO Box: 59 Tindale Street

City/Town: MUSWELLBROOK

State: NSW

Postcode: 2333

Phone number: 02 6543 2053

Facsimile: 02 6541 2041

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Residential Care Co-ordinator 1

Facility Manager 1

Registered nurses 2

Clinical Nurse educator 1

WHS Manager 1

Care staff 6

Administration assistant 1

Catering staff 2

Continuous Improvement and systems co-ordinator 1

Care recipients/representatives 10

Leisure and lifestyle officer 1

Enrolled nurse/Team leader 2

WHS Co-ordinator 1

Laundry staff 1

Cleaning staff 1

Maintenance staff 1

Sampled documents

Category Number

Care recipients’ files 6

Resident agreements 4

Medication charts 15

Personnel files 4

Other documents reviewed

The team also reviewed:

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


records, cleaning schedules/duty lists, goods supply ordering records, laundry manual and cleaning schedules

Clinical care: clinical assessments, care plans, progress notes, medical notes, allied health reports, pathology results, advance care plans and directives, care planning review schedules, continence management plans, doctors clinic records, podiatry and foot care

Clinical monitoring charts: observation charts - weights, temperature, pulse, blood pressure, blood glucose levels, pain monitoring logs, behaviour monitoring logs, bowel charts, ADL (activities of daily living) charts, wound charts and photo records

Comments and complaints: comments and complaints forms and register

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

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

Emergency flips charts, emergency evacuation procedures, fire equipment service records, fire equipment safety inspection checklist

External service contracts and service agreements, contractor and service providers induction handbook, internal maintenance tasks, planned external maintenance schedule, testing and tagging records

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

Food services – calibration records, cleaning schedules, nutritional and hydration forms, NSW Food Authority licence and audit reports, food safety program, menu, ordering processes, food and equipment temperature records, sanitisation of fruit and vegetable records

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

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

Information systems: policies, procedures, newsletters, meeting minutes, memo register, memoranda, meeting schedule, corporate documentation register, surveys, phone lists, doctors book, handover sheets, communication books, residents’ and staff handbooks, Registered Nurse referral folder, treatment folder

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

Leisure and lifestyle: activity calendar, leisure and lifestyle assessments and care plans, activity participation records, activity evaluation records, bus outing consents, outing venue risk assessments, residents and representatives meeting minutes, lifestyle officers reports, newsletters


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

Occupational health and safety: material safety data sheets, hazard register and report, staff injury data base, risk management process tools, WHS electronic system compliance internal audit report, safe work practice documents, manual handling instruction cards

Medication management: medication charts/profiles, register of schedule eight medications, medication incident report forms, record of signatures, medication refrigerator temperature

Planning and leadership: organisational chart, philosophy of care, organisational mission and values, strategic plan

Preventative maintenance schedule, reactive maintenance logs and maintenance service reports, electrical tagging and testing records

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

Security of tenure: resident handbook (organisational and Mt Providence Village), pre- admission resident agreements.

Observations

The team observed the following:

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

Annual fire statement displayed

Archive storage

Assessment information

Charter of residents rights and responsibilities and vision, mission, philosophy and values displayed

Cleaning equipment colour coded, chemicals in use and storage, spill kits, safety data sheets

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

Designated smoking area (residents)

Emergency evacuation back packs, first aid boxes, emergency torches

Equipment and supply storage areas

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


Feedback forms (internal and external) and other advocacy brochures available

Fire safety and fighting equipment including fire panel, fire extinguishers, blankets, evacuation plans, evacuation bag

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

Infection control facilities and equipment including signage, PPEs (personal protective equipment), outbreak management kit, spill kits, sharps disposal containers, hand washing facilities, sanitisers and hand washing instruction posters

Information posters for external comments and complaints system displayed

Interactions between staff, residents and visitors, meal service and staff assisting residents with meals and drinks

Laundry equipment including, soiled linen and resident’s laundry specific to Mt Providence Village

Living environment (internal and external)

Living environment and staff work areas

Manual handling and mobility equipment

Medication administration, medication storage

Menu displayed

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

NSW Food Authority licence displayed

Nurse call system

Quality Agency re-accreditation notices on display

Secure storage of resident and staff information

Short group observation in lounge/dining room

Staff implementing hot weather safety strategies

Suggestion box

Visitors sign in/out books.


Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

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

Recent improvements relating to Accreditation Standard One include:

Legislative changes as at 1 July 2014 impacted financial and funding arrangements for new residents. Pre-entry information packs and residential agreements were updated to reflect these changes. These processes are regularly audited to ensure compliance.

The home has increased registered nurses hours by eight hours per week and care staff hours by four hours a day. This management initiative was in response to the increasing care requirements of existing residents and a need to accommodate prospective residents with high care needs. Management explained the increase in hours has resulted in improved resident assessment, pain management and care delivered.

In May 2014 an integrated residential information system was updated at the home for the management of forms and charts to link with the progress notes and care plans. Management says implementation has been successful with staff able to use the system for resident care.

Management and staff identified the home did not have a system to formally evaluate the education staff was receiving. This resulted in a new evaluation form being introduced in September 2014 which is given to staff at the completion of the education session. Staff are now able to give feedback on education provided at the facility.


1.2 Regulatory compliance

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

Team’s findings


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

Examples of compliance with regulatory requirements specific to Accreditation Standard One

- Management systems, staffing and organisational development include:

The organisation is ensuring that all staff and relevant volunteers and contractors have a police record check, statutory declaration and are cleared to work at the home.

The professional registration status of registered nurses who work at the home and visiting allied health practitioners and medical officers is being monitored on an ongoing basis.

Management at the home notified residents and their representatives in advance of the upcoming re-accreditation audit and of their opportunity to speak with the assessors in confidence.

Mandatory reporting guidelines regarding elder abuse have been implemented at the home. Consolidated records of reportable incidents are maintained. Missing residents are also notified to the Police Department and Department of Social Services.

An information Management Register was implemented centrally on the intranet for incoming legislation updates and newsletter in all Calvary Retirement Communities Hunter facilities. A paper base copy is also situated in the Mt Providence Village library. This register is where all general and Legislative information is logged and actioned upon in each facility.


1.3 Education and staff development

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

Team’s findings


There is a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. There is a comprehensive induction and orientation program for all new staff to familiarise them with their new work environment. There is an education program, including topics covering the four Accreditation Standards. Mt Providence Village has a training needs analysis tool which forms the 2014/2015 education calendar. The education is developed with reference to performance appraisals, regulatory requirements, staff input and management assessments. It includes the use of an aged care education subscription service, the implementation of a new eLearning system, in-service training by education coordinator, registered nurses, training by visiting trainers and suppliers, and access to external training and courses and self-directed learning. Records of attendance at training are maintained and the effectiveness of the training is monitored through knowledge based questionnaires, skill based assessments, performance appraisals and post-education observations. Management and staff interviewed report they are supported to attend relevant internal and external education and training. Residents and representatives interviewed are of the view staff have the skills and knowledge to perform their roles effectively.

Review of the education documentation and interviews confirmed education has been provided in relation to Accreditation Standard One. Examples include orientation of new staff, mission and values, structure of the organisation, National induction program, compulsory education for all staff, complaints mechanisms and policies and procedures.

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


Comments and complaints can be made verbally and in writing. Information about how to do so is provided through discussion, documentation and brochures and notices displayed in the home. There are suggestion boxes for confidential lodgement of feedback and information about advocacy services is accessible. Comments and complaints are followed up by the relevant department with feedback provided after consideration and action if appropriate.

Staff know what to do if a resident or representative approaches them with a complaint. Residents and representatives are confident management would be responsive to any complaints they put forward.


1.5 Planning and leadership

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

Team’s findings


The organisation’s mission, values and philosophy of care are documented. Mt Providence Village strategic plan works towards achieving their mission through strategic planning processes. Observations and document review demonstrates the organisation’s mission and values are available to all stakeholders in printed format and are displayed in the home.

Interviews with residents/representatives and our observations showed management and staff model behaviours consistent with the organisation’s mission and values.

