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Aged Care Certification Guidelines November 2002 Revision

1999 Certification Assessment Instrument

Commonwealth Department of Health and Ageing - Aged Care Certification Assessment Instrument – November 2002 Page 1

AGED CARE CERTIFICATION ASSESSMENT INSTRUMENT GUIDELINES

NOVEMBER 2002

TABLE OF CONTENTS

1. INTRODUCTION ............................................................................................................................................ 2

2. OVERVIEW OF ASSESSMENT INSTRUMENT........................................................................................ 3

3. SPECIFIC GROUPINGS ................................................................................................................................ 5

Section 1. Safety (Section Weighting - 25 points) ......................................................................................... 6 Section 2. Hazards (Section Weighting - 12 points).................................................................................... 29 Section 3. Privacy (Section Weighting - 26 points)..................................................................................... 33 Section 4. Access, Mobility and Occupational Health & Safety (Section Weighting - 13 points).............. 40 Section 5. Heating and Cooling ( Section Weighting - 6 points) ................................................................ 45 Section 6. Lighting / Ventilation (Section Weighting - 6 points)................................................................. 52 Section 7. Security (Section Weighting - 12 points) .................................................................................... 56



AGED CARE CERTIFICATION ASSESSMENT INSTRUMENT GUIDELINES

NOVEMBER 2002 REVISION

1. INTRODUCTION

The certification program forms part of the Structural Reform Package introduced by the Government in the 1996-97 Budget. Its aim is to encourage improvements in the physical quality of residential aged care buildings.

As part of the certification process, residential aged care buildings are inspected and scored using a Certification Assessment Instrument, which assesses various aspects of building quality such as safety, access and lighting. Qualified building professionals who are independent of the Department carry out building inspections (known as certification assessments).

The initial certification assessments were undertaken against the 1997 Certification Assessment Instrument. The 1999 Certification Assessment Instrument was introduced in July 1999. The 1999 Certification Assessment Instrument superseded the original 1997 Certification Assessment Instrument.

The revision of the 1999 Certification Assessment Instrument (the Instrument) is a result of the introduction of the Building Code of Australia (BCA96) - 9c building classification and feedback from industry, assessors and providers. This feedback highlighted a number of areas of the Instrument that needed clarification for the purpose of providing transparency and direction of the expected outcomes of an assessment. These Guidelines have been developed to assist service providers and their building professionals to understand the certification process and the scoring system used in the revised Instrument.



2. OVERVIEW OF ASSESSMENT INSTRUMENT

The Assessment Instrument was developed for use in ascertaining the quality of the built fabric as part of the certification process for aged care facilities. The Instrument is generally grouped in the following sections:

Section 1 Safety Section 2 Hazards Section 3 Privacy Section 4 Access, Mobility, OH&S Section 5 Heating/Cooling Section 6 Lighting/Ventilation Section 7 Security

Sections 1, 3, 4 and 6 require the assessor to have a sound understanding of the regulations in relation to the Building Code of Australia, 1996 (BCA96) and relevant Australian Standards.

The other sections of the assessment document require judgement based upon knowledge of the aged care industry, good building practice and the quality of life that a facility is able to offer the resident taking into account the fabric of the building.

The Instrument has primarily been designed to accommodate those classes of buildings within Volume One of BCA96. There are few residential aged care buildings that have been classified by the relevant authority as a Class 1b building and the Department will assess these as they arise on a case-by-case basis.

These Guidelines use BCA96 as the primary technical reference for most elements within Section 1 (Safety). BCA96 has been developed in conjunction with all the States and Territories, the Commonwealth, fire authorities, industry and consumer representatives. BCA96 considers the latest information and technology on building products and practices and represents a minimum community standard for building construction. Maintenance of services and equipment as detailed within the Guidelines is not reflected within BCA96 on a nationally consistent basis. Maintenance is a means of ensuring that the equipment provided has the greatest chance of operating in accordance with its intended purpose. The close alignment of the Guidelines with BCA96 requirements provides designers with a level of confidence that their design, should it be acceptable to the relevant building authority, will broadly meet Section 1 (Safety) of the Certification Assessment Instrument.

The use of BCA96 as the technical requirement provides the designer with scope to use an Alternative Solution when designing an aged care building. This permits a significant opportunity for designers to deviate from the prescriptive BCA96 requirements. This flexibility provides greater opportunity for designs constrained by existing building structures to meet BCA96.

The necessary documentation for an ‘Alternative Solution’ should be presented to



the certification assessor prior to an assessment to ensure that full points are awarded where appropriate. Without supporting documentation the assessor will undertake an assessment based on BCA96 Deemed-to-Satisfy provisions and this may result in a lower score allocation. The supporting information may include plans approved by the relevant authority, reports, test reports, opinions, calculations or the like that are approved by an appropriately qualified person.

Full points will be awarded where the Guidelines specify BCA96 compliance. In these instances BCA96 may not require the installation of particular equipment based on the classification or building design, i.e. BCA96 is used as the criteria to achieve full points for Section 1 (e)(ii) Hose Reel locations, if the building is classified as 9c and the relevant BCA96 provisions specify no requirement for hose reels full points will be awarded.



3. SPECIFIC GROUPINGS

The following items are identified in order of their appearance in the Assessment Instrument, and are described in terms of both the issues surrounding each question and the designated categories for scoring each component.

Modifications/Dispensations Weighted Score: Nil

This section has been incorporated into the assessment process to provide the assessor with information in relation to potential modifications or dispensations, which may affect the scoring in Section 1 (Safety) of the Assessment Instrument. These questions do not attract any scores in the assessment process, but are included only to provide information to the assessor.

(i) This question is a Yes/No answer and considers whether the installation of sprinklers/fire suppression system provides concessions under the “Deemed-to-Satisfy” provisions of BCA96 in relation to the method of construction for fire safety. Such concessions could include the deletion of the requirements for fire separation, heat detectors, etc., and would result in full marks being awarded for the relevant questions.

(ii) This question is a Yes/No answer and considers whether modifications/dispensations have been granted by the relevant approval Authority for fire safety designs carried out under the “performance based” provisions of BCA96. Full marks may be awarded for those questions within Section 1 of the Assessment Instrument which are no longer applicable or have been relaxed as a result of modifications/dispensations, e.g. fire separation, distance of travel to an exit, distance to alternative exit, number of hose reels required, etc.

Evidence of modifications and/or dispensations must be provided by the facility proprietor (or representative) to the assessor at the time of inspection in the form of supporting correspondence and approvals, including certified plans if available.



Section 1. Safety (Section Weighting - 25 points)

a) Sprinklers/Fire Suppression Weighted Score: 2.0

This question considers the installation of sprinklers or a fire suppression system within a facility. This question rewards those facilities that have a system installed and maintained, irrespective of the relevant State legislative requirements, but sprinklers are not a mandatory requirement under certification.

A sprinkler system is only of some value if it is reliable. One of the most practical means of increasing the reliability of a system is to implement a regular maintenance regime.

If a sprinkler system is required by BCA96 the sprinkler system will need to be installed to the relevant Australian Standard.

Scores are allocated according to the following:

0 = not provided.

1 = partial system present but not operative.

2 = partial system present and operative.

3 = full coverage by sprinkler system not installed to relevant Australian Standard.

4 = facility appears to be fully protected to relevant Australian Standard without appropriate supporting documentation however has a regular maintenance certification.

