Bupa Rangeville - Aged Care Quality



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Bupa Rangeville

RACS ID 5410

280 Mackenzie Street

RANGEVILLE QLD 4350

Approved provider: Bupa Aged Care Australia Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 03 May 2020.

We made our decision on 13 March 2017.

The audit was conducted on 07 February 2017 to 09 February 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.

|Expected outcome |Quality Agency decision |

|1.1 Continuous improvement |Met |

|1.2 Regulatory compliance |Met |

|1.3 Education and staff development |Met |

|1.4 Comments and complaints |Met |

|1.5 Planning and leadership |Met |

|1.6 Human resource management |Met |

|1.7 Inventory and equipment |Met |

|1.8 Information systems |Met |

|1.9 External services |Met |

Standard 2: Health and personal care

Principles:

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.

|Expected outcome |Quality Agency decision |

|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.

|Expected outcome |Quality Agency decision |

|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

Principle:

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

|Expected outcome |Quality Agency decision |

|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

Bupa Rangeville 5410

Approved provider: Bupa Aged Care Australia Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 07 February 2017 to 09 February 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 07 February 2017 to 09 February 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: 108

Number of care recipients during audit: 106

Number of care recipients receiving high care during audit: 89

Special needs catered for: Care recipients with dementia and related disorders

Audit trail

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

Interviews

|Position title |Number |

|General Manager |1 |

|Clinical management team |3 |

|Regional support team |2 |

|Registered nurses |4 |

|Care staff |10 |

|Lifestyle staff |3 |

|Administration staff |2 |

|Catering staff |3 |

|Care recipients/representatives |15 |

|Laundry staff |2 |

|Cleaning staff |3 |

|Maintenance staff |1 |

Sampled documents

|Document type |Number |

|Care recipients’ files |12 |

|Summary/quick reference care plans |12 |

|Medication charts |15 |

|Personnel files |5 |

Other documents reviewed

The team also reviewed:

• Accredited food safety program

• Allied health referrals

• Audit schedule and audits

• Business continuity plan

• Care recipients’ information handbook

• Care recipients’ information package

• Cleaning schedules

• Clinical assessments and observation charts

• Clinical capability framework

• Clinical indicator data and trend analysis reports

• Continuous improvement logs

• Controlled drug registers

• Diaries and communication books

• Diet analysis forms

• Dietary lists

• Education and training records

• Employee handbook

• Evacuation folder

• External service provider reports

• Fire and emergency procedures manual

• Fire system service records

• Hand-over sheets

• Improvement log status report

• Lifestyle attendance and evaluation records

• Mandatory reporting consolidated log

• Meeting minutes

• Memoranda

• Menus

• New staff pack

• Newsletters

• Nurse-initiated medication orders

• Police certificate and visa tracking system

• Policies and procedures

• Preventive and corrective maintenance records

• Residential care agreement

• Registered nurse and allied health professional registrations folder

• Safety data sheets

• Self-assessment

• Service agreements

• Staff communication folder

• Staff orientation program

• Staff qualifications folder

• Staff training needs analysis

• Temperature monitoring records

• Volunteer induction and handbook

• Weight monitoring records

• Wound treatment records

Observations

The team observed the following:

• Activities in progress

• Brochures and information on display

• Cleaning in progress

• Designated care recipient smoking area

• Equipment and supply storage areas

• Hand-over processes

• Hand-washing facilities and personal protective equipment in use

• Interactions between staff and care recipients

• Living environment – internal and external

• Meal and beverage service

• Medication administration

• Short group observation

• Storage of medications

• Suggestion box

Assessment information

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

1 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”.

