Published_decision_(SA_and_RA)



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Orana Gardens Lodge

RACS ID: 0479

Approved provider: Dubbo RSL Aged Care Association Ltd

Home address: Cnr Coronation Dr & Windsor Pde DUBBO NSW 2830

|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 27 September 2020. |

|We made our decision on 25 August 2017. |

|The audit was conducted on 04 July 2017 to 06 July 2017. The assessment team’s report is attached. |

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

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal care

Principle:

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

2.1 Continuous improvement Met

2.2 Regulatory compliance Met

2.3 Education and staff development Met

2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met

Standard 3: Care recipient lifestyle

Principle:

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

3.1 Continuous improvement Met

3.2 Regulatory compliance Met

3.3 Education and staff development Met

3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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

4.1 Continuous improvement Met

4.2 Regulatory compliance Met

4.3 Education and staff development Met

4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

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Audit Report

Name of home: Orana Gardens Lodge

RACS ID: 0479

Approved provider: Dubbo RSL Aged Care Association Ltd

Introduction

This is the report of a Re-accreditation Audit from 04 July 2017 to 06 July 2017 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

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 this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 04 July 2017 to 06 July 2017.

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.

Details of home

Total number of allocated places: 128

Number of care recipients during audit: 116

Number of care recipients receiving high care during audit: 112

Special needs catered for: Special care units/ Dementia specific 45 care recipients

Audit trail

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

Interviews

|Position title |Number |

|CEO |1 |

|Facility manager |1 |

|Clinical registered nurses |2 |

|Support services manager |1 |

|Staff training coordinator |1 |

|Customer liaison officer |1 |

|Payroll roster clerk |1 |

|Endorsed enrolled nurse |1 |

|Team leaders/care staff |15 |

|Catering staff |5 |

|Care recipients |25 |

|Representatives |2 |

|Endorses enrolled nurse |1 |

|Laundry staff |1 |

|Cleaning staff |4 |

|Maintenance staff |1 |

Sampled documents

|Document type |Number |

|Care recipients’ files |12 |

|Wound charts |17 |

|Medication charts |24 |

|Personnel files |10 |

|Care recipient agreements |1 |

Other documents reviewed

The team also reviewed:

0. Activity and lifestyle documentation: monthly and daily activity programs, personal profiles, activity attendance records, activity evaluations

0. Care recipient room listing

0. Care recipients' individual incident reports including behaviours, falls, infections, medication errors, skin tears; clinical indicator registers - monthly trends and analysis

0. Cleaning audit reports, education and training records, policies and procedures, safe work statements, detailed cleaning checklist, duty statements for cleaners and pest control

0. Clinical care: bowel charts, blood glucose level monitoring, continence management, meals and drinks, weight monitoring, wound management/dressings, pain charts, incident reports, medical officers’ directives of care, case conferences, electronic care documentation

0. Comments and complaints register and feedback logs and forms

0. Continuous quality improvement (CI) including CI register, CI logs and activity plans, organisational chart; mission, vision and values statement; audit schedules and results, various meeting minutes, satisfaction survey results

0. Contractor register, external service agreements, insurance certificates of currency, relevant police certificate expiry dates

0. Education records including education registers, calendars, mandatory training report, induction program and workbooks, attendance records, competency assessment records, individual training files and certificates

0. Fire safety equipment records including regular tests on fire panel, early warning system, extinguishers, blankets, hose reels, smoke detectors, sprinkler system and emergency and exit lights; disaster management and emergency procedures manual, electrical testing and tagging

0. Food safety program and logs including servery manuals, food safety plan, equipment and food temperatures records, sanitizing, receipt of goods, cleaning, six weekly rotating menu, dietary preference forms and focus group audits

0. Human resources including staff orientation information, staff handbook, job descriptions, duty statements, immigration records, staff rosters, performance reviews, criminal history checks, statutory declarations and professional registrations

0. Information systems including the organisation's internet technology network, electronic mail, Government notices; care recipient and staff meeting schedules, agendas and minutes; memoranda, organisation alerts, staff communication diaries and handovers, policies and procedures

0. Inventory and equipment: equipment register and lists, maintenance requests, internal and external preventative maintenance schedule, equipment service records; thermostatic mixing valve testing records, electrical test tagging

0. Laundry service records including care recipient lists and cleaning schedules

0. Maintenance records including external services contract schedule; planned preventative and corrective maintenance records including annual plan, thermostatic mixing valve test report, legionella test reports

0. Medication management: drugs of addiction register, medication care plans, medication refrigerator temperature records, incident reports

