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Spiritus Edwin Marsden Tooth Memorial Home for Aged

Approved provider: The Corporation of the Synod of the Diocese of Brisbane

This home was assessed as meeting 42 of the 44 expected outcomes of the Accreditation Standards and accredited for two years until 14 August 2013. We made the decision on 28 June 2011.

The audit was conducted on 23 May 2011 to 25 May 2011. The assessment team’s report is attached. The accreditation period will provide the home with the opportunity to demonstrate that it is capable of monitoring systems, addressing the not met areas, and evaluating the effectiveness of actions taken. We will continue to monitor the performance of the home including through unannounced visits. Update After a re-assessment on 31 August 2011 we decided the home met all 44 expected outcomes under the Accreditation Standards.

Most recent decision concerning performance against the Accreditation Standards

Since the accreditation decision we have conducted an assessment contact. Our latest decision on 6 September 2011 concerning the home’s performance against the Accreditation Standards is listed below. Standard 1: Management systems, staffing and organisational development

Expected outcome Accreditation Agency’s latest 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





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





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





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

Home name: Spiritus Edwin Marsden Tooth Memorial Home for Aged Date/s of audit: 23 May 2011 to 25 May 2011 RACS ID: 5053 AS_RP_00851 v3.0

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Home and approved provider details

Details of the home Home’s name: Spiritus Edwin Marsden Tooth Memorial Home for Aged

RACS ID: 5053

Number of beds: 59 Number of high care residents: 45

Special needs group catered for: • Residents requiring a secured living environment

Street/PO Box: 162 Oceana Terrace

City: MANLY State: QLD Postcode: 4179

Phone: 07 3396 1564 Facsimile: 07 3393 3746

Email address: [email protected]

Approved provider Approved provider: The Corporation of the Synod of the Diocese of Brisbane

Assessment team Team leader: Glenda Cherry

Team member/s: Dee Kemsley

Date/s of audit: 23 May 2011 to 25 May 2011


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

Expected outcome Accreditation Agency decision

1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met

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


2.1 Continuous improvement Met 2.2 Regulatory compliance Met 2.3 Education and staff development Met 2.4 Clinical care Not 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 Not met 2.9 Palliative care Met 2.10 Nutrition and hydration Met 2.11 Skin care Met 2.12 Continence management Met 2.13 Behavioural management Met 2.14 Mobility, dexterity and rehabilitation Met 2.15 Oral and dental care Met 2.16 Sensory loss Met 2.17 Sleep Met


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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 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


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Site Audit Report

Spiritus Edwin Marsden Tooth Memorial Home for Aged 5053

162 Oceana Terrace

MANLY QLD

Approved provider: The Corporation of the Synod of the Diocese of Brisbane Executive summary This is the report of a site audit of Spiritus Edwin Marsden Tooth Memorial Home for Aged 5053 from 23 May 2011 to 25 May 2011 submitted to the Accreditation Agency. Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets: • 41 expected outcomes The information obtained through the audit of the home indicates the home does not meet the following expected outcomes: • 1.6 Human resource management • 2.4 Clinical care • 2.8 Pain management The Australian Government provides subsidies to accredited residential aged care homes. To maintain a home’s accreditation and remain eligible for these government subsidies an approved provider must be able to demonstrate that it meets the Accreditation Standards. There are four standards – each with a defining principle – comprising 44 expected outcomes. When a home applies for re-accreditation, an assessment team from the Accreditation Agency visits the home to conduct a site 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 each of the 44 expected outcomes. The Accreditation Agency then makes a decision to re-accredit or not to re-accredit the home. Each of the Accreditation Standards, their principles and expected outcomes are set out in full in the following pages, along with the assessment team’s reasons for its findings.


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Site audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the site audit from 23 May 2011 to 25 May 2011. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team Team leader: Glenda Cherry

Team member: Dee Kemsley Approved provider details Approved provider: The Corporation of the Synod of the Diocese of Brisbane

Details of home Name of home: Spiritus Edwin Marsden Tooth Memorial Home for Aged

RACS ID: 5053

Total number of allocated places: 59

Number of residents during site audit: 59

Number of high care residents during site audit:

45

Special needs catered for: Residents requiring a secured living environment

Street/PO Box: 162 Oceana Terrace State: QLD

City/Town: MANLY Postcode: 4179

Phone number: 07 3396 1564 Facsimile: 07 3393 3746

E-mail address: [email protected]


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

Number Number

Acting Facility Manager (AFM) 1 Residents/representatives 10 Group Manager of Practice Development and Quality (GMQ)

1 Cook 1

Acting Clinical Nurse Coordinator (ACNC) 1 External Contractor – Fire

Safety Systems 1

Registered nurses (RN) 3 Administration officer/Workplace Health and Safety Officer

1

Enrolled nurse (EN) 1 Diversional therapist 1

Care staff 2 Activities officer 1

Care staff – link nurse 1 Maintenance staff 1

Physiotherapist 1 Catering staff 2

Roster Coordinator 1 Cleaning staff 1

Administration Coordinator 1 Laundry staff 1 Workplace Health and Safety Officer/Fire Safety Advisor 1 Quality Coordinator 1