1 Team’s findings

The home meets this expected outcome

Bupa Rangeville (the home) pursues continuous improvement, using the Bupa Aged Care quality framework and has implemented improvements in response to the changing needs of care recipients, their representatives, staff and the organisation to meet the requirements of the Accreditation Standards. Planned audits, improvement logs, clinical indicator reports, incident and hazard reporting processes, external reviews and feedback from stakeholders are used to monitor systems and processes. Regular meetings for all levels of management, staff and care recipients facilitate communication and evaluation of improvement activities. Ongoing staff education ensures staff understand and implement relevant changes and improvements to the home’s processes. Care recipients and staff are satisfied that improvements continue to be implemented at the home and examples were provided of improvements implemented in response to their feedback.

Examples of recent improvements relating to management systems, staffing and organisational development, include the following:

• Through Bupa Aged Care’s graduate nurse program, the home has provided career advancement for a staff member who completed registered nurse training while working for Bupa and was mentored and supported through the program to enhance their skills, resulting in their appointment to a care manager role at the home. Two more new graduates are being recruited through the national assessment centre to complete the program in 2017.

• Three staff have been awarded Bupa scholarships to complete studies and enhance their qualifications, resulting in career advancement opportunities for staff and improved staff skills and retention rates for the home. Staff are satisfied with the opportunities for professional development and career advancement and management is satisfied with staff’s improved skills, knowledge and contribution to the Bupa Rangeville team.

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”.

1 Team’s findings

The home meets this expected outcome

Regulatory compliance changes are identified and integrated into the organisation’s policies and work instructions by the corporate team. Updated work instructions are communicated to staff via meetings, memoranda and emails; training is provided as required to ensure work processes reflect relevant legislation and professional standards. Legislation and regulatory compliance information is also available to staff at the home through the Bupa intranet. Monthly community meetings provide a forum to discuss changes and information provided in memoranda through the month, while regular leadership team and work health and safety meetings facilitate planning for implementation of changes and evaluation of monitoring activities. Compliance with relevant requirements is monitored through the annual internal audit calendar, third party reviews, central registers for monitoring criminal history clearance, mandatory training attendance and registration requirements. Policies and work instructions are reflective of legislative requirements, professional standards and guidelines.

In relation to Standard 1, Management systems, staffing and organisational development, for example,

• Care recipients are informed of planned Reaccreditation Site audits by the Australian Aged Care Quality Agency.

• Processes are established to ensure staff, volunteers and relevant contractors have a current police certificate.

• Professional staff’s registrations are monitored in accordance with the Australian Health Practitioner Regulation Agency (AHPRA).

1.3 Education and staff development

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

1 Team’s findings

The home meets this expected outcome

Staff are employed based on their skills, personal attributes and relevant qualifications held to perform the role. A staff needs analysis is conducted annually to facilitate planning of training and education activities for the year. A revised staff induction program was launched in 2016, which is specific to each site and role of the employee; the program commences on Day One and continues throughout the probationary period, ensuring new staff are provided with consistent information about the purpose and values of the organisation, legislative responsibilities and requirements of their roles. The organisation provides face-to-face and on-line mandatory education and other relevant in-service training in addition to opportunities for staff to attend external conferences, education and training in response to identified needs. The home encourages and supports staff to enhance professional qualifications and several staff are enrolled in Certificate IV Leisure and Lifestyle, Diploma of Nursing and Bachelor of Nursing courses.

In relation to Standard 1, Management systems, staffing and organisational development, education conducted over the last 12 months included for example,

• Aged care standards and continuous improvement

• Complaints handling

• Clinical instructor training.

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".

1 Team’s findings

The home meets this expected outcome

Care recipients and their representatives are able to raise concerns and provide feedback through the use of improvement logs, regular care recipient/representative meetings and individual care conferences. The General Manager and clinical management team have open-door policies and encourage care recipients/representatives to provide feedback about the care and services delivered to care recipients. Information relating to internal and external complaints mechanisms is included in the residential care agreement and ‘resident handbook’. Information about external complaints mechanisms and advocacy services is displayed at the home. Improvement forms are available at the entrance to the home for care recipients and their representatives, or other interested parties to document any concerns or complaints. A locked suggestion box outside the General Manager’s office provides an avenue for confidential complaints. Meeting minutes indicate issues are discussed and responded to. Care recipients /representatives are comfortable approaching staff and satisfied the care recipients’ concerns are addressed to their satisfaction.