0. Nutrition and hydration: specialised dietary requirements, seasonal menus, dietician review

0. Physiotherapy documentation: assessments and care plans, exercise schedule, walking program

0. Self-assessment report for re-accreditation and associated documentation

0. Workplace health and safety records including environmental audit schedule, workplace inspections and audits, chemical register, hazardous substances register, safety data sheets, staff incident reports, safe work practice statements

Observations

The team observed the following:

0. Activities and entertainment in progress, activities programs on display

0. Australian Aged Care Quality Agency - re-accreditation audit notices displayed throughout the home

0. Catering and laundry processes, cleaning in progress, trolley with equipment, current third-party food report displayed A rating

0. Charter of care recipients’ rights and responsibilities and the home's mission, vision and values, activity calendars, advocacy information displayed

0. Comments and complaints including posters, feedback forms, advocacy brochures readily available, locked suggestion boxes

0. Dining environments during midday meal services, morning and afternoon tea, staff serving/supervising

0. Electronic and hardcopy documentation systems

0. Equipment and supply storage areas - general

0. Fire safety and fighting equipment including fire panel, fire extinguishers, blankets, hose reels, evacuation plans, sprinkler system, assembly point, evacuation boxes, emergency flip charts displayed appropriately

0. Infection control resources: hand washing facilities, hand sanitisers, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies

0. Information noticeboards including daily menu display

0. Interactions between staff and care recipients/relatives/visitors during: meal service and lifestyle activities

0. Living environment - internal and external including chapel, hairdressing salon

0. Medication administration and storage

0. Mobility and manual handling equipment in use and in storage

0. Nurse call system in operation including care recipient access and call bell response times

0. Pressure relieving mattresses

0. Secure document storage including care recipient, staff and archived files

0. Security systems including nurse call system in operation with care recipient access, sign in/out registers, keypad access

0. Short group observation in Wattle special care unit memory unit dining room

0. Staff work practices and work areas including administration, clinical, life style, catering and serveries, cleaning, laundry and maintenance

0. Workplace safety equipment including safety signage, personal protective equipment, first aid

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 services, 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

Orana Gardens Lodge (the home) has an established system of continuous improvement and quality processes to ensure its performance is monitored and measured against the four Accreditation Standards. The system is underpinned by a wide range of processes including mechanisms used to assess, monitor and evaluate the quality of care and services being provided to care recipients. Mechanisms used to identify improvement opportunities include logs, internal audits, satisfaction surveys, comments and complaints, analysis of incidents and accidents, and staff education and performance reports. Planned improvement initiatives, actions, results and feedback are discussed and evaluated at meetings including management; support staff; work, health and safety and general staff meetings, and care recipient. Other feedback mechanisms used include staff memoranda and care recipient newsletters. Staff and care recipients and representatives interviewed said, and document review shows management pursues, encourages and is responsive to their feedback.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard One and recent examples include:

0. The performance management of a staff member identified the need to review and simplify the human resource policies. An appropriate workplace behaviour policy has been developed to improve staff awareness of staff bullying and harassment.

0. An external contractor has been appointed to manage the archiving, retrieval and destruction of records according to the homes policy. This new system is working efficiently, ensuring all documentation is managed with the utmost confidentiality and safety at all times.

0. A specialised nursing care form has been introduced to improve the scheduling of all care recipients, blood sugar levels, insulin injections, percutaneous endoscopic gastrostomy and B12 injections. The list is updated weekly and ensures all care recipients, specialised care needs are reviewed and attended according to the medical officer’s orders.

1.2 Regulatory compliance

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

Team’s findings

The home meets this expected outcome

The home has a system for identifying relevant legislation, regulatory requirements, professional standards and guidelines and has mechanisms for monitoring and maintaining compliance. The organisation receives notification of directives and changes in policy from the Australian Government, local health authorities, their membership with a peak body advisory service, and a legislation alert service it subscribes to. Action is taken as required to ensure the home maintains regulatory compliance. Relevant information is communicated to staff and/or care recipients and representatives through a variety of mechanisms including policies and procedures, various meetings, notice boards, information handbooks, care recipient agreements and staff education.

Examples of responsiveness to regulatory compliance relating to Accreditation Standard One Management systems, staffing and organisational development include:

0. Examples of regulatory compliance relevant to Standard One: Management are aware of the regulatory responsibilities in relation to police certificates and the requirement to provide advice to care recipients and their representatives about re-accreditation site audits; there are processes to ensure these responsibilities are met.

1.3 Education and staff development

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

Team’s findings

The home meets this expected outcome

The home ensures management and staff have appropriate knowledge and skills to perform their roles effectively through providing an orientation and annual education program. A ‘buddy’ program is used to support commencing staff and all staff are required to attend compulsory annual education and training sessions. Topics covered include elder abuse, fire safety, infection control and manual handling. Attendance at all sessions is recorded and management monitors and follows up on non-attendance. The effectiveness of the training provided is measured through audits, care recipient and representative feedback, observations, staff evaluations and questionnaires, a range of competency and skills tests and staff performance reviews. Staff said they are encouraged and reminded to attend education and training courses.