1.6 Human resource management

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

Team’s findings


There is a master roster with flexibility to adjust staffing levels and skills mix based on changes in residents’ needs. Rostered shifts are filled with permanent and casual staff without need to use agency staff. Policies and procedures guide staff recruitment and processes are in place for orientation of new staff. The knowledge and skill base of staff is monitored through observations by management, skills assessments and knowledge based questionnaires, and feedback obtained through the continuous improvement system. Staff performance appraisals are scheduled to be carried out annually. Staff generally say they have sufficient time to complete their duties. Residents/representatives say staff are competent and kind and are generally responsive to the needs of residents.

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


Relevant staff are familiar with the home’s procedures for ordering, checking, registering, distributing, and replacing goods and equipment. Research is carried out and trials take place where possible prior to purchasing new equipment and supplies. Staff are trained in the use of new equipment. Equipment is checked and serviced through the preventative maintenance program by maintenance staff and external contractors. Management advises they are able to purchase equipment and supplies needed for staff safety and delivery of quality resident care. Observations and feedback from staff, residents and their representatives confirms this.


1.8 Information systems

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

Team’s findings


Information is shared with residents, representatives and staff in a variety of ways including regular meetings, correspondence, notices, newsletters, memoranda and through education. Handovers and communication books are used by staff and external service providers to share relevant information about residents’ needs and preferences. There are policies and procedures covering all areas of operations which can be accessed by management and staff. Confidential records and electronic data are securely stored, backed-up, and can only be accessed by relevant personnel. Staff say there is good communication and residents/representatives say they are kept informed of matters relevant to them.

1.9 External services

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

Team’s findings


Preferred suppliers are identified by the organisation with relevant checks undertaken, formal agreements entered into, and orientation provided. Relationships with preferred suppliers are managed on an ongoing basis to ensure quality products and services are provided. There is a process for management at the home to provide feedback to the organisation about the performance of contractors and suppliers. Management is also pro-active at a local level in addressing issues of poor performance by external service providers. Contact lists are available to management and staff so they can access relevant external service providers when needed, including outside of business hours. Management and staff are satisfied with the arrangements in place for external service provision.


Standard 2 – Health and personal care

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



Team’s findings


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

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

Management identified inconsistencies in the home’s approach in the documenting in communication books and diaries. Staff were not using a standardised approach in documenting. This made it difficult to monitor and ensure communications with resident/representatives is reflected in a resident’s care plan. Management reviewed the process utilised when documenting and standardised the home’s approach. As a result staff document using the appropriate guidelines. This has facilitated a process ensuring information discussed with residents/representatives, in communication books and diaries are captured effectively.

Management identified that care staff needed to have the appropriate skills to ensure those residents who suffer with dementia are receiving appropriate care in an effective manner. Consequently the home organised for staff to receive training in dementia care.



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

Team’s findings


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

There is a system of review by an accredited pharmacist of residents’ medication management.

Registered nurses initially assess and plan care and provide ongoing management and evaluation of residents as specified in the Quality of Care Principles 2014.

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



Team’s findings


Refer to expected outcome 1.3 Education and staff development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education and training that management and staff attend relating to Accreditation Standard Two include: the education program covering such topics as: skin care and skin integrity, hygiene and personal care of the elderly, behaviour management and communication, continence management, diabetes, pain management, wound management, falls risk and clinical incident management and wound care.

2.4 Clinical care

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

Team’s findings


Residents receive clinical care that is appropriate to their individual needs and preferences. The home has systems to access, using a comprehensive suite of electronic assessments, monitor and evaluate residents’ care needs on entry to the home and on an ongoing basis. Information is obtained from residents and representatives when residents move into the home. The registered nurses develop individualised care plans which are reviewed and evaluated three monthly and when required through the home’s electronic clinical care system. Case conferencing is encouraged after entering the home, annually and whenever a concern


arises. Resident care needs are communicated to staff electronically, verbally and via handover sheets. Medical practitioners conduct regular reviews and in emergencies residents are transferred to hospital. Residents and their representatives expressed satisfaction with the care provided at the home.