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".

1 Team’s findings

The home meets this expected outcome.

Bupa Aged Care has documented the service’s purpose and values, and the organisation’s philosophy is incorporated within the “Person First” model of care. Their commitment to quality is expressed in the care recipient and employee communications, position descriptions and induction processes, and is displayed at the entrance to the home and marketing materials.

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".

1 Team’s findings

The home meets this expected outcome

The organisation has established human resource management systems to support a skilled and professional workforce. The General Manager (GM) guides the team and manages day-to-day operation of the home. Care Managers direct clinical care in each of the three communities within the home and a registered nurse is available on-site 24 hours, seven days a week. A pool of regular and casual staff is maintained to facilitate consistent care and services. Sufficiency of staff is monitored through care recipient and staff feedback. Staff are employed based on their skills, experiences and qualifications held relevant to the position. New staff are orientated to the organisation’s policies and work instructions, values and philosophy, and supported by an experienced staff member until they are comfortable in their roles. Position descriptions, care recipient care plans, work instructions and daily schedules guide staff practice. Ongoing education is provided across a range of topics and staff skills are monitored through observation, competency assessments and regular performance appraisals. Care recipients/representatives expressed satisfaction that staff are prompt and always courteous when attending to the care recipients’ needs.

1.7 Inventory and equipment

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

1 Team’s findings

The home meets this expected outcome

The home uses the organisation’s approved suppliers and order processes to ensure that adequate stocks of key supplies (linen, food products, medical supplies, chemicals, consumables and continence aids) are available. Orders are checked at the time of delivery to ensure product quality and deficiencies are followed up with suppliers. Stocks of goods held on site are appropriately stored. Equipment is purchased as required and maintained by appropriately qualified personnel through reactive and preventative maintenance programs and external service providers. Staff and care recipients/representatives are satisfied with the availability of goods and equipment at the home and that equipment is well maintained.

1.8 Information systems

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

1 Team’s findings

The home meets this expected outcome

Processes are established by the home to ensure information is managed in a secure and confidential manner that includes storage and access to files. Computerised information is password protected and staff have authority to access information relevant to their roles. The home collects and uses key information in relation to care recipient infections, incident data, audits and other care recipient/staff data to assist in the improvement of care and services. Key documents such as policies, work instructions and care plans are regularly reviewed and updated. Information is communicated effectively through meetings, newsletters, memoranda, email communications and verbal feedback. Care recipients /representatives are satisfied with consultation processes about issues concerning the care recipients and staff have access to relevant and timely information to perform their roles.

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".

1 Team’s findings

The home meets this expected outcome

The home uses external service providers to provide goods, equipment and specialised services in relation to pharmacy, allied health, pest control, equipment maintenance, waste disposal and fire safety. Bupa’s central procurement team negotiates and approves contracts with external service providers and service performance is monitored at the home by the leadership team on a job-by-job basis and through feedback from staff and care recipients. Suppliers provide the organisation with relevant licences, insurance details, registration certificates and criminal history checks as required within the terms of their contracts. Care recipients/ representatives and staff are satisfied with the quality of services provided by external suppliers.

2 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”.

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

Recent examples of improvements in relation to Standard 2 Health and personal care include the following:

• The int2roduction of laser therapy for pain management has had good results for care recipients experiencing pain. The therapy is prescribed by the physiotherapist and implemented by a care manager or registered nursing staff who have been trained in the therapy. Staff have identified therapeutic benefits for one care recipient who was previously unable to walk due to chronic back pain; after one week using the therapy, they have expressed significant reduction in pain and the use of opiates for pain management. They are now walking short distances requiring only supervision and assistance from one staff instead of two for transfers. Another care recipient, who fell and was unable to walk due to pain, regained their mobility and no longer requires analgesia after one week of daily therapy.