5 = facility fully protected by sprinklers to relevant Australian Standard with supporting documentation provided to that effect including regular maintenance certification.



b) Fire Compartmentation/Separation

(i) Required Weighted Score: 4.0

This question is concerned with controlling the spread of fire within a building. Specifically it relates to compartmentation of the facility into fire isolated areas as required by BCA96 for the relevant building classification.

The answer requires a Yes / No response.

No = The facility is of a nature that does not require fire compartmentation or separation and will score full points for its inherent safety. Remaining questions under Fire Compartmentation/Separation need not be answered if a No response is given to this question.

Yes = Fire compartmentation/separation is required, and the additional questions under this sub-section must be answered. With this response, scores are awarded to questions (ii) through to (vii).

(ii) Appropriate Treatment Weighted Score: 1.0

This question relates to the determination of whether appropriate treatment has been provided in relation to the fire separation of a building, with due regard to the separation between storeys, differing classifications of facilities, or adjoining structures.

Consideration should also be given to lift shafts, stairwells and equipment areas. The requirements of this question are fully covered by BCA96.


0 = the building has no fire walls separating areas that would be required to be separated under BCA96.

1 = the building is separated by fire rated walls or floors of inappropriate fire resistance level.

2 = compartments are separated by appropriate walls but other major penetrations are not separated (stairs, lift shafts).

3 = compartments are separated adequately but minor openings are not protected in accordance with BCA96.

4 = generally complies with BCA96 with minor non-compliance in some areas.

5 = complies with BCA96.



(iii) Integrity Weighted Score: 1.0

This question considers the ability of a fire compartment or fire separation system to retain its performance characteristics given circumstances that may compromise its integrity e.g. use of float glass where wired or fire rated glass is required, use of a hollow core door rather than a solid core door, etc.


0 = the facility has no continuous effective barriers to the spread of smoke and flames.

1 = barriers exist at present, but installation, construction or other circumstances make them ineffective.

2 = barriers exist but the integrity of the compartments is affected by the installation of services and equipment.

3 = barriers exist but the effectiveness is reduced by the operation or installation of openings.

4 = generally complies with BCA96 with minor non-compliance in some areas.




(iv) Compartment Size Weighted Score: 0.5

This requires verification of the level of compliance of maximum floor areas and volumes of fire compartments as defined in BCA96.


0 = no compartments present in the facility or compartments exceed size by greater than 20%.

1 = the size/volume of the compartments are excessively exceeded (10 - 20%).

2 = the size / volume of the compartments are marginally exceeded (5 - 10%).

3 = the size/volume of the compartments are marginally (< 5%) exceeded in ward areas.

4 = the size/volume of the compartments in ward areas comply with BCA96, but ancillary use areas (kitchen, laundry etc.) are marginally (< 5%) exceeded.

5 = the size / volume of the compartments do comply with BCA96 or are not applicable to building classification.

(v) Appropriate door type Weighted Score: 0.5

This refers to the installation of the appropriate door types within a building. The existence of information plates attached to the stiles of fire rated doors and frames is used to confirm that the doors and frames have the appropriate fire resistance level for the intended role. Other doors, such as solid core doors, need to be inspected to ensure that the construction of the door is appropriate.

The sighting of tags is primarily for technical verification of the construction and installation of the door and establishes if the door is appropriate.

Scores are allocated according to the following and are applied to doors that are required to be of a construction determined by BCA96:

0 = All doors are of an inappropriate type or could not be verified as appropriate.

1 = ≤ 25% of all doors are of appropriate construction.



4 = all fire doors tagged, however tag details are not visible or ≤75% of doors other than fire doors are of appropriate construction.

5 = all doors are of the appropriate construction.



(vi) Hardware Weighted Score: 0.5

The installation of correct hardware on fire and solid core doors is important for both retaining the integrity of the door and for egress. There may be circumstances where corrective action to hardware installations may involve a simple rectification or removal of extraneous fittings.

The correct installation of hold open devices and sequence closing devices, together with the inappropriate use of extraneous locks, barrel bolts etc. should be considered when answering this question. Hardware is to be installed as required by BCA96.


0 = incorrect type and/or installation.

1 = incorrect type and/or installation in most cases and difficult to rectify.

2 = incorrect type in all cases and incorrect installation in most cases but easily rectified.

3 = incorrect type and/or installation in most cases but easily rectified.

4 = generally complies with BCA96 with minor issues that are easily rectified.


(vii) Regular Maintenance Certification Weighted Score: 0.5

This question relates to the existence and currency of regular maintenance certification of the fire compartmentation/separation system irrespective of whether this is required by State legislation. This may be required in respect of active and/or passive fire safety measures employed to achieve the requirements of fire compartmentation/separation within a facility.

This will involve the sighting of certified maintenance records issued by an industry organisation (private certifier) and/or a legislative body.


No = No regular current maintenance certification in place.

Yes = Evidence of a regular current maintenance certification program provided.



c) Egress Provisions

(i) Number & Distribution of Exits Weighted Score: 1.0

Facilities must provide adequate means of escape from fire or other emergency situations from all parts of the building to a place of safety. This includes reasonable provision for egress by disabled residents. BCA96 sets out basic requirements for the appropriate number and distribution of suitable exits.

The provision of exits from a compartment and the appropriate location of discharge points from stairs serving upper floors should be considered in relation to this question.


0 = inadequate provision of exits.

1 = exits poorly distributed and separation distances do not comply with BCA96.

2 = exits poorly distributed, but separation distances comply with BCA96.

3 = exits well distributed, but most locations do not comply with the minimum and maximum separation distances required under BCA96.

4 = good distribution of exits, with minor non-compliance of separation distances in some cases.

5 = appropriate provision of exits and compliance with BCA96 in all areas.



(ii) Signage & Illumination Weighted Score: 1.0

This relates to the provision of appropriate lighting and illuminated signage to enable exits to be found during an emergency evacuation. The requirements of this question are covered by BCA96.


0 = no emergency lighting or illuminated signage exists.

1 = token effort at lighting and signage i.e. non-illuminated exit signs, inadequate emergency lighting to exits, no directional signs.

2 = deficiencies in regard to multiple criteria, including location of exits signs, spacing, location and type of directional signs, spacing of emergency lights.

3 = adequate coverage from illuminated signage and emergency lighting, but inadequate directional content.

4 = illuminated signage and emergency lighting providing adequate coverage, with minor deficiencies in directional content.

5 = emergency lighting and exit signage generally complies with BCA96.



(iii) Travel Distances Weighted Score: 1.0

This section covers the three main BCA96 areas pertaining to egress. These are as follows:

• distance to ‘point of choice’ (position in facility where choice of alternative exits is available) in accordance with BCA96.

• distance to nearest exit in accordance with BCA96.

• distance between alternate exits in accordance with BCA96.

Staff may need to make repeated trips into the facility to carry or wheel out residents during an emergency evacuation.

BCA96 addresses the requirements for egress from buildings.


0 = travel distances significantly exceed (>25%) BCA96 requirements.

1 = distances to point of choice and nearest exit are significantly exceeded (>25%), but distances between alternate exits comply with BCA96.

2 = all three areas listed above are marginally exceeded (≤25%).

3 = distances to point of choice and alternate exits are marginally exceeded (≤25%), but distance to nearest exit complies with BCA96.