Examples of education sessions and activities provide in relation to Standard One Management systems, staffing and organisational development include orientation and annual program topics, bullying and harassment, electronic documentation systems, first aid incident reporting and professional conduct.

1.4 Comments and complaints

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

Team’s findings

The home meets this expected outcome

The home has systems to ensure care recipients and their representatives have access to internal and external complaints processes. This includes displaying information about the internal and external complaints system and advocacy services at the main entrance to the home and on the noticeboards. Information on raising complaints is contained within the care and accommodation agreement and resident and relative handbook. These are provided to care recipients and their representatives as part of the entry process to the home. Feedback forms and suggestion boxes are located in various areas around the home to provide access to the internal complaints process. The home also conducts a regular care recipients’ meeting. Most care recipients and representatives advised they feel comfortable approaching management with concerns or complaints and are content with management’s response. A small number of care recipients and representatives express staff do not always follow up issues when they are raised with them.

1.5 Planning and leadership

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

Team’s findings

The home meets this expected outcome

The organisation’s mission, vision and value statements are on display throughout the home. The information is provided to care recipients/representatives on a care recipient’s entry to the home and to a commencing staff member. The information is provided through mechanisms including the care recipient information package and the staff handbook.

1.6 Human resource management

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

Team’s findings

The home meets this expected outcome

The home has appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the needs of care recipients. The home’s human resource policies and procedures underpin staff recruitment and selection, induction and performance management and provide guidelines for management and all staff. Staff records are maintained including position descriptions, criminal history checks, and relevant registration details. Staff said and document review shows they have access to an employee assistance program (EAP), and participate in education and training on topics relevant to the Accreditation Standards. Staffing levels and skills mix are monitored and adjusted on an ongoing basis in accordance with the care recipients’ needs. Monitoring mechanisms include clinical incident and accident data, care recipient and representative and/or staff feedback and staff performance reviews. Relief arrangements, to ensure roster coverage, are met by existing permanent and casual staff. There are job descriptions for all positions and staff interviewed said they have sufficient time to complete their duties and meet the needs of care recipients during their allocated shifts. While most of care recipients and representatives reported staff are responsive to request for assistance, a few care recipients reported delays in staff answering the buzzers and/or stated they are being rushed during care needs. Occasionally they feel the home is not well run as staff appear to be so busy.

1.7 Inventory and equipment

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

Team’s findings

The home meets this expected outcome

The home has a system and processes which ensure appropriate stocks of goods and equipment are fit for purpose and available at all times including mobility and manual handling aids, medical and personal care supplies, food, linen and furniture. The processes for ordering, storing and monitoring levels of supplies are delegated to designated personnel and overseen by the general manager. Maintenance records show equipment is serviced in line with a regular schedule and corrective maintenance is completed in a timely manner. The availability of appropriate goods and equipment is monitored through a number of mechanisms including audits, surveys, meetings and the home’s feedback mechanisms. We observed adequate supplies of goods and equipment available for the provision of health and personal care, care recipient lifestyle and the hospitality services. Staff said they have access to sufficient stocks of appropriate goods and equipment for quality service delivery.

1.8 Information systems

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

Team’s findings

The home meets this expected outcome

There are systems in place that effectively manage the creation, usage, storage and destruction of hard copy and electronic records in accordance with privacy legislation. The organisation effectively disseminates information to management, staff and care recipients and representatives through mechanisms including its private internet technology network, electronic mail and electronic documentation systems including clinical care records. Other mechanisms include memorandum, staff handovers, noticeboards, meetings and minutes, care recipient and staff handbooks, education sessions and policy and procedure manuals. Staff, care recipients and representatives interviewed said they are kept informed and are consulted about matters relevant to them. Care recipients said they have access to information to assist them in making decisions about their needs and preferences.

1.9 External services

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

Team’s findings

The home meets this expected outcome

The home has a system that ensures all externally sourced services are provided in a way that meets its needs and service quality goals. A range of external service providers operate within contracts and/or service agreements to provide maintenance and other services including air conditioning, health and personal care, fire systems, cleaning, the nurse call system and plumbing. The contracts/agreements encompass the home’s requirements and expectations for quality service provision and other relevant criteria including insurances, licences and police certificates. Management and staff monitor the performance of the service providers and take appropriate action, including their replacement if necessary, in order to ensure services are provided at the desired level. Management, staff, care recipients and representatives interviewed said they are satisfied with the standard of externally sourced services provided by the home’s preferred service providers.

Standard 2 – Health and personal care

Principle:

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

2.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Two and recent examples are listed below.