• In response to a concern about oral care, management identified some inconsistencies in practices. Refresher training was initiated for all care staff; specific oral care training was introduced during orientation for new staff and increased monitoring of staff practices has followed. As a result, management has identified some care recipients’ nutrition has improved as they are eating more and care recipients are more comfortable and satisfied with their oral care.

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”.

1 Team’s findings

The home meets this expected outcome

Refer to information in Expected outcome 1.2 Regulatory compliance. In relation to Standard 2 Health and personal care, for example:

• management ensures that care recipients receive appropriate care and services,

• medication management processes are in accordance with legislative requirements, and

• registered nurse staff are available to provide care as required.

2.3 Education and staff development

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

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.3 Education and staff development for information about the home’s education and staff development system and processes. The education program reflects identified training needs relating to health and personal care and staff have the opportunity to undertake a variety of training sessions relating to health and personal care, for example:

• hearing aid care and maintenance

• oral care, and

• opioids in pain management.

2.4 Clinical care

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

1 Team’s findings

The home meets this expected outcome

Care recipients receive clinical care appropriate to their needs and preferences. On entry to the home an interim care plan outlines care requirements followed by a period of scheduled assessments and completion of a long-term care plan. Registered staff undertake assessments and care planning in consultation with the care recipient, their representative, medical practitioner and other health professionals. Care evaluation occurs on a three monthly basis or more frequently if required. Communication of care occurs through verbal and written handover, care plans and duties lists. Clinical incidents are monitored and evaluated and relevant health professionals’ review clinical care outcomes. Care recipients are satisfied care is provided according to their needs and preferences.

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”.

1 Team’s findings

The home meets this expected outcome

Registered nurses assess care recipients’ specialised nursing care needs and access external specialist services for further assessment and support as required. Registered staff undertake all specialised nursing care including wound care, catheter care and diabetes management. Staff advised there is sufficient equipment, products and clinical information to support them in the provision of care recipients’ specialised nursing care. Care recipients/representatives are satisfied with the specialised nursing care provided to care recipients.

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”.

1 Team’s findings

The home meets this expected outcome

Care recipients are referred to other health specialists according to their needs and preferences. Registered staff and medical practitioners initiate referrals to other health professionals based on care recipients’ individual needs and preferences. Visiting services include physiotherapy, optometry, dietetic, podiatry and mental health specialists. Care recipients are assisted to attend external specialist appointments and clinics and instructions following appointments are communicated to staff. Care recipients/representatives are satisfied with the range of health services available to care recipients.

2.7 Medication management

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

1 Team’s findings

The home meets this expected outcome

Registered nurses and care staff manage care recipients’ medications according to the home’s policies and procedures. Medication assessments, completed when the care recipient enters the home, identify preferences, allergies and assistance required for safe administration. Medication charts detail specific orders, identification information and special considerations. All medications are stored securely and there is a system for pharmacy returns. Pharmacy reviews, audits and the incident reporting system contribute to the monitoring of safe medication systems. Care recipients/representatives are satisfied with the management of medications.

2.8 Pain management

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

1 Team’s findings

The home meets this expected outcome

On entry into the home, care recipients’ pain is assessed by registered nurses, clinical management and allied health staff. Care plans are developed and referrals are made to the physiotherapist for additional pain management treatments, including regular massage, exercises, laser therapy and heat packs. Assessment and charting is conducted when care recipients’ pain needs change and evaluation is undertaken following changes in pain management medication. The clinical management team monitor pain management strategies and staff described ways in which they identify pain and report any observation of care recipients’ pain to registered staff for further intervention. Care recipients/representatives are satisfied with staff assistance to manage care recipients’ pain.