4 = distance between alternate exits marginally exceeded (≤25%), however the remaining exit travel distance comply with BCA96.




(iv) Widths Weighted Score: 0.5

This question is of significance where most emergency evacuation is undertaken by physical assistance or by wheeled or mobility devices. The focus is therefore on corridor widths and escape routes and should take into account obstructions or intrusions (permanent or semi- permanent). The score allocated to this question should be based on the worst case of all corridors, hallways and doors which are designated for egress in case of fire and not on the average corridor width for the facility.


0 = less than 1 metre wide in both corridors and stairs.

1 = less than 1 metre wide in either corridors or stairs.

2 = less than or equal to 1.2 metres wide in corridors and only 1 metre wide for stairs.

3 = less than or equal to 1.5 metres wide in corridors and 1 metre wide for stairs.

4 = less than or equal to 1.8 metres wide for corridors with double opening doors and 1 metre wide for stairs, including larger stair landings.

5 = over 1.8 metres wide for corridors with double opening doors and at least 1.6 metres wide for stairs and landings.



(v) Secure Area Compatibility Weighted Score: 0.35

For the purpose of this assessment, secure areas are those areas within a facility that are required to restrict movement of some residents for their own personal safety e.g. dementia wards etc.

This question relates to the compatibility of the security systems installed within the facility, for the purpose of resident safety, with the need for emergency evacuation. Security systems should not restrict egress to available exits leading to a road or open space in an emergency.

Facilities where the provision of a secure area is not required or appropriate due to the resident profile (current or future) should score 5 for this question.


0 = security may cause substantial problems during emergency evacuations (e.g. difficult locking operation).

1 = security locks may restrict the efficient egress of residents and staff.

2 = security relies on centralised manual operation and staff procedures, e.g. a single key at a nurses’ station.

3 = security allows greater access for manual operation, e.g. all staff carry keys.

4 = easily activated automatic mechanism adjacent to exit.

5 = automatic unlocking on emergency alarm, or easily activated automatic mechanism adjacent to exits.

(vi) Blockage of Exits and Egress Routes Weighted Score: 0.35

This question relates to the inappropriate storage (permanent or temporary) of equipment, furniture or goods, which directly restricts or prevents egress from the facility. Assessment is based on housekeeping issues apparent on the day/time of inspection.


0 = exits concealed, obscured or access to exits restricted by built fabric, or occupant alterations.

1 = permanent storage of equipment or goods in exits or escape routes. Access to egress severely restricted or denied.

2 = partial blockage of exits by materials that could be relocated.

3 = regular temporary restriction of access/egress.

4 = irregular short-term restriction of access/egress.

5 = unrestricted access at all times to all egress points.



(vii) Discharge from Exits Weighted Score: 0.35

This question relates to the ability of a facility’s exits to discharge occupants from its designated escape routes into safe areas that BCA96 defines as open space. Consideration should be given to such factors as blockages, barriers or restrictions at the point of discharge, the location of alternative discharge points and the nature of connections between discharge points and safe areas. The suitability of the path of travel to open space will need to be determined by the assessor. Generally a surface such a mown lawn is not suitable for the purpose of wheelchairs or other mobility aids for frail aged persons.

BCA96 should be consulted for further details.


0 = blocked or seriously restricted discharge from exits due to built fabric or discharge into inappropriate spaces (enclosed court yards, service ways, etc.).

1 = permanent storage of equipment or goods restricts discharge or access to open space.

2 = partial restriction of discharge points or inadequate distribution of egress routes to road or open space and/or inadequate external ramps/paths of travel.

3 = majority of exits provide adequate escape potential.

4 = minor deficiencies only with discharge, paths of travel or ramps.

5 = unrestricted discharge from exits with adequate access to safe areas via suitable paths of travel. Complies with BCA96.



(viii) Storage Beneath Stairs and Ramps Weighted Score: 0.35

Areas beneath stairs and ramps are sometimes used for additional storage space, and can compromise the function of the egress path and negate the stair or ramp as a viable escape route. This is usually easily rectifiable, although some facilities may house equipment, combustible or hazardous materials in permanent enclosed storage cupboards of inadequate construction.

BCA96 is used as the technical reference to this question. Construction of any storage area associated with stairs and ramps should be constructed in accordance with BCA96. Where there are no storage areas under stairs and ramps a maximum score should be allocated.


0 = enclosed areas not fire isolated or open areas under stairs are used for storage of flammable and combustible or volatile liquids e.g. cleaners store.

1 = enclosed areas not fire isolated or open areas under stairs are used for storage of combustible materials e.g. paper.

2 = enclosed areas not fire isolated and not occupied, with mechanisms to control unauthorised usage e.g. locked and manager holds key.

3 = fire-isolated but without fire-rated door.

4 = fire-isolated with minor defects, e. g. faults with fire protective sheeting, gaps or holes are apparent.




(ix) Door Swing & Hardware Weighted Score: 0.75

The question considers the direction of swing and the type and operation of door hardware associated with designated exit doors within a facility.

BCA96 should be consulted in determining the appropriate installations for safe evacuation.


0 = all, or very high proportion of doors swing against egress direction and have incorrect hardware.

1 = high proportion of doors swing against egress direction or have incorrect hardware.

2 = equal proportion of complying and non-complying doors evident in the facility.

3 = most doors comply but are fitted with some non-complying hardware.

4 = general compliance with BCA96 exhibited with some minor issues needing attention.

5 = doors comply with BCA96.

(x) Regular Maintenance Certification Weighted Score: 0.35

This question relates to the existence and currency of regular maintenance certification of emergency lighting and illuminated exit signs irrespective of whether this is required by State legislation.




Yes = Evidence of a regular current maintenance certification program.



d) Smoke Compartmentation/Separation

This section considers the ability of the building to restrict the spread of smoke within a facility in accordance with the requirements of BCA96.

• Consideration should be given to the different requirements for smoke containment for the relevant building classification in accordance with BCA96

(i) Required Weighted Score: 5.0

This question considers appropriate provision of smoke compartmentation in accordance with the requirements of BCA96.


No = The facility is of a nature that does not require smoke compartmentation and will score full points for its inherent safety. Remaining questions under Smoke Compartmentation need not be answered if a No response is given to this question.

Yes = Smoke compartmentation is required and the additional questions under this sub-section must be answered. With this response, scores are awarded to questions (ii) through to (v).

(ii) Integrity Weighted Score: 2.0

This question considers the ability of a smoke compartment to retain its performance characteristics given circumstances that may compromise its integrity e.g. construction of smoke barriers with inappropriate materials or detailing.


0 = the facility has no continuous, effective barriers to the spread of smoke.

1 = barriers exist at present, but installation, construction or circumstances make them ineffective.

2 = barriers exist but the integrity of the compartments is affected by the installation of services and equipment, e.g. power cables, air-conditioning ducts, pipes.

3 = barriers exist but their effectiveness is reduced by the operation or installation of openings.

4 = generally complies with BCA96, with some minor issues to address.




(iii) Compartment Size Weighted Score: 1.0

This question considers the level of compliance in relation to maximum floor areas and volumes of smoke compartments in accordance with BCA96. BCA96 has specific smoke compartmentation requirements for the different BCA96 building classifications.


0 = no compartments present in the facility or compartment size is exceeded by more than 20%.

1 = the size/volume of the compartments are substantially exceeded (10 - 20%).