2.5 Specialised nursing care needs

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

Team’s findings


The home has systems and processes to support the specialised nursing care needs of residents’. The home is currently providing, and has the equipment and skills to support care needs such as diabetes management, wound management, anti-coagulant therapy and oxygen therapy. Registered nurses are on call at all times. The registered nurses access residents’ for specialised nursing care and undertake or supervise any specialised nursing treatments. Residents are referred to a range of allied health professionals and other specialists to assist the home’s staff to manage residents’ complex and specialised needs.

Residents/representatives said they are satisfied the home’s staff are able to provide specialised nursing care.

2.6 Other health and related services

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

Team’s findings


The home ensures residents are referred to appropriate health specialists in accordance with residents’ needs and preferences. The home has processes to refer residents to a range of services such as physiotherapist, speech pathology, dietician and podiatry. In addition the home can access services from the local hospitals for palliative care advice, wound management and the mental health team. A hairdresser is also available in the home.

Residents are assisted to access external services through transport provided by the residents’ representatives or as arranged by the home. Information and recommendations made by health professionals are referred to the medical officer and actioned where necessary. Residents/representatives confirm residents are referred to specialists as the need arises.


2.7 Medication management

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

Team’s findings


The home has systems to ensure that residents’ medication is managed safely and correctly. This includes the ordering, storage, disposal, administration, recording and review of medications. The home uses a single dose blister pack system and liaison with the supplying pharmacist ensures that new or changed medications are supplied promptly. Medications are stored securely and we observed safe and correct medication administration by care staff, who have completed medication competency assessments. Regular pharmacological reviews are undertaken and medications are adjusted as needed by the residents’ medical practitioners. Review of medication charts show they contain all relevant information and identification of residents. Residents/representatives expressed satisfaction with the way residents’ medication is managed.

2.8 Pain management

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

Team’s findings


To ensure that residents are as free from pain as possible all residents are assessed for pain on entry to the home and ongoing pain assessments are conducted to monitor residents’ pain. Consultation with the resident, physiotherapist and their medical practitioner is conducted by the home and the specific management strategies are documented in their care plan. A dedicated registered nurse is employed to conduct a pain clinic each week that provides treatments such as exercise, heat packs, massage therapy and use of a TENS machine. Care staff described the interventions they use to relieve resident pain such as mobilisation, repositioning, massage, hot packs after consultation with the registered nurse. The effectiveness of interventions is evaluated by all staff to ensure pain relief treatments remain effective. Residents said they are satisfied with how the home manages their pain.

2.9 Palliative care

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

Team’s findings


The home has systems in place to ensure the comfort and dignity of residents requiring palliative care is maintained. Advance care plans or medical orders for life sustaining treatment are discussed with the resident/representative on entry to the home and at case conferences. Residents are supported to remain in the home for palliative care if this is their preference. Family members are able to stay with residents and meals and refreshments are available. Clergy are available for spiritual care and additional emotional support if that is the wish of residents. The home has access to the local palliative care services for specialist advice and support.


2.10 Nutrition and hydration

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

Team’s findings


The home has systems to provide residents with adequate nutrition and hydration through initial and ongoing assessment of residents’ dietary preferences, likes and dislikes. Special dietary requirements are specified in residents’ care plans and communicated to catering staff. Staff monitor and assist the residents’ at meal times and observe the amount of food and fluid consumed and report poor intake to the registered nurse. Residents are weighed monthly or more frequently to monitor any changes and additional nourishing fluids such as fortified drinks and dietary supplements are provided when weight loss is identified. The home refers residents to a dietician and speech pathologist as required. Assistive devices such as special cutlery and plates are provided. Resident/representatives said they are satisfied with the home’s meals, which allow residents an alternate choice at each meal.

2.11 Skin care

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

Team’s findings


The home has an effective system to ensure that residents’ skin integrity is consistent with their general health. Initial and ongoing assessments are conducted to identify skin care needs and management strategies are incorporated into the resident’s care plan. To maintain skin integrity the home provides assistive devices such as pressure relieving mattresses and uses strategies such as regular repositioning, application of emollients and limb protectors. The home has a podiatrist and foot care nurse who regularly visit to provide assessment and foot care. Residents’ wounds are managed appropriately, sufficient supplies of wound care products are available and referrals are made as required. The home monitors accidents and incidents including wound infections and skin tears. A hairdressing service is available at the home for residents. Residents/representatives report satisfaction with the way the home manages residents’ skin care needs.