Sampled documents

Number Number

Residents’ files 9 Medication charts 14 Summary/quick reference care plans 3 Personnel files 6

Other documents reviewed The team also reviewed: • ‘Are we doing it right’ forms • ‘Information for residents, family and friends’ folder • Activities calendar • Activity attendance sheets • Advance Health Care Plan • Annual calendar of meetings • Archive sheet • Assessment tools • Asset register • Audit schedule and results • Bowel management folder • Code of conduct (staff) • Comment/complaint log • Compliments and comments register • Computerised information system/staff resources • Continuous improvements plan


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• Diary • Dietary needs/preference forms • Duties lists • Education calendar • Employee action plan • External contracts folder • Fire alarm action (pictorial) • Fire maintenance program • Food safety audit – corrective action plan • Four weekly cycle menu • Fridge temperature control forms (kitchenettes) • Graduate registered nurse programme guideline • Guideline and protocol folder • Handover sheet • Hazard reports • Internal audit report • Interview guide • Kitchen cleaning programs • Kitchen temperature logs • Learning and development plan • Maintenance requisition • Mandatory reporting register • Mandatory training matrix • Master roster • Material safety data sheets • Meeting minutes • Memorandum • Monthly newsletter • Newsletter • Nutritional database • Orientation and mandatory training program • Orientation sign-in sheet (agency staff) • Pain management folder • Pest control invoices • Podiatry folder • Police certificate/professional registration matrix • Policies folder • Position descriptions • Preoperational checklist (kitchen) • Reactive maintenance folder • Resident evacuation list • Resident handbook • Resource folder for agency staff • Restraint authorisation • Room for improvement log • Self directed learning program guide • Shifts to fill form • Staff availability for extra staff • Staff handbook • State fire and rescue maintenance inspection record • Strategic plan • Training attendance register and evaluation forms • Weight management folder


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• Workplace health and safety assessment report form • Wound management folder Observations The team observed the following: • Activities in progress • Advocacy and complaints investigation scheme and other information brochures on

display • Archive areas • Chapel • Charter of residents rights and responsibilities in on display • Cleaner’s room and trolley • Colour coded linen skips • Emergency exits with signage • Evacuation plans on display • Family members and staff interacting with residents • Fire exits and egress routes • Fire fighting equipment, fire panel/detection alarm system • Hair dresser facility • Internal and external living environment • Kiosk • Kitchen and food preparation/storage processes • Laundry processes • Lunch time meal service • Maintenance shed • Manual handling and mobility aids • Medication administration • Menu on display • Mission statement on display • Notice boards • Outbreak kits • Personal protective equipment being accessed by staff • Residents’ photo gallery • Residents’ designated smoking areas • Spill kits • Staff room • Storage of supplies, equipment and chemicals • Visitor, volunteer and residents sign-in/sign-out books • Wall mounted hand sanitisers • Waste disposal facilities


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Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Spiritus Edwin Marsden Tooth Memorial Home for the Aged (the home) has a continuous quality improvement program which is managed and monitored by the Quality Coordinator, in conjunction with the Facility Manager. Opportunities for improvement are identified through scheduled audits, completion of improvement logs, resident and staff meetings, the comments and complaints process, clinical indicators, third party reviews, and one-to-one discussions with residents/representatives and staff. Issues identified are addressed at monthly quality meetings with follow-up actions attended to as required. Improvements are logged into a register with actions and results being fed-back to staff and residents at meetings; further review generally takes place if appropriate before closure. Residents/representatives and staff are satisfied that improvements continue to be implemented at the home and that their suggestions are considered and result in action. Management report examples of recent improvements relevant to Standard One which include: • Following an improvement request submitted in relation to ensuring stocks of equipment

are adequate and appropriate for service delivery, an equipment audit was conducted. As a result, the home has recently purchased the following equipment: − 20 electric beds (including low-low beds) with accompanying pressure relieving

mattresses − 10 shower chairs − One bariatric shower chair with wheels − Two hoists with appropriate slings − Air mattresses where trialled and purchased − Two care trolleys − One additional dressing trolley − Eight linen skips with triple bag holders Management reported that these purchases have enabled the home to provide appropriate ongoing care to residents with increased and changing care needs.

• A graduate nurse program, facilitated by the Learning and Development manager, has recently been introduced by the organisation; two new graduate registered nurses have recently been recruited by the home. Management reports that this has resulted in the home being able to recruit newly qualified staff and staff reported that they feel supported in their ongoing professional development by the home.

• Following a suggestion raised by staff to improve inter staff communication; heads of

department introduced an informal 30 minute meeting every week to discuss resident movements within the home, and new admissions. Staff report satisfaction with the flow of information.


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• Additional staff have been appointed to diversional therapy roles and management have increased the numbers of hours therapy staff are available to provide lifestyle activities to residents. There are now four staff members available to provide leisure interests and activities to residents enabling two staff (one in secure environment and one in the general area) to be available to assist residents with emotional support and activities of interest five days per week. Residents and representatives express satisfaction with the increased staff available for activities.