2 = the size/volume of the compartments are exceeded (5 - 10%).

3 = the size/volume of the compartments are marginally (< 5%) exceeded in ward areas.

4 = the size/volume of the compartments in ward areas comply with BCA96, but ancillary use areas (kitchen, laundry etc.) are marginally (< 5%) exceeded.

5 = the size/volume of the compartments comply with BCA96.

(iv) Hardware Weighted Score: 1.0

The installation of correct hardware on smoke doors is important for both retaining the integrity of the doors and for egress. There may be circumstances where corrective action to hardware installations may involve a simple rectification or removal of extraneous fittings.

The correct installation of hold open devices and sequence closing devices, together with the inappropriate use of extraneous locks, barrel bolts etc. should be considered when answering this question. BCA96 should be used as the technical requirement to determine hardware requirements.


0 = type and/or installation is not in accordance with BCA96.

1 = incorrect type and/or installation in most cases and difficult to rectify.

2 = incorrect type in all cases and incorrect installation in most cases but easily rectified.

3 = incorrect type and/or installation in most cases but easily rectified.

4 = type and/or installation in compliance with BCA96 in most cases, others easily rectified.

5 = complies with BCA96

(v) Regular Maintenance Certification Weighted Score: 1.0



This question considers the existence and currency of regular maintenance certification in relation to smoke compartmentation/separation systems within a facility irrespective of whether this is required by State legislation. This may be required in respect of active and/or passive smoke safety measures employed to achieve the requirements of smoke compartmentation/separation within a facility.



No = No regular current maintenance certification in place

Yes = Evidence of a regular current maintenance certification program.



e) Fire Fighting Equipment

This issue generally relates to the equipment provided for occupants and fire brigade to undertake fire fighting operations.

(i) Hydrant Locations Weighted Score: 0.5

This question considers the adequate location and coverage of hydrants (either internal or external of facility) in accordance with the requirements of BCA96 and appropriate Australian Standard.


0 = coverage distances substantially exceeded (>10%) and/or location does not comply.

1 = coverage distances substantially exceeded (>10%), but location complies.

2 = coverage distances and location marginally exceeded (≤10%).

3 = coverage distances marginally exceeded (≤10%), but location complies.

4 = coverage distances complies, but location is incorrect.

5 = both coverage and location comply with BCA96.

(ii) Hose Reel Locations Weighted Score: 0.25

Hose reels will typically be used by untrained personnel, and therefore need to be accessible, well maintained and prominently located. It is important that access to this equipment is not compromised by any measures that may have been taken to prevent resident tampering.

BCA96 specifies requirements for the location and installation of hose reels.


0 = not provided.

1 = insufficient numbers for correct coverage.

2 = sufficient numbers, but inappropriately located and difficult to access.

3 = sufficient numbers and appropriately located, but difficult to access.

4 = sufficient numbers with satisfactory access, but not appropriately located.




(iii) Regular Maintenance Certification Weighted Score: 0.5

There are certain aspects of fire fighting systems that need to be regularly tested and maintained in order for them to function efficiently. It will not be possible for inspectors to actively test every aspect of a system’s operation and so reliance on a third party certification of the functionality of the system should be sought.

Assessors are required to verify the existence and currency of certification tags attached to the fire fighting equipment.



Yes = Evidence of up-to-date regular current maintenance certification provided.

(iv) First Response Fire Fighting Devices Weighted Score: 0.75

This question addresses the provision of items such as fire extinguishers, fire blankets and other first response equipment. These items need to be conveniently positioned and logically located. They will usually be operated by untrained persons and should be the appropriate type of equipment for the perceived fire risk.

These devices should not be considered substitutes for other required forms of fire control. The location of such equipment may be affected by the nature of residents and the type of care they require.

The type and location of fire extinguishers will be assessed against the requirements of BCA96.


0 = not provided.

1 = provided, but their nature makes them of negligible use (out of test, domestic type or size, unserviceable or illegal).

2 = insufficient numbers provided.

3 = sufficient numbers but incorrect type.

4 = sufficient numbers and correct type, but poorly located.

5 = comply with legislation and regulations.



f) Alarm, Detection & Evacuation Systems

(i) Smoke Detectors Weighted Score: 1.5

Smoke detectors are an integral part of the early warning system and accordingly need to be located at appropriate centres with due consideration to the suitability of the locations chosen. They should also be connected to a fire indicator board located within the facility, with an external connection to the relevant fire brigade monitoring service.


0 = not provided.

1 = inadequate installations (number, location, domestic stand-alone type, etc.)

2 = not correctly installed.

3 = connected to external alarm bell only.

4 = connected to the relevant fire brigade monitoring service via a fire indicator board.

5 = connected to the relevant fire brigade monitoring service via an Emergency Warning and Intercommunication System (EWIS).



(ii) Heat Detectors Weighted Score: 1.0

Heat detectors are typically less effective for early warning than smoke units, but have their place in situations where smoke detectors could potentially register repeated false calls e.g. kitchens, laundries etc. Ideally a facility should exhibit an appropriate mix of both types of units.

Adequate installation of heat detectors is defined as comprising either total coverage throughout the facility, or alternatively installation in appropriate areas (kitchen, laundry) in conjunction with correct coverage of smoke detectors throughout the facility.


0 = not provided.

1 = inadequate installations (number, location, domestic stand-alone type etc.)

2 = not correctly installed.

3 = connected to external alarm bell only.

4 = connected to the relevant fire brigade monitoring service via a fire indicator board.

5 = connected to the relevant fire brigade monitoring service via an Emergency Warning and Intercommunication System (EWIS).



(iii) Manual Call Points Weighted Score: 1.0

Manual Call Points are important in the early stages of a fire to effectively raise the alarm and make the initial notification to an external monitoring centre. Ideally they should be appropriately distributed throughout a facility and be clearly identifiable as an emergency alarm system.


0 = not provided.

1 = single point only with local alarm only.

2 = few fitted with local alarm only.

3 = few fitted and poorly distributed, but with external connection.

4 = adequate numbers with external connection, but poorly distributed.

5 = comprehensive coverage with external connection.

(iv) Regular Maintenance Certification Weighted Score: 0.5

This relates to the existence and currency of regular maintenance certification of alarm, detection and evacuation systems which may exist within a facility irrespective of whether this is required by State legislation.

This will involve the sighting of certified maintenance records issued by an appropriately licensed and qualified company or authority and/or a legislative body.



Yes = Evidence of a regular current maintenance certification program provided.



g) Summoning Assistance and Evacuation Systems

(i) Public Address (Voice) Weighted Score: 0.75

The provision of a system for the paging of staff or for making emergency announcements will assist in the effective emergency evacuation of the facility.


0 = system not installed.

3 = system installed and operating, but in common areas only.

4 = system installed and operating in all areas except ablution or toilet areas.

5 = system installed and operating, with full coverage to all areas.

(ii) Staff Call Weighted Score: 0.75

Staff Call systems are used to summon staff in the event of a resident finding themselves in need of urgent aid. Therefore the type and distribution of staff call points throughout a facility should reflect the fact that they will be operated under some degree of distress.


0 = system not installed.

2 = system installed but with partial coverage only.

3 = system installed with full coverage, but location of resident controls makes it difficult to use.

4 = system installed with full coverage, but not with bed identification devices, i.e. room only.