2.9 Palliative care

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

1 Team’s findings

The home meets this expected outcome

Staff practices and care strategies ensure the dignity and comfort of terminally ill care recipients. Palliative care needs and preferences are included in assessment and care planning processes. Medical practitioners and registered staff regularly review care and have access to palliative care specialists if needed. Palliative care resources, supplies and equipment are available and staff receive relevant education. Staff advised they maintain care recipients comfort and dignity and respect their choices. Discussions with care recipients and cards and letters of appreciation demonstrate family and friends are satisfied with the care and support provided by staff and others at the home.

2.10 Nutrition and hydration

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

1 Team’s findings

The home meets this expected outcome

There are systems in place to meet care recipients’ nutrition and hydration needs. Monitoring of nutritional status occurs through monthly weighs, food and fluid intake charting, and use of healthy weight range values. Registered staff and the medical practitioner monitor each care recipient’s nutritional status and supplements are used as required. A dietician and speech pathologist visit the home on a referral basis for care recipients with nutritional and swallowing problems. Specialised cutlery and crockery are available for care recipients to assist them to maintain their independence. There are communication processes to advise catering staff of dietary plans including variations. Care recipients/representatives are satisfied with the provision of nutrition and hydration and the assistance given to care recipients with meal and refreshment services.

2.11 Skin care

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

1 Team’s findings

The home meets this expected outcome

Care recipients’ skin integrity is consistent with their general health. Care recipients’ skin integrity and pressure area risk are assessed on entry to the home. Care plans detail interventions and equipment to maintain care recipients’ skin integrity. Specialised mattresses and cushions, limb protectors and repositioning assist in maintaining care recipients’ skin care needs. Skin tears and wounds are monitored by registered staff and via monthly clinical indicators that are reviewed by the clinical management team. Care recipients/representatives are satisfied with the assistance provided by staff to maintain care recipients’ skin care.

2.12 Continence management

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

1 Team’s findings

The home meets this expected outcome

Care recipients’ continence is managed according to their individual needs and preferences. Staff assess each care recipient to determine if any continence aids are required and the level of assistance needed to manage continence care. Staff maintain continence charting and discuss abnormal findings during clinical handover. The home’s approach to continence management encourages promotion of each care recipient’s independence. Care recipients/representatives are satisfied staff meet care recipients’ continence needs and are mindful of privacy and dignity when approaching the sensitive issue of incontinence.

2.13 Behavioural management

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

1 Team’s findings

The home meets this expected outcome

Staff and other allied health professionals ensure care recipients with challenging behaviours are assessed and managed effectively. Care recipients with complex cognitive impairment live within two secure areas of the home. Prior history information, charts and a range of assessments identify responsive behaviours and inform staff of care recipients’ level of cognitive impairment. Care plans include possible causes of behaviours and provide staff with individualised strategies when attending to care needs. Staff report behaviour related incidents as they occur and have an understanding of mandatory reporting guidelines. Referrals occur to dementia advisory services and mental health specialists for further advice when needed. Care recipients/representatives are satisfied staff attend to behavioural matters as they arise in a respectful and timely manner.

2.14 Mobility, dexterity and rehabilitation

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

1 Team’s findings

The home meets this expected outcome

There are processes to ensure care recipients have access to appropriate care and equipment to maintain their mobility and dexterity. Registered staff complete assessments identifying care recipients’ mobility risks and care needs. Further care advice is sought from physiotherapy and occupational therapy personnel as required. Appropriate transfer equipment and assistive devices are available. Education programs provide resources to staff for manual handling and safe transfer techniques. Staff report incidents related to care recipient falls and follow up by a medical practitioner and physiotherapist occurs. Care recipients/representatives are satisfied with the assistance provided to maintain mobility and dexterity.

2.15 Oral and dental care

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

1 Team’s findings

The home meets this expected outcome

Care recipients’ oral and dental health is maintained. Staff gather historical information and complete an oral hygiene assessment to identify any gum, teeth, mouth and swallowing concerns. Care plans record details on the frequency of oral care and any staff assistance required. Staff assist care recipients to access visiting and external dental services when required. Medical practitioners are consulted when care recipients experience mouth and gum problems. Care recipients/representatives are satisfied with the assistance care recipients receive from staff regarding their oral hygiene.