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 recommendation Does comply The organisation has established systems to identify and ensure compliance with a wide range of legislation, professional standards and industry guidelines; and has access to government bodies and industry sources that provide regular updates of legislative and regulatory requirements. This system is monitored and managed out of head office, in conjunction with the Facility Manager, and updates are discussed with key personnel and actioned as is required. Changes are communicated to staff via policy and procedure reviews, education sessions (for example orientation and compulsory annual training), staff meetings, memos and/or are attached to payslips. Changes are also communicated to residents and families where appropriate. The home has a system in place to ensure that all staff have a current favourable criminal record check, a process to inform residents and their representatives of accreditation audits, and residents and other stakeholders have access to appropriate complaints mechanisms. Compliance with legislation is monitored through the audit process, performance appraisals and observation of staff work practices. 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 recommendation Does comply The home provides an education program for staff that includes orientation and annual mandatory training, identified training needs and other development opportunities. Education sessions are communicated to staff via monthly education calendars placed on the staff notice board, as well as verbal and written notification. The Facility Manager oversees the education program, ensures education records are maintained and monitors attendance through a paper database. Processes are in place to support staff to attend external courses and training. The ongoing education and development needs of staff are identified through feedback from residents and staff, review of audits and clinical indicators, and staff performance appraisal process; results have been combined with organisational education requirements to develop the training calendar. Management monitors the skills and knowledge of staff through audits and observation of staff practice. The home coordinates in-service education sessions relevant to Standard One including the Accreditation Standards and the home considers the effectiveness of each session.


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1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s recommendation Does comply The home has a comments and complaints system, managed and monitored by the Facility Manager, which captures compliments and complaints from residents, representatives, staff and other interested parties. Residents are informed about internal and external avenues of complaint via the resident handbook, notices and brochures displayed in the home, and through one-to-one discussions with management and staff. Feedback/suggestion forms are available and accessible to residents, together with secure suggestion boxes located in the communal areas. Resident meetings also provide a forum for residents to raise issues of concern. The Facility Manager, in conjunction with the Quality Coordinator, registers and acts upon all complaints received and monitors progress toward resolution via this register, in a timely manner. Feedback is provided to the originator either verbally or in writing. Residents/representatives are familiar with various ways to initiate a suggestion and report that they feel comfortable in expressing any issues of concern. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s recommendation Does comply The organisation has documented the home’s vision, mission, values and strategic intent; this is on display within the home, is incorporated into the residents’ handbooks and made available to staff via the organisation’s computerised information website. 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 recommendation Does not comply The home has not ensured there are appropriately skilled and qualified staff sufficient to ensure that residents’ cares are delivered in accordance with their needs. Registered staff are not monitoring clinical care services and as a result residents clinical care needs are not being identified, actioned as planned, and/or reviewed, reassessed and evaluated in a timely manner.


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1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply The home has processes and personnel in place to monitor and maintain goods and equipment for the delivery of care and services to residents. The maintenance officer and/or external contractors complete preventative and routine maintenance work at the home to ensure the safety and useability of equipment; an audit schedule is in place to guide the regular maintenance of goods and equipment. Faulty equipment and other maintenance issues are identified through completed maintenance requests, regular audits, completed improvement logs and incident/hazard reports; these forms are available to all staff. Staff are trained in the use of new equipment where required; an impress system is in place to ensure stock levels of supplies are monitored and maintained by key personnel. Equipment and goods are appropriately stored and areas containing hazardous material are secured and identified by signage. Residents and staff are satisfied with the appropriateness and availibility of the goods and equipment provided by the home. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply The home has processes in place to ensure effective information management systems are in place. Electronic and paper based records are maintained by the home with restricted/locked access to residents’ and staff files. Electronic information is secured by password access and data is backed up to prevent the loss of important information. Care plans and verbal and/or written handover process generally provide staff with relevant information to ensure residents’ care needs are met; accessible manuals, policy and procedures guidelines, and legislative information guide staff practice. Information is disseminated to residents/representatives through the resident handbook, family discussions, newsletter, one to-one-to discussions, meetings and notice boards. There is a system in place to archive material in a designated secure locked area. The effectiveness of information systems is reviewed through regular audits, scheduled organisational review of documentation, and staff and resident/representative feedback. Staff and residents/representatives express satisfaction with the timeliness of communication processes and access to information appropriate to their needs. 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 recommendation Does comply The home has systems and processes in place to ensure that all externally contracted services are provided to meet residents’ care and related services needs. A range of contractors and external providers operate within formalised agreements to provide services in relation to fire safety systems and various building maintenance and equipment services. The home monitors the performance of external service providers and takes appropriate