0. A trial was attended in liaison with a nutritional consultant for care recipients who were under weight or not gaining weight. A nutritional supplement was given to care recipients and their weight was monitored during the trial. The results overall were positive care recipients who participated in the trial maintained their weight or gained weight. The nutritional supplement will be continued to be served to any care recipient who requires it to ensure all care recipients nutritional needs are met at all times.

0. A consultant advised the sleep assessment tool being used by the home was not capturing the care recipients sleep patterns. A new three day sleep assessment has been developed, it is easier to use and has a better outcome for care recipients. All care recipients sleep patterns were re-assessed in April-May 2017.

0. A need was identified care staff required further education on behaviour management. The home consulted the Dementia Behaviour Management Service (DBMAS) to conduct an education session for staff. Staff are now able to manage individual behaviours of the care recipients more effectively. The home liaises with the DBMAS team when necessary to assess care recipient behaviour management plans.

2.2 Regulatory compliance

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

Team’s findings

The home meets this expected outcome

Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Two:

0. A record is kept of the current registration of registered and enrolled nurses and other health care professionals.

0. Clinical registered nurses is responsible for the assessment, planning and evaluation of care needs identified and delivered to care recipients with specialised nursing care needs.

0. Medications are stored in accordance with the relevant legislation including; The Poisons and Therapeutic Drugs Act and Regulations.

0. The home has procedures for the notification of unexplained absences of care recipients and maintains a register for recording these incidents.

2.3 Education and staff development

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

Team’s findings

The home meets this expected outcome

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.

Education and training provided in relation to Accreditation Standard Two includes responding to challenging behaviours, bullying and harassment catheter care management, dementia care, medication administration, palliative care and wound management.

2.4 Clinical care

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

Team’s findings

The home meets this expected outcome

Orana Gardens Lodge provides care recipients with appropriate clinical care through initial and ongoing assessments, care planning and evaluation processes. The home has systems that enable care recipients and representatives to exercise control over the care they receive and to provide input into care recipients' care planning. The clinical nurse and registered nurses review and evaluate care recipients’ individual plans of care every three months or when required. Relevant staff are informed of any alterations/exceptions to the usual care required by the care recipient through handovers, progress notes, meetings, communication diaries and verbally. Care recipients’ weights, vital signs and urinalysis results are recorded monthly or as ordered by the medical officer. An accident and incident reporting system is in place for the reporting of incidents such as falls, skin tears and behaviours of concern. Staff demonstrate knowledge of care recipients’ care needs ensuring that care recipients’ clinical care is being met. Care recipients and representatives interviewed are satisfied with the timely and appropriate assistance given to care recipients by care staff however some care recipients stated they were not encouraged to independently attend any of their daily care needs.

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 meets this expected outcome

Care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officer input when required. This includes registered nurse input into assessment, management and care planning for care recipients. The home currently provides specialised nursing care for care recipients requiring dementia care, diabetic management, catheter care, oxygen therapy, stoma care, wound care and pain management. Staff are provided with education in specialised nursing procedures. Staff confirmed they have access to adequate supplies of equipment for the provision of care recipients’ specialised nursing care needs. Care recipients and representatives are satisfied with the level of specialised nursing care offered to care recipients by nursing, medical and/or other health professionals and related service teams.

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 meets this expected outcome

Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates timely referrals for care recipients are arranged with appropriate health specialists as required. The registered nurse has regular access to a physiotherapist, podiatrist, speech pathologist, optometrist and community clinical nurse consultants. Regular review and evaluation of care recipients’ health and well-being and referrals are carried out by the registered nurse in collaboration with care staff and medical officers. Effective monitoring is achieved through the handover of key care recipient information to relevant staff. When required, care recipients’ medical officers are alerted and consulted. Care recipients and representatives stated referrals are made to the appropriate health specialists in accordance with care recipients’ needs and preferences.

2.7 Medication management

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

Team’s findings

The home meets this expected outcome

Orana Gardens Lodge has processes to ensure care recipients’ medication is managed safely and correctly. These include policies and procedures, regular pharmacy deliveries, the secure storage of medications and internal/external audits. Staff administer medication using a prepacked system and the clinical nurse and registered nurse oversees the home’s medication management system and processes. Review of care recipients’ medication profiles show current medical officers’ orders are recorded and information includes medication identification sheets, care recipients’ photographic identification and medication allergy status. All staff who administer medications are assessed according to the home’s medication policy through annual skills based assessments or as required. Care recipients and representatives said they are satisfied with the home’s management of care recipients’ medication.