2.16 Sensory loss

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

1 Team’s findings

The home meets this expected outcome

Nursing and recreational staff undertake assessments to identify care recipients’ sensory needs upon entry to the home. Hearing, vision, communication and sensory assessments provide input into management strategies for sensory loss. Management refer care recipients to other health professionals as required and upon request. The recreational program tailors activities to engage care recipients experiencing sensory loss. Staff are familiar with procedures to assist care recipients with the management of their sensory loss and sensory aids. Care recipients/representatives expressed satisfaction with the care of care recipients’ sensory needs.

2.17 Sleep

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

1 Team’s findings

The home meets this expected outcome

Care recipients are assisted to achieve natural sleep patterns. Assessment of care recipients’ personal preferences and routines occurs on entry to the home and informs care planning. Care plans detail individual routines and any relevant nursing interventions required to assist with natural sleep. Strategies to assist with sleep include medication management and non-pharmacological interventions such as warm drinks, pressure area care and other comfort measures. Care recipients are satisfied staff monitor their sleep during nightly rounds and provide assistance when needed or requested.

3 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”.

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

Recent examples of improvements in relation to Standard 3 Care recipient lifestyle include the following:

• When care recipients moved to their new home at Rangeville, the new environment was large and comfortable, but care recipients expressed sadness at the loss of the intimacy of their previous environment. In order to create a community environment for care recipients in their new home, the three different areas of the home were staffed and operated as three separate communities that have their own community activities and come together for large group activities according to their interests. A buddy system was introduced for those interested to introduce new care recipients into their community. As a result, friendships have developed; care recipients visit each other and feel part of a community. Care recipients and their representatives expressed satisfaction with their introduction to their community and with the inclusiveness of the home.

• Staff identified some care recipients wanted to do their own ironing or other household tasks. An ironing chat morning was introduced in a small lounge of the home. Five care recipients who do not usually attend group activities are now socialising in this group, ironing for each other and generally more engaged in the life of their community.

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”.

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.2 Regulatory compliance for information about the system to ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. In relation to Standard 3 Care recipient lifestyle, for example, the home has processes to:

• manage the reporting of care recipient assaults or suspected assaults

• ensure that confidentiality of care recipient information is maintained, and

• ensure care recipients/representatives are informed about how care recipient information is used, who has access and for which purpose that access is provided.

3.3 Education and staff development

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

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.3 Education and staff development for information about the home’s education and staff development system and processes. The education program reflects identified training needs and staff have the opportunity to undertake training sessions relating to care recipient lifestyle; for example:

• person first foundations, and

• care recipient’s journey process.

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".

1 Team’s findings

The home meets this expected outcome

The home has systems to ensure that each care recipient receives support in adjusting to life in the home and on an ongoing basis. Information regarding care recipients’ cultural, spiritual and other interests is obtained on entry and assists staff to support care recipients to settle into the home. Visiting families and friends are welcomed, birthdays are celebrated and outings are arranged. Care recipients are encouraged to decorate their room with personal items to help create a homelike atmosphere. Staff provide care recipients with emotional support and arrange, as required, for one to one visits from a religious/pastoral representative of their choice. Care recipients/representatives are satisfied with the way care recipients are assisted to adjust to life at the home and the ongoing support they receive.

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".

1 Team’s findings

The home meets this expected outcome

Management and staff demonstrate they support care recipients to achieve optimal independence, maintain friendships, family connections and community links. The home’s assessment process identifies care recipients’ cognitive, mobility and dexterity levels, any risk taking behaviours and preferences for social interaction. Recreational programs include sensory stimulation activities and community outings. The home assists care recipients to vote in elections, shop for personal items and entertain visitors. Supplied equipment aids and utensils encourage independence. Care recipients/representatives are satisfied staff assist care recipients to be independent.