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action when required; external service contractors providing service at the home are required to sign-in/out. Performance is regularly evaluated through observation and resident/staff feedback. Staff and management are satisfied with quality of services provided by external service providers.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has a continuous quality improvement program which is managed and monitored by the Quality Coordinator, in conjunction with the Facility Manager. Opportunities for improvement are identified through scheduled audits, completion of improvement logs, resident and staff meetings, the comments and complaints process, clinical indicators, third party reviews, and one-to-one discussions with residents/representatives and staff. Issues identified are addressed at monthly quality meetings with follow-up actions attended to as required. Improvements are logged into a register with actions and results being fed-back to staff and residents at meetings; further review generally takes place if appropriate before closure. Residents/representatives and staff are satisfied that improvements continue to be implemented at the home and that their suggestions are considered and result in action. Management report examples of recent improvements relevant to Standard Two which include: • Following a review of medication management the home identified that there was an

increasing number of controlled drug errors associated with the storage of these drugs due to limited space and difficult access. A new controlled drug safe has recently been purchased and installed. Registered staff report that the new safe made it easier to administer residents narcotic medication in a safe and correct manner.

• The home has recently undertaken a review of residents’ continence management and as a result has implemented a new suite of continence tools and provided education to staff on the use of these tools. Continence team members (link nurses) have been introduced and trained to monitor initial and ongoing continence aid use for appropriateness, and attend to ordering of supplies.

• As the home has experienced an increasing acuity of residents care needs, and following feedback from care staff, management changed the model of care in place from carers assisting with administration to qualified staff (registered nurses and enrolled nurses) administering medications only. Management report this improvement has increased resident safety in the area of medication management.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s recommendation Does comply The organisation has established systems to identify and ensure compliance with a wide range of legislation, professional standards and industry guidelines; and has access to government bodies and industry sources that provide regular updates of legislative and


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regulatory requirements. This system is monitored and managed out of head office, in conjunction with the Facility Manager, and updates are discussed with key personnel and actioned as is required. Changes are communicated to staff via policy and procedure reviews, education sessions (for example orientation and compulsory annual training), staff meetings, memos and/or are attached to payslips. Changes are also communicated to residents and families where appropriate. All registered staff are required to provide a current nursing registration prior to commencement of work and expiry dates are monitored by management, the home complies with regulations relating to the storage and administration of schedule eight medications and staff ensure privacy and confidentiality of resident care and information. Compliance with legislation is monitored through the audit process, performance appraisals and observation of staff work practices. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff that includes orientation and annual mandatory training, identified training needs and other development opportunities. Education sessions are communicated to staff via monthly education calendars placed on the staff notice board, as well as verbal and written notification. The Facility Manager oversees the education program, ensures education records are maintained and monitors attendance through a paper database. Processes are in place to support staff to attend external courses and training. The ongoing education and development needs of staff are identified through feedback from residents and staff, review of audits and clinical indicators, and staff performance appraisal process; results have been combined with organisational education requirements to develop the training calendar. Management monitors the skills and knowledge of staff through audits and observation of staff practice. The home coordinates in-service education sessions relevant to Standard Two based on the current health and well-being status and care needs of residents. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does not comply Clinical supervision is not adequate to ensure residents receive appropriate clinical care. Care is not consistently provided as directed and/or prescribed. Indicators of changed health status are not identified, re-assessed, reviewed, monitored and actioned. As a result, management are not able to demonstrate residents clinical care needs are met. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s recommendation Does comply Resident’s specialised nursing care needs are assessed on entry by a registered nurse who develops a plan of care to guide cares of individual specialised nursing procedures. Access


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to resources and external specialists supports the provision of care. Registered staff implement and evaluate care interventions, and current status is recorded and communicated through handover discussions. Education and training is provided when cares or equipment needs are identified. Registered staff demonstrate knowledge of residents’ care needs and report there are appropriate equipment/supplies to deliver individualized care. Residents indicate they are satisfied with the specialised nursing care provided. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s recommendation Does comply Residents are supported to access other health and related services consistent with their care needs and preferences. Where there is an identified need, referral processes are initiated and allied health services provide consultation onsite. Examples of visiting health and related services include physiotherapy, geriatrician, podiatry, optometrist, pathology and palliative care and residents are supported to undertake visits to external service providers as required. Recommendations by allied health professionals are generally implemented, monitored and evaluated in accordance with the resident and their plan of care. Residents report satisfaction with the support and assistance provided by the home to access other health and related services when needed. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply Medical officers’ prescribe medication which is documented on medication charts to guide staff administration; registered staff administer medications to residents. Medications are reviewed by the medical officer and visiting pharmacist on a regular basis. Medication charts contain relevant information to ensure safe and correct administration occurs. Controlled drugs are stored securely and records are maintained to demonstrate accountability. Processes are generally in place for the identification of expiry dates and return of unused medications. Nurse initiated medication is documented and authorised by the medical officer. As required (prn) medication is provided when needed and evaluated for effectiveness. Medication incidents are reported and acted upon. Residents report satisfaction with the management of their medication. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does not comply Management does not effectively demonstrate the home’s pain management approach ensures all residents are as free as possible from pain. Registered nurse assessment does not occur in response to residents expressing their pain management needs and as a result residents pain needs are not met in a timely manner.