2.8 Pain management

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

Team’s findings

The home meets this expected outcome

All care recipients are assessed to identify their pain history on entry to the home with medical officer input in determining the effectiveness of interventions. A multidisciplinary approach involving the care recipient’s medical officer, nursing staff, physiotherapist and recreational activity officers supports the care recipient’s pain management program. Staff are knowledgeable about the many ways of identifying care recipients who are experiencing pain. Pain management strategies include pharmacological reviews, various non-pharmacological interventions and treatment in liaison with care recipients’ medical officers. Care recipients are repositioned, assisted with movement and exercise, given gentle heat therapy, massage and are involved in distraction therapy. Care recipients said the care provided at the home relieves their pain or it is managed so they are comfortable.

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 meets this expected outcome

The home has a suitable environment and culture to ensure the comfort and dignity of terminally ill care recipients is maintained. Where possible, care recipients' end of life wishes are identified and documented on entry to the home or at an appropriate time thereafter, through the assessment process. The home has specialised clinical and comfort devices to ensure and maintain care recipient palliation needs and preferences. The local clergy visit and are available to provide emotional and spiritual support. The home has a variety of resources and equipment that families, friends and staff can use for the benefit of the care recipient. Staff receive ongoing education and describe practices appropriate to the effective provision of palliative care. Care recipients and representatives said the home’s practices maintain the comfort of terminally-ill care recipients.

2.10 Nutrition and hydration

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

Team’s findings

The home meets this expected outcome

Refer to expected outcome 4.8 Catering, cleaning and laundry service for care recipient feedback on the quality of meals.

The home has processes to provide care recipients with adequate nourishment and hydration. Care recipients are assessed for swallowing deficits and other medical disorders, allergies, intolerances, food likes and dislikes, as well as cultural or religious aspects relating to diet. Provision is made for care recipients who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information is recorded on a care recipient’s nutrition and hydration form and sent to the kitchen. Care recipients are provided with assistance at meal times and assistive cutlery and crockery are available. The home monitors nutrition and hydration status through staff observations and recording of care recipients’ weights with variations assessed, actioned and monitored. Care recipients are referred to a dietician and/or speech pathologist when problems arise with nutrition. Care recipients and representatives are satisfied they are able to have input into menus and care recipients’ meals.

2.11 Skin care

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

Team’s findings

The home meets this expected outcome

The home has a system to ensure care recipients’ skin integrity is consistent with their general health. Initial assessment of the care recipient’s skin condition is carried out along with other assessments relating to and influencing skin integrity. Care recipients have access to nutritional support, podiatry, hairdressing and nail care according to their individual needs and choices. Maintenance of skin tears, skin breakdown and required treatments are documented, reviewed and noted on wound care charts. The home’s reporting system for accidents and incidents affecting skin integrity is monitored monthly and is included in clinical indicator data collection. The home has a range of equipment in use to maintain care recipients’ skin integrity. Care staff help to maintain care recipients’ skin integrity by providing regular pressure care, by applying skin guards and by using correct manual handling practices. Care recipients and representatives are satisfied with the skin care provided to care recipients and report that staff are careful when assisting them with their personal care activities.

2.12 Continence management

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

Team’s findings

The home meets this expected outcome

The home has a system for identifying, assessing, monitoring and evaluating care recipients’ continence needs to ensure their continence is managed effectively. Processes are in place for the distribution of care recipients’ continence aids and informing staff of care recipients’ continence aid needs. Care recipients are assisted and encouraged to maintain or improve their continence level in a dignified and supportive manner. Care staff have access to adequate supplies of continence aids to meet care recipients’ needs and they provide care recipients with individualised toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies. For example: regular drinks, aperient medications if necessary and a menu that contains high fibre foods such as fresh fruit and vegetables and a variety of fruit juices. Infection data, including urinary tract infections, is regularly collected, collated and analysed. The home’s continence supplier provides ongoing advice and education for staff and care recipients. Feedback from care recipients and representatives shows satisfaction with the continence care provided to care recipients.

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 meets this expected outcome

The needs of care recipients with challenging behaviours are managed through consultation between the care recipient and representative, staff, medical officers and allied health professionals. Care staff and recreational activity officers implement a range of strategies to effectively manage care recipients with challenging behaviours. The care recipients’ challenging behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate. Staff are able to recognise the triggers and early warning signs exhibited by some care recipients and put in place appropriate strategies to manage behaviours. The team observed the environment to be calm and care recipients well groomed. Care recipients and representatives said staff manage care recipients’ challenging behaviours well.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings

The home meets this expected outcome

Care recipients are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by care recipients for transferring and mobility. A care recipient’s mobility status and falls risk are assessed by a registered nurse when the care recipient moves into the home and as their needs change. This is followed by a physiotherapy review if necessary. Individual treatments include massage, heat treatments and exercises. Falls prevention strategies include the completion of risk assessments. Interventions noted include group exercises and the provision of specialised equipment such as mobility aids, ramps and handrails. Staff are able to discuss an individual care recipient’s needs and were seen assisting care recipients to mobilise within the home. Care recipients said they are satisfied with the program and assistance they receive from staff.