3.6 Privacy and dignity

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

1 Team’s findings

The home meets this expected outcome

The home recognises and respects each care recipient’s right to privacy, dignity and confidentiality. Established systems ensure secure storage of confidential records and personal information and care recipients’ right to privacy is acknowledged in the home’s policies. Staff practices are monitored and staff receive training on how to provide personal care services discreetly. Staff strategies to maintain care recipients’ privacy and dignity including knocking on doors before entering, ensuring doors are closed when attending to personal care and being mindful of privacy when discussing care recipients’ care needs. Care recipients/representatives are satisfied care recipients’ privacy, dignity and confidentiality is maintained.

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".

1 Team’s findings

The home meets this expected outcome

The home encourages and supports care recipients to participate in a wide range of activities that interest them. Care recipients and their families are invited to complete a personal profile and the Recreational Activity Officers use this to complete assessments of the care recipients’ lifestyle history and preferences. Assessment information is used to develop therapy care plans and contribute to the development of the lifestyle and activity program. Activities are evaluated through recording attendance, activity evaluations, satisfaction surveys and via verbal feedback and requests. The activity program includes physical, cognitive, cultural, sensory and spiritual activities of both group and individual options. Staff invite care recipients and their families and friends to attend activities and ensure care recipients are supported to access activities that reflect their needs, preferences and capabilities. Care recipients/representatives are satisfied staff support care recipients’ participation in activities that are of interest to them.

3.8 Cultural and spiritual life

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

1 Team’s findings

The home meets this expected outcome

Management and staff demonstrate they foster and value care recipients’ cultural and spiritual lives. Initial assessments capture preferences including celebratory days, beliefs, religious choices, cultural preferences and palliative care wishes. Staff have access to interpreters if needed. Various denominations hold group and individual religious services. Visiting cultural and volunteer groups are welcome. Special events and significant days are celebrated and care recipients’ dietary preferences accommodated. Care recipients/representatives are satisfied with the support provided to meet 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".

1 Team’s findings

The home meets this expected outcome

Management and staff are committed to promoting care recipients’ right to participate in choices and decisions regarding their clinical care and lifestyle preferences. Authorised powers of attorney or guardianship information are available where required. Displayed brochures, handbooks and agreements contain information on care recipients’ rights and responsibilities, the complaints process, external advocacy services and policies relating to clinical care and lifestyle choices. Audits, surveys and feedback from meetings monitor satisfaction and staff have access to policies and procedures on choice. Care recipients/representatives are satisfied individual choices and decisions are encouraged, respected and supported by management and staff at the home.

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".

1 Team’s findings

The home meets this expected outcome

The organisation has a system to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Care recipient information covers security of tenure and care recipients’ rights and responsibilities. The General Manager and administration team discuss entry requirements and agreements with care recipients and representatives. Any change of rooms only occurs after consultation with the care recipient and their representatives. Management clarify and confirm care recipients’ rights and responsibilities, security of tenure information and financial concerns on an ongoing basis as required. Care recipients/representatives are satisfied care recipients have secure tenure within the home and are aware of their rights and responsibilities.

4 Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a sage 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”.

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

Recent examples of improvements in relation to Standard 4 Physical environment and safe systems include the following:

• Care recipients/representatives have expressed their satisfaction with the enhanced living environment since their move to the new home at Rangeville. They are enjoying their improved access to external courtyards that provide comfortable seating and landscaped gardens for care recipients and visitors to enjoy. The increased privacy and space in their rooms allows them to feel more at home in their new home.

• In response to a care recipient concern about the volume of the call-bell system, the supplier was contacted and volume reduced without compromising staff’s ability to hear the alert, as calls are redirected to staff’s DECT phones. Care recipients/representatives are satisfied with the improvement.

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”.