5 = system installed with full coverage.



(iii) Other Alarms Weighted Score: 0.5

This relates to the existence of other adequate alarms throughout the facility for the purposes of warning occupants of fire, summoning assistance and security or personal monitoring. These alarms are additional to the systems outlined previously and could include:

• electronic paging system.

• personal monitoring devices.

• electronic security alarm on doors.

• localised warning devices.


0 = no additional alarm system(s) installed.

1 = one additional alarm with localised warning only, e.g. loud hailer, buzzer on door.

2 = two additional alarms with localised warning only.

3 = one additional alarm connected to a central monitoring system, e.g. pagers, personal monitoring devices.

4 = two additional alarms connected to a central monitoring system.

5 = several additional alarm systems installed or installation of a comprehensive additional system.



Section 2. Hazards (Section Weighting - 12 points)

This section relates to all types of hazards (other than “extreme hazards”) that may exist at a facility, with potential ramifications for both residents and staff. The internal and external environments of the facility need to be reviewed in terms of the potential risk of physical injury that may be present.

The majority of problems will most likely stem from areas such as maintenance, deterioration, unsuitable surfaces, landscaping and inappropriate installation of fittings and fixtures. Assessors may however expect to encounter a range of site specific conditions that are easily classified or included in the following listings.

It must also be noted that some residents may access areas that are not intended for their use and this must be considered in any evaluation of safety. Residents may be physically frail, mentally confused or sensorially impaired and therefore exposed to many differing types of dangers.

Discretionary scoring is to be employed to the circumstances existing at any facility, with the assessment based on the conditions encountered on the day of the assessment.

The assessment of hazards not only encompasses the specific hazards identified on site, but also maintenance records used to record the occurrence and rectification of hazards, and the level of proactivity employed to deal with the identification of hazards The purpose of these activities is to encourage a managed and effective approach to eliminating hazards and maintaining a safe environment for residents and staff.

This section has therefore been structured to specifically identify these issues.

(a) Maintenance Records Weighted Score: 4.0

Maintenance records are kept as a means of ensuring all identified hazards are rectified. This is achieved by signing and dating the record entry as firstly the hazards are identified, and secondly as they are rectified. Ideally the timeframe between identification and rectification should be in the order of 1 to 3 days to minimise the potential risk to staff and residents.

0 = no maintenance records provided.

1 = maintenance records provided but not used.

2 = items in maintenance records outstanding for a considerable period.

3 = maintenance records provided and used, but incomplete or poorly managed.

4 = most items dealt with in reasonable time frame i.e. 1 - 3 days.

5 = maintenance records up to date, signed and dated with all items addressed.



(b) Preventative Maintenance Programs Weighted Score: 2.0

The level of proactivity focuses on the identification of hazardous situations and the elimination of such before they develop and potentially lead to more dangerous situations.

0 = no method or procedure in place to deal with identification of hazards or possible hazardous situations (Negligence).

1 = limited method or procedure in place to identify and deal with hazards or possible hazardous situations.

2 = some attempt made to identify hazards, but actions taken in an inconsistent manner with no specific programs or documentation in place for recording and monitoring responses.

3 = hazards are identified and recorded in a reactive manner, but not addressed within a reasonable time frame.

4 = hazards rectified in a reasonable time as they become apparent, but no specific program in place to actively monitor and prevent hazardous situations.

5 = detailed preventative maintenance program in place, together with risk evaluation procedures which allow potential hazards to be identified and eliminated before they develop.

(c) Specific Hazards

The three components of Part (c) address the three specific groupings of hazards. A listing of commonly identified hazards is provided for each grouping, however due regard is required to be given to the severity of the hazard and its potential implications from the point of view of risk to residents and staff.

For example, hazards located in a main thoroughfare that may trip a resident such as uneven door thresholds, slippery floors or uneven external paving may result in a deduction of 2 marks, whereas those located in more remote areas may incur 1 mark penalties. Minor flaking paint in food preparation areas or above residents’ beds may warrant a deduction of only half a point.

The perceived threat to resident safety is therefore to be critically assessed with the marks for each identified hazard to be deducted from a maximum score of 5 for each section of Part (c).



(i) Internal Hazards Checklist Weighted Score: 2.0

(place in appropriate box, Yes indicates hazard exists)

Yes No

Slippery floor surfaces Slippery stairs nosings Overly thick carpet pile Overuse of power leads and double adapters Abrasive wall surfaces Handrail construction which pinches fingers or grip is too small/large Old or dilapidated electrical wiring or fixtures Ceiling fans too low Flaking paint Uneven door thresholds or floor surfaces Doors without viewing panels which swing into corridors and within corridors Proximity of heaters to furnishings/fittings etc. Others (list others encountered)

The discretionary score (0 - 5) allocated for the specified hazards may be dependent both on the seriousness of the hazards and the number encountered.

(ii) External Hazards Checklist Weighted Score: 2.0


Yes No

Uneven ground or paved surfaces Potential trip hazards on or near access paths and areas General maintenance of lawns - grass too long Overhanging tree branches Steps, steep ramps or banked areas without handrails Moss/slippery pavements Inappropriate storage of implements/equipment Others (list others encountered)




(iii) Special Hazards Checklist Weighted Score: 2.0


Yes No

Water features or swimming pools inappropriately constructed Proximity to hazardous conditions (e.g. busy roads, rivers, lakes, cliffs etc.) where the site perimeter is unsecured Site construction/refurbishment works Hydrotherapy pool without handrails Others (list others encountered)


Extreme Hazards - Explanatory Note

For the purposes of assessment, “extreme hazards” are defined as those hazards identified by the assessor which are considered “life threatening” and should be attended to as a matter of urgency. As indicated previously, they should generally not be looked upon in the same light by the assessor as “hazards” which are defined above.

Some examples of “extreme hazards” are:

• preliminary blocked fire escape doors.

• exposed electrical wiring .

• potential contamination by asbestos, flaking lead paint etc.

• no fire emergency warning system where required under BCA96.

• no fire suppression system in place as required under BCA96.

• extreme cases of structural instability.

In the case of an “extreme hazard” being identified at a particular facility, the assessor is required to complete an Extreme Hazards Report and forward it to the relevant State/Territory Office within 12 hours of completing the assessment.



Section 3. Privacy (Section Weighting - 26 points)

Section 3 considers issues in relation to the dignity and privacy of residents within an aged care facility. Specific aspects which are assessed include:

• number and distribution of beds.

• privacy afforded to residents by the movement of others in and around the site.

• number, configuration and distribution of toilets and ablution (shower and bath) facilities throughout the building; and

• appropriate screening of toilets and ablution facilities, taking into account the dignity and privacy of residents.

(a) Distribution of Beds Weighted Score: 8.0

The table requires completion to identify how many rooms/wards in the facility contain one, two, three etc. beds. The second row to be completed summarises the number of residents in total that could potentially occupy beds in any given size of room e.g. three rooms each containing five beds can potentially accommodate fifteen residents.



(b) Privacy of Special Use Rooms Weighted Score: 3.0

This question considers issues in relation to the location and adequate screening of special use or multi-functional rooms to ensure privacy during their use by residents, staff and visitors.

Special use rooms are rooms, other than residents’ sleeping rooms and bathrooms, which are used by residents for purposes for which visual and acoustic privacy would be a reasonable expectation in a homelike environment eg small meeting rooms, rooms used for consultation with visiting specialists eg doctors, podiatrists.