2.12 Continence management

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

Team’s findings


The home has systems to ensure that residents’ continence is managed effectively. On entry to the home residents are assessed for their continence needs and then on an ongoing basis. Care staff are knowledgeable about residents’ care needs and preferences for toileting and the use of continence aids. Aids to manage and support residents with continence care include a range of pads, exercise programs, toileting schedules, dietary supplements and medications. The home has an adequate supply of continence aids and linen. Infection data, including urinary tract infections, is regularly collected, collated and analysed.

Residents/representatives said they are satisfied with the way in which residents’ 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 systems to access and manage residents with challenging behaviours. This includes initial and ongoing assessment and monitoring of residents’ behaviour needs. The care plan is developed to include strategies that address the residents’ specific needs.

Residents are referred to their medical practitioner and/or mental health team for review when necessary. Staff demonstrate an understanding of residents’ behaviours and resident specific interventions they use to minimise the incidence of the behaviour. These interventions include offering food and fluids, toileting the resident, changing the resident’s continence aid, checking for pain, repositioning or providing the resident with a specific activity. Resident/representatives said they are satisfied with the way in which the home’s staff manage resident’s behaviours of concern.


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


Optimum levels of mobility and dexterity are achieved for all residents. On entry to the home each resident’s mobility, dexterity and rehabilitation needs are assessed and documented by the physiotherapist to ensure care meets resident needs and preferences. Exercise groups are held and residents are encouraged to attend. Staff supervise and assist residents to mobilise and residents are encouraged to use their mobility aids. Review of documents confirmed strategies are implemented at the home to reduce the incidence of resident falls. Incident/accident data, including resident falls is regularly collected, collated and analysed.

Staff at the home confirmed that they complete annual compulsory manual handling training. Residents/representatives said they are satisfied with the care provided.

2.15 Oral and dental care

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

Team’s findings


Residents’ oral and dental health is maintained, including initial assessment of residents oral and dental needs. Residents are referred and assisted to access dentists and dental technicians when required both visiting and external of their choice. Oral health care is monitored daily by care staff during teeth and denture cleaning. The day to day oral care is attended as per residents care plans with residents being encouraged to brush their own teeth or dentures to maintain their independence. Aids to maintain dental hygiene include toothbrushes, toothpastes and mouth swabs. Residents said that staff assist them to maintain their oral and dental hygiene.

2.16 Sensory loss

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

Team’s findings


Residents’ sensory losses are identified and managed effectively. Sensory loss is identified on entry to the home and an assessment is completed to identify residents’ specific needs. Residents have access to specialist services including speech therapy, audiology and optometry. Residents said staff assist them in cleaning their glasses, fitting their hearing aids and replacing hearing aid batteries. Activities such as massage therapy, relaxing music and large print resources provide sensory stimulation. Residents said they are satisfied with the manner in which the home identifies and manages their sensory loss.


2.17 Sleep

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

Team’s findings


The home assists residents to achieve natural sleep patterns through a sleep assessment, care planning and staff support at night. Care staff reported that if residents are having difficulty sleeping, staff will offer warm drinks or snacks, assist the resident to the toilet, repositioning in bed, pain management or provide reassurance to promote relaxation and sleep. The home also uses strategies such as dimming the lights, answering buzzers promptly and ensuring noise is at a minimum. Residents advised they are satisfied with the home’s approach to sleep management.


Standard 3 – Care recipient lifestyle

Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Accreditation Standard Three Resident lifestyle: resident meetings, the comment and complaint system, verbal comments and surveys are used to gather suggestions and feedback on the lifestyle systems of the home.

The home has implemented improvements in relation to Accreditation Standard Three Resident lifestyle including:

Management and staff identified the need to provide emotional support to staff and residents/representatives at a time of grief and loss. Resource material is made available and staff are able to verbalise their feeling in a supportive manner. Staff report they have used the resource material effectively .They also report feeling they have improved their skills and knowledge in providing support to residents/representatives as needed.