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.2 Regulatory compliance for information about the system to ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. In relation to Standard 4 Physical environment and safe systems, for example:

• all staff attend mandatory training in fire safety, manual handling and infection control

• a current food licence is displayed.

4.3 Education and staff development

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

1 Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.3 Education and staff development for information about the home’s education and staff development system and processes. The education program reflects identified training needs and staff have the opportunity to undertake a variety of education and training relating to Standard 4 Physical environment and safe systems, such as:

• chemical use and safety

• memorable dining experience, and

• floor scrubber operation.

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".

1 Team’s findings

The home meets this expected outcome

Management is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. Processes include an on-site maintenance officer, a planned preventive maintenance schedule, prompt response to maintenance requests, regular environmental inspections, hazard and incident reporting processes. Care recipients are accommodated in single rooms with en-suite bathroom facilities and staff monitor the rooms to ensure furniture is safe and trip hazards are eliminated where possible. Common areas are easily accessed for meals and lifestyle activities. Two secure units in the home provide specialist accommodation for care recipients who require a secure community. Incidents involving residents are documented and followed up in the care recipient’s care record and through the incident management system. Care recipients /representatives are satisfied with the safety and comfort of the 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".

1 Team’s findings

The home meets this expected outcome

The home’s safety system is supported by trained workplace health and safety representatives, a safety officer and a workplace health and safety committee that meets regularly and reviews hazards and risk management processes. Safety training is provided for staff at induction and compulsory on-line training annually and as required. Policies and procedures are updated in response to legislative changes and staff are provided with information and training about the changes. Issues raised from regular environmental inspections are addressed promptly or included in the home’s continuous improvement process to ensure significant and systemic issues are prioritised and tracked to completion. Maintenance is conducted on buildings and equipment to ensure safety and useability. Chemicals are stored securely and current safety data sheets are accessible to staff. Staff are familiar with incident and hazard reporting processes and satisfied with management’s response to issues.

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".

1 Team’s findings

The home meets this expected outcome

Fire detection and alarm system, fire-fighting installations and equipment, and emergency lighting have been inspected and maintained in accordance with the relevant standards. Fire exits and pathways to exit are free from obstacles and exit doors operate in accordance with requirements. Fire evacuation drills are conducted as part of regular training sessions. Processes ensure that quick and easy access to current care recipient information is available in the event of an emergency evacuation. All staff have received fire safety training within the last 12 months. Staff have an accurate knowledge of fire and emergency procedures and their role in the event of an alarm and evacuation. Security procedures are in place and consistently implemented to protect care recipients and staff.

4.7 Infection control

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

1 Team’s findings

The home meets this expected outcome

The home has an established infection control program to identify and contain potential and actual sources of infection including in the event of an outbreak. The program includes a food safety program, a vaccination program for care recipients and staff and pest control measures. Infection control education is provided to all staff. Care recipients’ infection statistics are recorded and reviewed by the clinical management team. Personal protective equipment is in use and hand washing facilities, hand sanitisers, sharps’ containers and spill kits are readily accessible. Cleaning schedules and laundry practices are monitored to ensure infection control guidelines are followed and food is handled in accordance with the food safety program. Staff are aware of infection control measures, including the appropriate use of personal protective equipment, hand hygiene procedures and precautions to be taken in the event of an outbreak.

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".

1 Team’s findings

The home meets this expected outcome

Catering staff have been trained and implement quality monitoring processes to ensure food safety. Meals are prepared on site and temperatures are monitored to ensure safety and care recipient satisfaction. Temperature monitoring and quality control processes are consistently applied. Care recipients are consulted about their preferences and their requests are considered and provided where possible. Equipment and supplies of cleaning products are available and in good working order. All kitchen and cleaning items and care recipients’ clothing and flat linen is laundered on site. Care recipients/representatives are satisfied with the catering, cleaning and laundry processes and with the flexible approach of management and staff to their individual requests. Staff are satisfied with their working environment.

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