Factors to consider in this assessment include:

• location of rooms in relation to main thoroughfares within a building.

• availability of rooms with adequate screening for privacy if required.


0 = location of all rooms provide no privacy.

3 = location adequate in majority (>50%) of cases.

4 = location adequate in most (≥75%) cases.

5 = location provides excellent level of privacy in all cases.



(c) Privacy of Residents Weighted Score: 2.0

This question addresses the privacy of individual residents within their own sleeping spaces.

Consideration should be given to the effectiveness of privacy measures in ensuring an appropriate level of privacy from other persons within the room and from passageways and thoroughfares.

Scores are allocated according to following:

0 = no privacy provided to residents by screening.

1 = basic screening (eg. non-closing curtains with bottom edge more than 100 mm from floor, portable screens) provided to residents in majority (>50%) of shared bedrooms.

2 = basic screening (eg. non-closing curtains with bottom edge more than 100 mm from the floor, portable screens) provided to residents in all shared bedrooms.

3 = curtains that are opaque in all conditions, fully enclose the sleeping space with bottom edge no more than 100 mm from the floor provided to residents in majority (>50%) of shared bedrooms OR solid screening which provides the same level of privacy or better.

4 = curtains that are opaque in all conditions, fully enclose the sleeping space with bottom edge no more than 100 mm from the floor provided to residents in most (>75%) shared bedrooms OR solid screening which provides the same level of privacy or better.

5 = curtains that are opaque in all conditions, fully enclose the sleeping space with bottom edge no more than 100 mm from the floor provided to residents in all shared bedrooms OR solid screening which provides the same level of privacy or better.



(d) Ablution Facilities

(i) Number of Ablution Facilities Weighted Score: 3.0

A numeric response is required for this question to indicate the total number of ablution facilities (showers and baths) that are used by residents. This total should exclude those used for other purposes such as storage that would prevent their intended use. Comments relating to the identification of ablution facilities that are used for other purposes are essential.

(ii) Configuration Weighted Score: 2.0

An important issue when considering the adequacy of ablution facilities is that access or use of the facilities by residents and staff is not limited or restricted. The need for assistance by most residents and the increasing use of mobility aids will impact on the appropriateness of the form, nature and construction of such amenities.

Strict compliance with codes may be relaxed by authorities to accommodate the need to provide care to high dependency, older or increasingly frail residents. Where no specific legislation applies, approximately 50% of ablution facilities should allow mobility aids and staff assistance.

Scores are allocated to the following:

0 = poor access potential, no scope for assisted or independent usage.

1 = poor access potential, limited scope for assisted or independent usage.

2 = fair access provisions with limited scope for assisted or independent usage.

3 = fair access provisions and partial allowance for assisted or independent usage in the majority of facilities.

4 = some minor non-compliance with regulations relating to such issues.

5 = complies with regulations relating to such issues. The majority of ablution facilities provided take account of the limited mobility and high dependence of residents and the requirements of staff.



(iii) Screening of Ablution Facilities Weighted Score: 1.5

This question considers the provision of adequate screening of ablution facilities in preserving the privacy and dignity of the residents.

Factors to be considered include:

• location of ablution facilities in relation to main thoroughfares.

• provision of suitably constructed air locks or fixed wall screening where the ablution facility opens onto a passageway or public room. It is considered that the use of shower screens behind main doors is inappropriate.

• line of sight from outside the ablution facility to users of it.

• number and configuration of facilities within an ablution block.

Scores are awarded according to the following:

0 = no adequate provision for privacy screening of ablution facilities.

3 = ablutions facilities are adequately screened for the residents’ privacy in the majority (>50%) of cases.

4 = ablutions facilities are adequately screened for the residents’ privacy in most (≥75%) cases.

5 = ablution facilities are adequately screened for the privacy of the residents in all cases.



(e) Toilet Facilities Weighted Score: 3.0

(i) Number of Toilet Facilities

A numeric response is required for this question to indicate the total number of toilet facilities that are used by residents, but excludes those toilets that are used for other purposes such as storage, that would prevent their intended usage. Comments relating to the identification of toilet facilities that are used for other purposes are essential.

(ii) Configuration Weighted Score: 2.0

An important issue when considering the adequacy of toilet facilities is that access or use of the facilities by residents and staff is not limited or restricted. The need for assistance by most residents and the increasing use of mobility aids will impact on the appropriateness of the form, nature and construction of such amenities.

Strict compliance with codes may be relaxed by authorities to accommodate the need to provide care to high dependency, older or increasingly frail residents. Where no specific legislation applies, approximately 50% of ablution facilities should allow mobility aids and staff assistance.

Scores are allocated to the following:

0 = poor access potential, no scope for assisted or independent usage.

1 = poor access potential, limited scope for assisted or independent usage.

2 = fair access provisions with limited scope for assisted or independent usage.

3 = fair access provisions and partial allowance for assisted or independent use in the majority of facilities.

4 = some minor non-compliance with regulations relating to such issues.

5 = complies with regulations relating to such issues. The majority of amenities provided take account of the limited mobility and high dependence of residents and the requirements of staff.



(iii) Screening of Toilet Facilities Weighted Score: 1.5

This question considers the adequacy of screening for toilet facilities in preserving the privacy and dignity of the residents.

Factors to be considered include:

• location of facilities in relation to main thoroughfares.

• provision of suitably constructed air locks or fixed wall screening where the toilet facility opens onto a passageway or public room. It is considered that the use of shower screens behind main doors is inappropriate.

• line of sight from outside the toilet facility to users of it.

• number and configuration of facilities within a toilet block.

Scores are awarded according to the following:

0 = no adequate provision for privacy screening of toilet facilities.

3 = toilet facilities are adequately screened for the residents’ privacy in the majority (>50%) of cases.

4 = toilet facilities are adequately screened for the residents’ privacy in most (≥75%) cases.

5 = toilet facilities are adequately screened for the privacy of the residents in all cases.



Section 4. Access, Mobility and Occupational Health & Safety (Section Weighting - 13 points)

This section of the assessment is primarily concerned with the accessibility and amenity of the facility in general. The focus is on the ease with which residents and staff can utilise and move about the facility.

Australian Standards will apply to certain parts of this section and consideration should also be given to relevant State legislation. In particular, specific legislation should be considered when reviewing such aspects as grab rails and ablution facilities.

It should be noted that in many facilities assessed, a proportion of residents will require assistance in all aspects of their daily activities. Therefore, the performance of those issues to be evaluated should be assessed with this in mind. The assessment of adequate space requirements needs to be conducted in light of the fact that not all residents are independently mobile and some may need to be moved around the facility in large wheel chairs, lifting harnesses or beds.

(a) Number of Floors Weighted Score: 3.0

Whilst the front of the assessment instrument and report lists the number of storeys relevant to the building in general, from the point of view of access and mobility of residents this is not necessarily equivalent to the number of floors.

The number of floors in Section 4 refers to those levels within a building to which residents have a reasonable right of access. This includes all activities areas and the rooms of other residents for socialising. This also includes floors where the other residents may actually reside in a facility with a separate approval number, either upstairs or downstairs.

The number of floors must also include a floor with access to external ground level. For example, if a facility has all residents residing on the second floor with only laundry services etc. on the lower floor, it would be regarded as a building with one floor providing that the second floor containing the residents has direct access to the ground outside, but as a building of two floors if ground level access is via the lower level only.