To improve staff knowledge and skills by increasing the range of education available the aged care channel has been installed at Mt Providence Village. Programs can be recorded and staff can view them and complete the work books at their convenience.



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

Team’s findings


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

The organisation’s policies and documentation relating to residents’ financial arrangements have been updated to reflect recent changes in aged care legislation.

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

The organisation’s privacy policy has been reviewed and updated in line with the Australian Privacy Principles.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively.

Examples of education and training that management and staff attend relating to Accreditation Standard Three include: the orientation and in-service programs covering such topics as; resident rights, dignity and respect for residents, privacy and confidentiality, compulsory training on the elder abuse/mandatory reporting.

3.4 Emotional support

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

Team’s findings


Residents expressed appreciation to staff for the support and assistance staff provide during their entry to the home and settling in period. The entry process includes gathering information from residents and representatives to identify residents’ existing care and lifestyle preferences. This information is recorded in social and lifestyle assessments and an individualised care plan is developed. Residents are orientated to the home and care and life style staff spend extra one on one time with residents during the settling period. Residents are welcome to


personalise their rooms with small familiar items and photographs. The team observed staff interacting with the residents in an understanding and caring manner.

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


Residents said they are satisfied with the opportunities available to them to participate in the life of the community, maintain friendships and maximise their independence. The home provides an environment in which representatives, family, friends and community groups are welcome to visit. The activity program contains both internal and external activities such as regular bus outings and entertainment by community groups. Volunteers attend the home to assist residents to engage in activities and special events.

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


Residents/representatives reported that residents’ privacy, dignity and confidentiality is respected at all times. Staff respect the privacy and dignity of residents by knocking and waiting for permission before entering residents’ rooms and treating residents in a respectful manner. Resident records and information is securely stored and only accessible by authorised personnel. Staff and volunteers sign a confidentiality agreement on commencement at the home. Residents/representatives sign consents for use of information. There are sitting rooms, an activities room and outdoor areas of the home where residents may entertain family and friends.

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


Residents expressed satisfaction with the activity program offered by the home. A lifestyle care plan is developed for each resident on entry to the home which outlines previous and current interests. The home has systems to ensure residents are encouraged and supported to participate in their interests and activities. Residents’ activity interests are included in the monthly activity program which is displayed in communal areas of the home. The monthly activities program takes into account significant theme days and residents preferred activities. Some examples of leisure interests provided include church services, bingo, hoi, art therapy, bus outings, music therapy, barbeques, school visits, exercise programs and many special event celebration days. Information obtained from residents’ meetings is also used to plan and


evaluate activities offered by the home. Residents expressed satisfaction with the activities available.

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


Residents reported they are satisfied with the support provided for their cultural and spiritual needs. The individual requirements of residents to continue their beliefs and customs are identified in the assessment process on entry. Specific cultural days such as Australian Day, Christmas, Father’s Day, Mother’s Day and special birthdays are commemorated with appropriate festivities. Residents and representatives expressed appreciation for the efforts of staff to entertain and please the residents on these occasions. A number of religious clergy hold services at the home and residents are invited to attend these if they wish to do so.

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


Residents reported satisfaction with the choices available to them at the home. Participation in group activities is the choice of the resident and they are asked to choose how they wish to spend individual time with lifestyle staff. Residents have personalised their rooms with memorabilia and small items of their choosing. Residents and representatives participate in decisions about the services residents receive through discussions with staff, resident meetings, surveys, case conferences and through the comments and complaints processes. Feedback about matters raised is provided through residents’ and representatives’ meetings. Residents expressed satisfaction with the actions taken by management on matters raised.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


The home is able to demonstrate that residents have secure tenure within the home and understand their rights and responsibilities. Relevant information about security of tenure and residents’ rights and responsibilities is provided in the resident and accommodation agreements and the handbook. This is discussed with prospective residents and their representatives prior to and on entering the home. The Charter of Residents’ Rights and Responsibilities is displayed and included in publications. Residents and representatives told


us they are kept informed about matters of importance to them, they feel secure of residency within the home and they confirm an awareness of their rights and responsibilities.