2.15 Oral and dental care

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

Team’s findings

The home meets this expected outcome

The home has systems to ensure care recipients’ oral and dental health is maintained. Care recipients’ dental needs are identified through assessment and consultation with the care recipient and representative on a care recipient’s entry to the home and as their needs change. Appropriate dental health is planned and staff are informed of the care recipients’ needs. The care recipient’s medical officer is consulted if there are any needs and a referral may be made to a specialist and/or a dentist for further assessment or treatment. Ongoing care needs are identified through care recipients’ feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Care recipients are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Care recipients and representatives said they are satisfied with the oral and dental care provided to them.

2.16 Sensory loss

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

Team’s findings

The home meets this expected outcome

The home assesses care recipients’ vision and hearing initially on entry and on an ongoing basis. Other sensory assessments for touch, smell and taste are undertaken when assessing care recipients’ nutritional needs, dexterity and interest in activities. These are documented on care recipients’ care plans to prompt and instruct staff on how to care for and engage care recipients appropriately. The home’s activity program features activities to stimulate care recipients’ sensory functions. Staff described types of group and individual activities which encourage active participation from care recipients with sensory deficits. Staff said they employ various strategies to assist care recipients with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance care recipients’ participation, adapting the environment to ensure it is conducive to maximising care recipients’ enjoyment and participation in the chosen activity. Care recipients and representatives said they are satisfied with the home’s approach to managing care recipients’ sensory losses.

2.17 Sleep

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

Team’s findings

The home meets this expected outcome

The home assists care recipients to achieve natural sleep patterns through a sleep assessment, care planning, choice of time for going to bed and rising, and staff support at night. Staff are able to explain the various strategies used to support care recipients’ sleep. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, repositioning and night sedation if ordered by the medical officer. Care recipients can use the nurse call system to alert the night staff if they have difficulties in sleeping. Care recipients stated they sleep well at night. Care recipients and representatives said they are satisfied with the home’s approach to care recipients’ 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.

3.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Two and recent examples of this are listed below.

0. The need for a customer liaison officer (CLO) was identified to support care recipients and representatives during the admission process and on an ongoing basis. The CLO meets the care recipient prior to entry and explains the information in the admission pack to them. On entry the CLO presents the care recipients with a welcome pack. The CLO follows up the care recipient on a one to one basis after entry to ensure they have everything they need and a familiar face to talk to as required.

0. The CLO and recreational officers have now increased the one on one interaction for care recipients who due to their higher acuity are no longer able to attend activities as often as they would normally. This ensures staff emotionally support care recipients one on one regularly.

0. A visiting pet therapy activity has been added to the activities, the care recipients enjoy the interactions with the dog and handler. Feedback from the care recipients has been positive.

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 care recipient lifestyle”.

Team’s findings

The home meets this expected outcome

Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Three:

0. In accordance with the Aged Care Reforms introduced from 1 July 2014, all accommodation pricing and service information is provided on the .au website.

0. Information is provided to care recipients and representatives in the care recipient handbook and the care recipient agreement. Information includes care recipients' rights and responsibilities including security of tenure and the care and services to be provided to them. The Charter of care recipients' rights and responsibilities is included in the care recipient agreement and is displayed in the home.

0. Commencing staff and volunteers are required to sign a code of conduct including confidentiality to ensure care recipients' rights to privacy and confidentiality are respected.

3.3 Education and staff development

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

Team’s findings

The home meets this expected outcome

Education and training provided in relation to Accreditation Standard Three includes compulsory training on compulsory reporting of elder abuse, harassment and bullying customer service, privacy, and volunteer training in leisure and lifestyle concepts.

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

The home meets this expected outcome

There are effective systems to ensure each care recipient receives initial and ongoing emotional support. New care recipients are supported by management and staff through orientation to the home; introductions to other care recipients and to activities of interest in the home as they occur. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Staff encourage care recipients to engage in life at the home while also respecting their independence, choices and privacy. Most care recipients and representatives expresses satisfaction with the support received from staff during their settling in period and thereafter, while a few stated staff do not adequately support care recipients.

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

The home meets this expected outcome

The home has processes which encourage care recipients’ independence and participation in community life. There is a range of individual and general strategies implemented to promote independence including exercise and lifestyle engagement programs. Each care recipient’s level of independence and their need for assistance is assessed on entry to the home and reviewed as needed. The home promotes care recipients’ links with the community through for example bus trips; visits from community groups; and voting in government elections is facilitated on-site. Staff gave examples of how they assist an individual care recipient to remain as independent as possible as part of daily interactions. Care recipients and representatives said they are satisfied with the home’s processes to maximise care recipients’ community involvement and independence.