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2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply Consultation with the resident and their representative about residents’ terminal care wishes including any specific cultural and spiritual care needs is conducted and recorded to guide staff. Changes in residents’ health status and their ongoing care needs (including pain management) are planned in consultation with the medical officer, external professionals from hospital palliative care teams and registered staff; resources and equipment are provided and training in the use of pain management equipment is provided to staff when required. Ongoing consultation occurs with the resident, their representative and family members during the palliative process. Private areas are available, environmental adjustments are made when required, such as, soft music and dimmed lighting and clinical and therapy staff provide emotional support to residents and their families. Residents/representatives are satisfied that resident’s terminal care wishes are respected. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply An individual dietary profile is established which includes information about the specific dietary needs, preferences and the need for additional aids to assist the resident to eat and drink. This information is provided to kitchen staff. Consideration is given to the likes and dislikes of residents to enhance their appetite; cultural preferences and individual allergies. Residents’ weights are generally monitored to identify unplanned weight gain/loss by registered staff. Strategies are implemented when residents refuse meals or experience difficulty in swallowing and referrals to speech pathologist and/or dietitian are initiated when needs indicate. Tray service is provided to residents should they prefer to eat in their room or become unwell. Alternative meals, textures, fluids and supplements are provided, as required. Staff demonstrate knowledge of individual care needs in relation to nutrition and hydration. Residents report satisfaction with their meals, snacks and drinks offered and the assistance by staff. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply Residents at risk of impaired or altered skin integrity are identified through assessment tools which identify contributing risk factors. Education on correct manual handling techniques is provided to staff to minimise the risk of skin tears and preventative strategies are incorporated and recorded on care plans. Aids and equipment including pressure relieving mattresses, cushions, feet and limb protectors are utilised to minimise the risk of skin breakdown. Topical skin products and treatments are prescribed and implemented where indicated. Skin tears are recorded through the incident reporting processes and reviewed by


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registered staff. Wound management is undertaken by registered staff in consultation with the medical officer and a range of products are utilised. Residents are satisfied with the management of their skin integrity. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply The individual continence care needs and established toileting routines of residents are identified using assessment tools and bowel monitoring charts. Individual programs are implemented to optimise residents’ continence and dignity and communicated to care staff through handover and care plans. Bowel management strategies including consideration for appropriate diet and fluids are implemented and monitored; mobility is encouraged via exercise. Care staff demonstrate knowledge of individual resident programs and the use of prescribed aids and allocated products. Residents are satisfied with the care and assistance provided to manage their continence. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply The individual needs of residents with challenging behaviours are identified on entry and assessment and monitoring processes are initiated to identify triggers and develop care plans. Staff demonstrate responsiveness to the individual needs of residents through therapies such as diversional strategies, conversation and individual activities of interest. Consideration is given to non verbal indicators of pain and contributing factors of demonstrated behaviours. Meaningful daily activity and an exercise program is incorporated into the behaviour management strategies and the effectiveness of interventions is monitored and evaluated. The home has a secure unit for those residents at risk of wandering or who need specialised dementia care. Referrals to doctors, behavioural specialists including psycho geriatric/mental health and dementia behavioural teams are conducted to enhance the management of challenging behaviours. Education is provided to staff to enhance their understanding of dementia and related conditions. Residents/representatives are satisfied that the home manages the challenging behaviours of residents effectively. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply Residents’ desired level of independence, functional ability and manual handling needs are identified on entry and strategies are implemented. The use of manual handling and transfer aids to support residents’ mobility and safety are utilised. Staff are provided with education on manual handling techniques. The Physiotherapist provides assessment and planning of mobility and exercise programs designed to improve mobility; appropriate aids are supplied to assist residents to be as independent as possible. Falls are reported and analysed to


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identify trends and/or required interventions. Residents report satisfaction with the assistance and equipment provided to maintain and/or improve their mobility and dexterity and rehabilitation. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply The oral and dental history and current care needs of residents are identified and care plans reflect resident preferences for their mouth care and hygiene. Care staff monitor the condition of residents’ oral hygiene with consideration given to the need for additional fluid intake; staff attend to mouth toileting as required. Changes to the resident’s oral health status results in re-assessment of appropriate meal consistency. Staff demonstrate knowledge of the individual oral and dental care needs of residents and education and training is provided to staff. Evaluation of the effectiveness of strategies for managing residents’ oral and dental health occurs consistent with their general health status and preferences. Referrals to dentists are facilitated if required and assistance is provided to attend. Residents are satisfied with the assistance provided by staff to manage their oral and dental care. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply The presence of sensory loss is identified on entry and residents’ sensory needs and preferences are considered to optimise hearing, sight, touch and taste. Care interventions are detailed on care plans and referral to specialists is initiated where there is an identified need. Staff assist residents to clean and fit sensory aids and demonstrate knowledge of the individual needs of residents and their preferences for wearing and maintaining aids. Assistance is provided with meals and attendance at activities to optimise residents’ participation and communication at desired levels, for example placement of table settings, seating in activities and provisions of communication tools. Residents are satisfied with the assistance provided by staff to enhance their sensory abilities. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Residents report they are satisfied with the support provided to them to ensure they obtain sufficient sleep and rest. Resident’s individual sleep and rest patterns are identified on entry and sleep assessments are conducted to ensure optimal rest patterns are supported. Care plans detail the resident’s preferences such as rising and settling times. Comfort measures used to assist residents with sleep disturbances such as offering food and fluids, repositioning, continence care, pain relief and emotional support are employed to assist the resident to return to sleep. Exercise programs and activities are used to assist with achieving nocturnal sleep patterns and flexibility with activities of daily living occurs to support individual sleep and rest patterns.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has a continuous quality improvement program which is managed and monitored by the Quality Coordinator, in conjunction with the Facility Manager. Opportunities for improvement are identified through scheduled audits, completion of improvement logs, resident and staff meetings, the comments and complaints process, clinical indicators, third party reviews, and one-to-one discussions with residents/representatives and staff. Issues identified are addressed at monthly quality meetings with follow-up actions attended to as required. Improvements are logged into a register with actions and results being fed-back to staff and residents at meetings; further review generally takes place if appropriate before closure. Residents/representatives and staff are satisfied that improvements continue to be implemented at the home and that their suggestions are considered and result in action. Management report examples of recent improvements relevant to Standard Three which include: • The home identified that additional stimuli for residents in the secure unit was required.