(b) Provision of a Lift Weighted Score: 3.0

Any lift for the use of passengers is to be assessed on the basis of its ability to be operated by residents independently. Evidence of the pending or progressive installation of a lift in a facility shall be treated as if the lift were already installed.


A facility deemed to have one floor does not require a lift and will therefore receive full marks.



(c) Ramps - Internal / External Weighted Score: 3.0

The provision of appropriate ramps in lieu of stairs both in and about a facility is of considerable importance in assisting the independence of residents and in aiding staff to assist residents. The nature and appropriateness of such ramps, and the potential for unassisted use by residents need to be considered.

Scores are allocated according to the following guidelines:

0 = no ramps are provided in situations where they would normally be required or reasonably be expected.

1 = insufficient ramps are provided where they would reasonably be expected.

2 = some ramps have been provided, but are inappropriate for independent use.

3 = stairs have been converted to form ramps of an unsuitable nature or ramps have been retro-fitted to provide some level of amenity. Limited potential for independent use.

4 = most ramps comply with codes, but others may be too steep or have insufficient or inappropriate railings.

5 = ramps purpose built, comply with codes and standards and are of such a nature as to facilitate independent, safe use by residents.



(d) Grab Rails Weighted Score: 2.0

Wherever assisted mobility may be an issue it is necessary for grab rails to be fitted. Standards and legislation covering this issue should be consulted. These provide basic guidelines for such installations but assessment should be significantly weighted by a demonstrated need. The type, size and materials used should be considered in the evaluation, as should the provision of grab rails in external areas. Other issues to be considered are continuity of rails along walls and around corners and provision along both sides of the corridor where widths permit.


0 = no rails provided.

1 = limited or inappropriate provision or type of rails.

2 = inappropriate type of rails, but adequate coverage.

3 = appropriate type of rails but insufficient numbers provided.

4 = generally appropriate type of rails with some minor sections either non-continuous or inappropriate.

5 = complies with all codes and regulations, and fitted to accommodate demonstrated use patterns.



(e) Circulation and Communal Areas Weighted Score: 1.0

The principal concern of this question is to ensure that appropriate amounts of circulation space are provided to accommodate the anticipated needs of disabled/impaired residents.

Evaluation of this should consider the impact of inadequate corridor widths, congestion of circulation space and handrails provided internally and externally to all areas.


0 = generally no scope for unhindered movement for disabled or impaired residents.

1 = limited scope for unhindered movement, permanent storage of goods or equipment restricting access, resident and staff amenity significantly compromised.

2 = some areas demonstrate unhindered movement, however significant restrictions inhibit movement of residents.

3 = some restrictions encountered in the typical use of primary thoroughfares. Reduced circulatory flexibility.

4 = the majority of mobility needs are met however some restrictions are encountered.

5 = facilitates free and efficient movement of residents and staff and takes full account of mobility needs and operational imperatives. All areas adequately provided with handrails.



(f) Human Engineering Weighted Score: 1.0

This relates to the interface between the facility and residents or staff. This would incorporate such items as door hardware, appropriateness of fixtures and fittings and the adjustment/manipulation of such items by users.

Consideration should be given to specific issues including handles on taps and doors (including height of handles), temperature control of hot water systems, light switches and climate control devices.


0 = little or no allowance for the special needs of users.

1 = limited allowance for special needs of users with numerous inadequacies.

2 = limited allowance for special needs of users with some inadequacies.

3 = reasonable provision of appropriate fittings and fixtures, with some inadequacies.

4 = some special needs not addressed with the majority of issues provided for.

5 = excellent level of human engineering exhibited throughout the facility.



Section 5. Heating and Cooling ( Section Weighting - 6 points)

(a) Adequate Provision - Heating Weighted Score: 2.0

The necessity and importance of heating can be established from the Winter Outdoor Design Temperature (dry bulb) for comfort conditions (WOT).

In accordance with Fig 2-10F: Air Treatment Zones Adopted by the Australian Government, as detailed in the “Australian Institute of Refrigeration, Air-conditioning and Heating (AIRAH) Application Manual for Humid Tropical Air-conditioning”, specific zones have been defined which detail the requirements for heating within a facility for different locations throughout Australia.

These zones are illustrated graphically on Figure 5.1 and are defined as follows:

• Zone 1 - WOT > or = 15oC Only local temporary heating is necessary.

• Zone 2 - 7oC > WOT > 15oC Basic heating is necessary.

• Zone 3 - WOT < or = 7oC Quality heating is necessary.

The following list outlines a range of possible heating systems listed in order from basic to more sophisticated:

H1 Solid fuel stoves, fire places H2 Electrical radiant elements or heating fans H3 Electrical wall panel heaters H4 Gas space heaters H5 Gas ducted heating system H6 Hydraulic radiator system or fan-coil system H7 Hydraulic floor heating system H8 Electrical floor heating system H9 Reverse cycle air-conditioning - room air conditioner H10 Reverse cycle air-conditioning - split (non-ducted) H11 Reverse cycle air-conditioning - ducted, central



Scores for defining the adequate provision of heating within a facility are determined according to the following criteria with intermediate scoring permissible where a mixture of systems exist:

0 = little or no ability to ensure comfort control over heating.

3 = active and passive measures exist for the basic control of prevailing thermal conditions, e.g. heaters.

5 = extensive ability to control conditions exemplified by full, reverse cycle air-conditioning or equivalent (depending on local conditions).

The following table summarises the systems satisfying the evaluation criteria above for the three zones:

Score Zone 1 Zone 2 Zone 3

0 None None, H1 None, H1, H2

3 H1, H2 H2, H3 H3, H4, H9

5 H3-H11 H4-H11 H5-H11 (except H9)





(b) Adequate Provision - Cooling Weighted Score: 2.0

The necessity, importance and suitable type of cooling can be established from the Summer Outdoor Design Temperatures (dry bulb and wet bulb) for comfort conditions. (SOT-DB & SOT-WB)

Specific zones have been defined again using the reference outlined in Section 5(a), which detail the requirements for cooling within a facility for different locations throughout Australia.

These zones are illustrated graphically on Figure 5.2 and are defined as follows:

• Zone 1 - SOT-DB > 35oC and/or SOT-WB > 22oC - Refrigerated cooling is necessary.

• Zone 2 - 30oC < SOT-DB < 35oC and SOT-WB < or = 22oC - Evaporative cooling acceptable.

• Zone 3 - SOT-DB < or = 30oC - Only air moving devices i.e. fans are necessary.

The following list provides a summary of the possible cooling systems listed in order from basic to more sophisticated:

C1 Local fixed or portable fans C2 Ceiling sweep fans C3 Evaporative cooling - room-type C4 Evaporative cooling - ducted (Note: supply air is humid) C5 Add-on coil cooling system (to ducted heating) C6 Room air conditioner C7 Split air-conditioner (non-ducted) C8 Refrigerated air-conditioning - ducted C9 Chilled water system with fan-coil units



Scores for defining the adequate provision of cooling within a facility are determined according to the following criteria with intermediate scoring permissible where a mixture of systems exist:

0 = little or no ability to ensure comfort control over cooling.

3 = active and passive measures exist for the basic control of prevailing thermal conditions, i.e. fans.