3.6 Privacy and dignity

This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".

Team’s findings

The home meets this expected outcome

There are systems to ensure care recipients’ privacy and dignity is respected in accordance with individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs with respect to their privacy. Permission is sought to protect privacy for example in the use of photographs. All personal information is collected and stored securely with access only by authorised staff. Staff sign a confidentiality agreement to protect care recipients’ personal information. We observed staff respecting care recipients’ privacy by knocking on their doors prior to entering and interacting with care recipients in a dignified and respectful manner. Care recipients and representatives stated care recipients’ privacy and dignity is well respected.

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

The home meets this expected outcome

Care recipients are encouraged and supported to participate in an extensive range of interests and activities of interest to them. Care recipients’ specific needs, interests and preferences are assessed through completion of a personal profile on entry to the home and monitored on an ongoing basis. A care plan that reflects the care recipients’ social, spiritual and culture preferences and needs is developed to ensure all staff have an understanding of the individual care recipient. The physiotherapy team at the home provide an integrated program and promote exercise as a means to maintain an active life within the individual’s capability. The range of activities is designed to meet care recipients’ sensory, intellectual, physical, social and spiritual needs. Programs based on their individual choices and interests are offered in all areas of the home seven days a week. One-to-one visits are offered for care recipients unable or who prefer not to participate in group activities. Attendance records are maintained to assist recreational activity officers with program planning. Care recipients stated they are satisfied with the activities program in the home. They stated they especially enjoy bus trips; ‘fast’ bingo; art and music therapy; and the daily exercise programs.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings

The home meets this expected outcome

The home has processes to promote care recipients’ interests, customs, beliefs and cultural backgrounds that are identified during the assessment process. Multi-lingual information is available for care recipients from a culturally and linguistically diverse background if required. Care recipients are actively encouraged to maintain cultural and spiritual links in the community. Care recipients are encouraged and supported to maintain affiliation with their own place of worship. Pastoral visitors of various denominations regularly attend and religious services are also held at the home. The home recognises and celebrates days of cultural significance and anniversaries of importance to the care recipients. Care recipients and representatives said they are satisfied with the support provided for care recipients’ cultural and spiritual needs.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".

Team’s findings

The home meets this expected outcome

The home has processes to ensure each care recipient (or their representative) participates in decisions about the services received by the care recipient. These processes uphold the care recipient’s right to exercise choice and control over his or her lifestyle. Care recipients are informed and given opportunities to provide input into the home through systems such as assessment and care planning processes, surveys and at meetings. Where care recipients are unable to make choices for themselves, an authorised decision maker is identified. Care recipients gave examples of how they are able to exercise choice and decision making. These included their personal care regimes; waking and sleeping times; choice of general practitioner; choice of meal; and attendance at activities. Care recipients and representatives said staff support care recipients in making their own lifestyle choices and decisions.

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 meets this expected outcome

The home has processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. All care recipients are offered a care recipient agreement and information handbook prior to, or on their entry to the home. The facility manager and/or customer liaison officer discuss the information in the documents with the care recipients/representatives including security of tenure, fees and charges, care and services, care recipients’ rights and complaints processes. The facility manager stated any room changes in the home would be discussed and agreement reached prior to any moves being undertaken. Care recipients and representatives expressed satisfaction with care recipients’ security of tenure at the home and demonstrated awareness of care recipients’ 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.

4.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Two and recent examples of this are listed below.

0. Orana gardens lodge has had a complete landscape and garden make over. This has resulted in the external areas gardens and lawns creating a pleasant area for the care recipients to sit outside in the sun and enjoy the outdoors. Feedback from care recipients who take advantage of this upgrade are very happy with the change.

0. An external consultant carried out a review of the infection control systems in the home to ensure all procedures and protocols are managed as per the homes infection control policy. This policy has assisted to identify any improvements to be incorporated into the refurbishment plan currently being undertaken. Hand washing stations have been upgraded with new hand basins and tiled to the ceilings. Staff received infection control education during this review.

0. Feedback identified the four week menu did not give enough variety of meals for the care recipients. The menu was adjusted in liaison with a dietician and adjusted to a six week menu and wastage audits were attended on food left in the bain marie after meals had been served. The new menu was developed to ensure all care recipients received balanced diet and maintain their nutritional and hydration needs. This has resulted in care recipients having more choices and variety in meals each day. Refer to expected outcome 4.8 for care recipient feedback on the quality of homes meal service.