As a result they recently introduced improved visual stimuli in the form of fiddle boxes, scrapbooks, dolls and an interactive chook house. Family members and visitors to the home have provided positive feedback and staff report decreased behaviours following the implementation of these activities.

• Following a request by residents the home has reintroduced bus outings in March 2011

for the enjoyment of their residents. Diversional therapy staff arrange the hire of a bus and two outings have recently been undertaken; residents report their satisfaction at the reintroduction of this leisure activity.

• An ‘information for residents, family and friends’ folder has recently been introduced by

the home and is located with the visitor sign-in/sign-out books in communal areas of the home. This folder contains the current activity calendar, newsletter, appointments for allied health and hairdresser visits, meal times and resident meeting minutes. Management reports that visitors had commented positively on this initiative.

• To ensure residents individual interests, customs and beliefs are recognised and

accommodated, the home has introduced monthly cultural presentations as part of the activities provided. Staff are invited to do a half hour presentation of their country of birth and three sessions have been conducted to date; management reports that these sessions have been well received.


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3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s recommendation Does comply The organisation has established systems to identify and ensure compliance with a wide range of legislation, professional standards and industry guidelines; and has access to government bodies and industry sources that provide regular updates of legislative and regulatory requirements. This system is monitored and managed out of head office, in conjunction with the Facility Manager, and updates are discussed with key personnel and actioned as is required. Changes are communicated to staff via policy and procedure reviews, education sessions (for example orientation and compulsory annual training), staff meetings, memos and/or are attached to payslips. Changes are also communicated to residents and families where appropriate. The home has a system in place to manage the mandatory reporting of assaults to the police and Department of Health and Ageing in accordance with regulatory requirements. Compliance with legislation is monitored through the audit process, performance appraisals and observation of staff work practices. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff that includes orientation and annual mandatory training, identified training needs and other development opportunities. Education sessions are communicated to staff via monthly education calendars placed on the staff notice board, as well as verbal and written notification. The Facility Manager oversees the education program, ensures education records are maintained and monitors attendance through a paper database. Processes are in place to support staff to attend external courses and training. The ongoing education and development needs of staff are identified through feedback from residents and staff, review of audits and clinical indicators, and staff performance appraisal process; results have been combined with organisational education requirements to develop the training calendar. Management monitors the skills and knowledge of staff through audits and observation of staff practice. The organisation coordinates in-service education sessions relevant to Standard Three based on the current care needs of residents and to ensure resident lifestyle is enhanced. 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s recommendation Does comply Residents report satisfaction with the emotional support provided by management and staff upon admission to the home and when changes occur. Individual needs including language, cultural and spiritual needs are assessed and care plans provide guidance to staff. Entry processes include gathering information from the resident and/or their representative regarding lifestyle background, personality traits, likes, dislikes and current abilities and


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interests; this information is reflected in care plans. Emotional support is provided by management, clinical, therapy and care staff to assist residents in the development of friendships and encourage/support them to participate in activities they enjoy. Staff provide support in a manner that aims to minimise the impact of transition to communal living and change in life situation; family visits are encouraged. Lifestyle staff provide initial and ongoing support to residents. Feedback from residents/representatives is gained through surveys and case conferencing, comments/complaints processes, meetings and individual resident/staff communication. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s recommendation Does comply Residents are assisted to maximise their independence relating to health and personal care interventions and are encouraged and supported to be as independent as possible via participation in outings with family members and continue with activities within the local community where their capabilities allow. Residents' independence is fostered by providing individualised mobility aids, eating utensils, en-suited rooms and the opportunity to individually decorate their rooms with furniture and items of personal significance. Social functions and interaction with friends and family is promoted within the home environment. Residents indicate satisfaction with the level of assistance and support regarding their independence. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s recommendation Does comply Residents’ right to privacy, confidentiality, dignity and respect is recognised and maintained by management and staff. Information regarding the right to privacy and dignity is detailed within residents’ handbook and is explained on entry to the home. Resident’s personal needs and preferences regarding privacy and dignity are identified and specific needs incorporated into care plans. Residents’ administrative and care files are stored and accessed in a manner that provides security and confidentiality of information; discussions regarding individual needs are conducted in private areas. Staff receive education regarding residents’ right to privacy and respect; staff practices relating to privacy include knocking on doors, addressing residents by their preferred name, closing doors when providing personal care and being aware of the particular needs of residents with cognitive impairment. Residents expressed satisfaction that their privacy and dignity is maintained and respected.