Standard 4 – Physical environment and safe systems

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



Team’s findings


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

An external audit was undertaken of the Fire protection, safety equipment and regular and reactive maintenance given by an external contractor. Results indicated the external company was not meeting the required expectation of the homes. Mt Providence Village sourced tenders for the appointment of a new external contractor who has commenced in the home. The home stated this contractor is meeting the required needs of the home.

To improve access to work health and safety (WHS) and standardise documentation across the organisation a new WHS computerised system has been introduced. The new system includes lodging, investigation and actioning incidents which occur at the home, collecting data and disseminating this information to appropriate personnel, and identifying educational needs. Staff have received appropriate education in the new system, with additional consultation, evaluation and education given where required. This system aims to ensure relevant legislation is reflected and the rights of the employee and residents are upheld.


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

Team’s findings


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

The home has a current annual fire safety statement and maintains its fire prevention, alert and fighting systems and equipment on an ongoing basis.

The home has a current licence with the NSW Food Safety Authority and is responsive to the findings in annual inspection reports.




Team’s findings


Refer to expected outcome 1.3 Education and Staff Development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of education and training that management and staff attend relating to Accreditation Standard Four include: the orientation and in-service programs which includes training in; fire safety, work health and safety, manual handling, infection control and outbreak management. Mandatory training for all staff in fire safety, evacuation and emergency response awareness and evacuation, manual handling and workplace health and safety. Training in chemical safety provided by an external supplier.

Food safety training for catering staff and external course for fire safety officers.

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 demonstrate they are actively working to provide a safe and comfortable environment consistent with residents’ care and lifestyle needs. Mechanisms, such as entry and orientation processes for new residents, satisfaction surveys, newsletters and meetings provide information and allow residents and their representatives to contribute ideas about their living environment. The home is constructed on one level with wide hallways, comfortable internal communal areas and well-kept garden and courtyard areas for residents to enjoy the sunshine and entertain visitors. Accommodation consists of pleasantly furnished single rooms with en-suites. Hand rails in the hallways, support equipment in the bathrooms, mobility aids, and access to a nurse call system contribute to safety in the living environment. Internal temperatures are comfortably maintained. Environment and safety audits are completed and actions implemented to correct any identified issues.


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


Regular environmental audits and inspections are carried out to pro-actively identify occupational health and safety issues. There are functioning hazard and staff incident reporting systems. Occupational health and safety is discussed at staff meetings where it is a standing agenda item. Issues identified are investigated and actioned to eliminate or mitigate risk. Safety equipment and supplies are available to staff in sufficient supply they report.

Education is provided to staff about safe manual handling and other relevant topics. There are policies and procedures to guide injury management and there is an employee assistance program to support staff. Staff say that management is responsive to staff suggestions and requests relating to 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 attend mandatory fire safety awareness and evacuation training each year and know what to do in the event of the fire alarm sounding. An annual fire safety statement has been obtained and is on display. Emergency exits are clearly marked and kept free of obstruction. There is an early warning detection system and fire-fighting equipment which is being maintained. Emergency procedures have been reviewed, updated and relevant information is readily accessible to staff and others. Consideration has been given to the need for back-up emergency supplies to be kept on site and to be ready to take in case of evacuation. There are evening lock-up procedures which are carried out by staff. Audits are carried out covering aspects of the environment, including fire safety and security.

4.7 Infection control

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

Team’s findings


Staff are trained in infection control, have their hand hygiene practices assessed, and are given information, equipment and supplies to prevent and manage infection risks. Influenza vaccine is offered to residents and staff each year and there is an immunisation program for staff. The catering service complies with food safety requirements according to an inspection report and licence from the NSW Food Authority. Disinfection in the laundry is through thermal and chemical means and workflow allows for separation between clean and ‘dirty’ areas. Cleaning procedures are implemented across all areas of the home. Residents are monitored for signs and symptoms of infection and there is action in liaison with general practitioners as needed. Preparations have been made for managing an infectious outbreak. Infection rate


data is collated and analysed to identify opportunities for improvement. Staff are knowledgeable about infection control principles and practices relevant to their work.

4.8 Catering, cleaning and laundry services

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

Team’s findings


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

mt providence village - aacqa.gov.au · pdf filewe made our decision on 05 february ......

Documents