0. The need to remove the blinds from the windows in the Lodge hallway was identified as they were blocking the light and sun from coming into the area. The windows have been tinted with a reflective coating and window seats have been placed along the corridors. This has resulted in care recipients and representatives to enjoy the sun when sitting or walking along the hallway. Care recipients and representatives stated they are enjoying sitting in this area during the day now.

4.2 Regulatory compliance

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

Team’s findings

The home meets this expected outcome

Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

0. Fire safety equipment is inspected, tested and maintained in accordance with regulations and staff complete annual compulsory fire education and evacuation training.

0. The home has an infection control program that is managed in accordance with government health regulations and guidelines.

0. A food safety program is in place and the home received a compliant rating in its Food premises report dated 27 June 2017

0. Safety data sheets (SDS) are displayed next to chemicals in use at the home

4.3 Education and staff development

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

Team’s findings

The home meets this expected outcome

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.

Education and training provided in relation to Accreditation Standard Four includes fire safety and evacuation, food safety, infection control, manual handling and safe chemical handling.

4.4 Living environment

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

Team’s findings

The home meets this expected outcome

The home is actively working to provide a safe and comfortable environment consistent with the needs of care recipients. Care recipients are accommodated in wings with personalised single rooms with ensuites and double rooms with a shared bathroom. Two of the wings are secure and provide a memory support program for care recipients living with dementia. Each household features a kitchenette, dining room, communal area and lounge room, as well secure external courtyards and gardens accessible to the care recipients. The living environment is clean, well-furnished and free of clutter. It is well lit and has air conditioning throughout and the buildings and grounds are well maintained. The home has a program of preventative and corrective maintenance undertaken by a list of preferred external service providers which is supported by routine repair and maintenance undertaken by the home’s maintenance team. The safety and comfort of the living environment is monitored through environmental workplace inspections, care recipient and representative feedback, incident/accident reports and observations by staff. The care recipients and representatives we interviewed expressed their satisfaction with the comfort and safety of the home’s living environment.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings

The home meets this expected outcome

The organisation has a comprehensive work, health and safety system with a work, health and safety committee on site. Workplace inspections monitor the living and working environment and hazards are reported and actioned. Identified risks are recorded on the maintenance program, prioritised for repair and actioned by the maintenance officer or external contractors. Staff complete manual handling training during orientation and annually. Personal protective clothing and equipment is provided and was observed being used appropriately. Position descriptions include work, health and safety responsibilities for the roles.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".

Team’s findings

The home meets this expected outcome

Systems are in place to ensure the safety and security of care recipients and staff. Checks of equipment by external contractors, auditing processes, fire and emergency evacuation procedures are in place. Evacuation maps are correctly orientated and emergency flip charts are located at strategic points throughout the building. The home is fitted with fire warning and firefighting equipment, smoke and thermal detectors, extinguishers, fire blankets, hose reels, emergency lighting and a sprinkler system. Chemical storage is secured, personal protective clothing available and safety data sheets located in suitable positions throughout the home. Designated smoking areas have been assigned for care recipients and staff. Staff attend compulsory fire safety training and demonstrate an understanding of evacuation procedures. Records of attendance at training are maintained and monitoring of this process occurs. The home is monitored by a night patrol contractor. An emergency evacuation and relocation plan has been drafted and emergency evacuation boxes include current care recipients’ names, mobility status and care needs.

4.7 Infection control

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

Team’s findings

The home meets this expected outcome

The home has an effective and efficient infection control program in place. Policies and procedures for infection control including outbreak management guidelines are available to all staff. Surveillance and reporting processes and hazard risk management are in place. Preventative measures include orientation and ongoing training and competencies for staff. All aspects of the program are regularly audited. Cleaning and maintenance schedules, temperature monitoring, use of spills kits and safe disposal of general and infectious waste support the program. Personal protective clothing and equipment, hand washing facilities and hand sanitisers are readily available across the home. We observed staff following infection control practices in their various roles and in their day to day interactions with care recipients.

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 home meets this expected outcome

There are systems and processes to ensure hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment. Meals are provided by the organisation’s central kitchen located at the country club off site. Catering staff have implemented food safety guidelines in the kitchen and food temperature checks are conducted on delivery of the food to the serveries across the home. Processes ensure that care recipients’ food and drink preferences and special dietary requirements are identified. The living environment is observed to be clean. Cleaning staff demonstrate a working knowledge of the home’s cleaning schedules, infection control practices and safe chemical use. Laundry staff explained the laundry processes, including the collection, storage and management of linen and personal clothing. Care recipients’ personal wash is returned in a timely manner to their rooms. Infection control practices are adhered to in the central and domestic laundries. Care recipients were complimentary of the staff and expressed satisfaction with cleaning and laundry services provided to them. Six care recipients expressed dissatisfaction with the quality of the meals served.

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