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3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s recommendation Does comply Residents’ past and current interests are identified through interview and completion of lifestyle assessment which lead to the development of care plans; these reflect resident’s individual physical and cognitive abilities. The lifestyle program includes general and specific interest group activities; monthly activity calendars are posted in communal areas and communicated to residents by activities staff each day. Programs are evaluated by review of participation rates, resident meetings and surveys. The activity program is currently diversifying in the number and choice of activities offered. Residents expressed satisfaction with the leisure and activity programs offered by the home and the encouragement by staff for them to participate. 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 recommendation Does comply Residents’ spiritual beliefs, customs, cultural and ethnic backgrounds and needs are assessed through consultation with the resident/representative. Regular church services are conducted and residents supported to attend and lifestyle staff assist residents to celebrate days of cultural and religious significance. Community resources are available and can be accessed for information and advice if required. Residents are satisfied with the support and assistance they receive to maintain their cultural and spiritual needs and preferences. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s recommendation Does comply Residents are enabled to exercise choice and make decisions regarding the care and services received through discussions with staff; meetings, surveys and the home’s comments/complaints mechanisms. Residents’ preferences for cares and activities of daily living are assessed on entry to the home and ongoing. Assessment processes identify those residents unable to make decisions and alternative decision makers such as adult guardian, enduring power of attorney, or significant other are appointed to do so on their behalf. Information is communicated to residents with the capacity and ability to make informed choices in both written and verbal forms. Staff interactions with residents support the right of residents to make choices and provide them with the opportunity to make their own decisions, within their capacity. Residents are satisfied they are provided with information regarding their rights and responsibilities and have access to information regarding advocacy services if required.


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3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s recommendation Does comply Information is provided to residents/representatives about tenure and their rights and responsibilities. An admission package (including handbook and residential care agreement) is provided and management meet with residents and their representations during admission to explain the process and provide support. Assessment processes identify those residents unable to make decisions and alternative decision makers such as adult guardian, enduring power of attorney, or significant other are appointed to do so on their behalf. The Charter of Residents’ Rights and Responsibilities is provided and copies are displayed throughout the home. Residents are encouraged to seek legal and financial advice prior to entering the home and copies of relevant documentation are available to guide staff when contact is required. Consultation with residents/representatives occurs when care changes occur. Residents/representatives are aware of their rights and responsibilities, who to contact if they have queries or concerns and report they are secure in their tenure at the home.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has a continuous quality improvement program which is managed and monitored by the Quality Coordinator, in conjunction with the Facility Manager. Opportunities for improvement are identified through scheduled audits, completion of improvement logs, resident and staff meetings, the comments and complaints process, clinical indicators, third party reviews, and one-to-one discussions with residents/representatives and staff. Issues identified are addressed at monthly quality meetings with follow-up actions attended to as required. Improvements are logged into a register with actions and results being fed-back to staff and residents at meetings; further review generally takes place if appropriate before closure. Residents/representatives and staff are satisfied that improvements continue to be implemented at the home and that their suggestions are considered and result in action. Management report examples of recent improvements relevant to Standard Four which include: • Following an infection control audit undertaken by the home, and feedback from staff in

relation to the accessibility of hand washing facilities, management installed wall mounted hand sanitisers throughout the facility in strategic locations. Management reports that this initiative has increased staff access to appropriate hand cleansing treatments to support the home’s infection control program.

• As a result of a suggestion made by an external dementia behaviour management

service, the home has recently relocated the centrally situated nurses’ station within the secure unit, to an area at the end of the unit. As a result, residents are now able to freely walk within the unit and are not hampered by any closed-off areas (that previously would require extra navigation). The relocated nurses station is fronted by glass windows which allows staff to monitor residents as required; a carer is required to be on the floor at all times. Staff report that this change has provided residents with a main thorough-fare within the unit to enable an additional area to walk through, and the larger nurses’ station has provided staff with additional room for resources.

• During a review of fire evacuation systems it was identified by a staff member that

resident evacuation lists could be enhanced by including more comprehensive information. The list has now been reconfigured to include the mobility requirements of residents, their special needs and next-of-kin details. Management report that these additions ensure resident safety will be enhanced in the event of a fire or the requirement to evacuate the home.


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4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s recommendation Does comply The organisation has established systems to identify and ensure compliance with a wide range of legislation, professional standards and industry guidelines; and has access to government bodies and industry sources that provide regular updates of legislative and regulatory requirements. This system is monitored and managed out of head office, in conjunction with the Facility Manager, and updates are discussed with key personnel and actioned as is required. Changes are communicated to staff via policy and procedure reviews, education sessions (for example orientation and compulsory annual training), staff meetings, memos and/or are attached to payslips. Changes are also communicated to residents and families where appropriate. The home has systems in place to ensure fire certification and other environmental requirements (for example workplace health and safety) are met; the home’s food safety program has been approved and is generally implemented. Compliance with legislation is monitored through the audit process, performance appraisals and observation of staff work practices. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff that includes orientation and annual mandatory training, identified training needs and other development opportunities. Education sessions are communicated to staff via monthly education calendars placed on the staff notice board, as well as verbal and written notification. The Facility Manager oversees the education program, ensures education records are maintained and monitors attendance through a paper database. Processes are in place to support staff to attend external courses and training. The ongoing education and development needs of staff are identified through feedback from residents and staff, review of audits and clinical indicators, and staff performance appraisal process; results have been combined with organisational education requirements to develop the training calendar. Management monitors the skills and knowledge of staff through audits and observation of staff practice. The home coordinates in-service education sessions relevant to Standard Four based on the current care needs of residents and legislated training requirements in relation to the physical environment and safe systems. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s recommendation Does comply The living environment and resident safety and comfort needs are generally assessed and reviewed through regular staff meetings, risk assessments, audits, incident/hazard reports,


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maintenance requests and staff observation. The home consists of single en-suite rooms and the environment provides safe access to clean and well maintained internal and external communal areas, with appropriate furniture sufficient for residents needs. Handrails are in place throughout the home and walkways facilitate resident mobility outside. The maintenance officer, in conjunction with the Facility Manager, implements and oversees a planned preventative maintenance program on buildings, infrastructure and equipment. Restraint is utilised for some residents and authorisation and monitoring is undertaken. Staff ensure all external entrances to the home are secure in the evening, and staff have access to police and emergency telephone numbers in the event of a security breach. Residents are satisfied with the safety and comfort of their living environment. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply Management demonstrates that it has processes, procedures and practices in place to provide a safe working environment for staff. The homes’ safety system is supported by a workplace health and safety officer who visits the home on a regular basis, and a workplace health and safety representative is on site. Regular environmental audits are conducted and management maintains a register of hazards identified at the home. Quality/workplace health and safety meetings are conducted on a monthly basis and meeting minutes are provided to staff. Orientation and annual mandatory training is provided in relation to manual handling, safe chemical usage, infection control and fire safety; staff have access to manual handling equipment, personal protective equipments and spills kits throughout the home. Chemicals are stored securely and material data safety sheets are generally accessible to staff. Staff demonstrate knowledge of incident and hazard reporting processes, and an understanding of safe work practices. 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 recommendation Does comply The home has systems in place for the detection and action in the event of a fire, security breach or other emergency incidents. The home’s fire safety system includes fire detection alarm and control panel, a sprinkler system, and fire fighting equipment which is regularly inspected and maintained by the external contractors in conjunction with the Fire Safety Advisor. Fire evacuation plans are displayed throughout the home; fire exits and pathways to exit are free from obstacles and exit doors are clearly marked. Staff attend mandatory fire safety training during orientation and annually thereafter. A call bell system is in place for residents and coded entry/exit is required for the secure unit; an evening lockdown system is in place. Emergency and disaster procedure manuals are available for staff and staff have knowledge of their responsibility in the event of a fire or emergency situation.


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4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply Organisational policies/procedures are in place to guide staff practice regarding infection control, including government guidelines and management procedures. Resident infections are recorded and this information is collated, monitored and analysed for trends. Staff are provided with infection control education during orientation and ongoing thereafter. Infection control information and statistical data is communicated to staff. Colour coded equipment is used in the clinical, cleaning, laundry and catering service areas to minimize risks of cross infection and temperature monitoring occurs for foods and fluids. Work instructions guide cleaning practices and a pest control program is maintained. Hand sanitizing resources are located throughout the home; infection control strategies such as personal protective equipment, food safety guidelines, spill kits and sharps containers are available to staff. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s recommendation Does comply The home has processes in place to provide hospitality services that meet the needs and preferences of the residents. The home’s meals are prepared in the on-site kitchen where a rotating four week menu is in place, which offers a choice of meals as required. Residents are regularly consulted about their dietary preferences with any changes being communicated to catering staff in writing. Feedback is gained through monthly resident meetings and informal one-to-one discussion with staff. Stored stock is rotated, food is generally served within safe temperature ranges, and the speech pathologist and/or dietitian is consulted in relation to residents’ modified texture diets and thickened fluids needs. Laundry services are provided on-site within infection control guidelines and returned to residents in a timely manner. The cleaning staff utilise a colour coded cleaning system for cleaning in the kitchen, dining room and communal areas, resident rooms and bathrooms. Residents/representatives are satisfied with the hospitality services provided by the home.

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