5 = extensive ability to control conditions exemplified by full, reverse cycle air-conditioning or equivalent (depending on local conditions).

The following table summarises the systems satisfying the evaluation criteria above for the three zones:

Score Zone 1 Zone 2 Zone 3

0 None, C1 None None

1 C2 C1 None

2 C3, C4 C2 None

3 C5, C6 C3 C1

5 C7-C9 C4-C9 C2-C9





(c) Occupant Control - Heating Weighted Score: 1.0

This question considers the level of potential control available to individual residents in respect of heating equipment provided at the facility. Scores are allocated according to the following criteria, with intermediate scoring permissible where a mixture of different levels of control exist:

0 = no real control or ability to influence climatic conditions

• no heating equipment provided at the facility

• no automatic temperature regulation device

3 = basic control of conditions possible in a general, whole of facility sense

• central temperature control

5 = each resident has individual control of conditions within their own living area

• zone temperature control (reheat or damper)

• thermostatic radiator valves

• temperature controller of individual heating equipment

(d) Occupant Control - Cooling Weighted Score: 1.0

This question considers the level of potential control available to individual residents in respect of cooling equipment provided at the facility. Scores are allocated according to the following criteria, with intermediate scoring permissible where a mixture of different levels of control exist:

0 = no real control or ability to influence climatic conditions • no cooling equipment provided at the facility • no automatic temperature regulation device

3 = basic control of conditions possible in a general, whole of facility sense • central temperature control

5 = each resident has individual control of conditions within their own living area • zone temperature control (reheat or damper) • thermostatic radiator valves • temperature controller of individual cooling equipment



Section 6. Lighting / Ventilation (Section Weighting - 6 points)

(a) Adequate Provision - Lighting Weighted Score: 2.0

(i) Illumination Levels

The lighting levels required within a facility from artificial light sources shall be in accordance with recommendations for service illumination levels as defined in AS 1680.

The following checklist is provided to determine the adequacy of illumination levels for each of the specified areas within a facility. The illumination levels shall be determined by measurement with a Lux Meter and shall be taken as the average of the relevant areas throughout the entire facility.

Adequate Illumination Level Area Recommended

Illumination Level Yes No

• Entry 150 lux

• Living 150 lux

• Bedroom

- General areas 150 lux

- Bedside reading 240 lux

• Corridors and Hallways 100 lux

• Kitchen


- Task area (food preparation) 300 lux

• Recreation 300 lux

• Bathroom


- Basin / mirror 300 lux



(ii) Natural and External Lighting

The amount of natural daylight into the rooms of the facility shall be adequate to allow visibility for unhampered movement on a normal clear day. Ability for an occupant to be able to distinguish between night and day is essential.

In bedrooms and especially multiple-bed sleeping rooms a reading light shall be provided to each individual bed with a control switch which is easily accessible by the occupant in the bed.

Entrances and exits shall be adequately lit at night by the provision of external light fittings as appropriate.

The following checklist is provided as an indication of the adequacy of the facility in relation to natural and external lighting.

Adequate Illumination Level Question

Yes No

• Are occupants able to distinguish between day and night in the following rooms:

- Living

- Bedroom

- Recreation

• Is there an external light fitting at entrance to facility?

• Is a reading light provided at each bed?

• Is mobility maintained around the bedroom without the aid of artificial light?

The scoring for the adequacy of lighting is to be awarded out of a possible 5 marks and shall be evaluated on the proportion of the number of “Yes” responses.



(b) Adequate Provision - Ventilation Weighted Score: 2.0

Ventilation may be achieved via natural or mechanical means or a combination of the two.

Functionally, the two mechanical ventilation systems should be differentiated as follows:

• Fresh air supply for occupants

• Exhaust ventilation (i.e. odour removal)

Natural ventilation criteria are related to the area of openings (doors & windows) and are defined in the BCA96 as a minimum of 5% of floor area.

Mechanical ventilation criteria are usually described in terms of air flow or air change rates as defined in AS1668.2.

Whilst natural ventilation is preferred to be controlled by the individual, mechanical ventilation should be automatic in most situations.

Scores for defining the adequate provision of ventilation are given according to the following criteria with intermediate scoring permissible where a mixture of the level of ventilation exists, e.g. RAC or A/C in some sections of the facility.

0 = limited or no capacity to effect necessary levels of ventilation

• no adequate openings for natural ventilation (no mechanical ventilation).

3 = basic ventilation operates effectively in primary areas

• adequate openings in bedrooms and in living areas

• fixed or adjustable vents in ablution facilities

5 = effective ventilation available to all parts of the facility and achieving legislated rates of air change.

• adequate openings in every room, or

• ducted, central system with fresh air supply, or

• RAC or split A/C with fresh air supply

• mechanical ventilation for ablution facilities



(c) Occupant Control - Lighting Weighted Score: 1.0

The ability or at least the potential for residents and staff to exercise control over the status, operation and adjustment of lighting.

Scores are allocated according to the following criteria with intermediate scoring permissible where a mixture of different levels of control exist:

0 = no real control or ability to influence lighting

3 = basic control of conditions possible in a general, whole of room sense.

5 = each resident has individual control of lighting within their own living area.

(d) Occupant Control - Ventilation Weighted Score: 1.0

The ability or at least the potential for residents and staff to exercise control over the status, operation and adjustment of ventilation.

Scores are allocated according to the following criteria with intermediate scoring permissible where a mixture of different levels of control exist:

0 = no real control or ability to influence ventilation rates

• fixed ventilation devices or no devices installed

3 = basic control of conditions possible in a general, whole of facility/room sense.

• windows, doors and adjustable louvers in common areas

• manually controlled exhaust ventilation systems

• central, ducted system with fresh air intake

5 = each resident has individual control of ventilation within their own living area

• windows, doors or adjustable louvers in every room

• room air conditioner with fresh air damper

• automatic exhaust ventilation systems



Section 7. Security (Section Weighting - 12 points)

The physical security of residents and staff is very important in the assessment of the functional amenity of an aged care facility. Security can relate to threats from external sources as well as protection for residents from placing themselves inadvertently at risk.

The appropriate level of security can only be evaluated as what would reasonably be required in the event of demonstrated or perceived risks. It is vital that the security measures adopted do not compromise the effective evacuation of people from the area in the event of an emergency.

Evaluation is to be confined to the impact of security issues on the built fabric of the facility.

(a) Securing of Possessions Weighted Score: 2.0

This question relates to the ability of residents to secure their personal effects on an individual basis, and the control of access to them. Due regard must be given to the adequacy of storage; for example, lockable wardrobe or chest of drawers (adequate capacity) as opposed to a lockable drawer (limited capacity).


0 = no provision of lockable, resident controlled spaces, or facility controlled storage of goods and effects.

2 = policy in place to supply adequate lockable storage in residents’ rooms on request, but not uniformly applied.

3 = lockable storage in residents rooms of limited capacity.

4 = lockable storage in most residents’ rooms of adequate capacity for each resident.

5 = lockable storage in residents’ rooms of adequate capacity for all residents, or the ability to secure entire room with access controlled by the resident.



(b) Securable Building Weighted Score: 4.0

This question considers the ability to secure the building in order to address any demonstrated or perceived risks to residents or staff in the normal operations of the facility.

Some items to be taken into consideration include the following:

• exits unlocked from the outside to permit undetected entry

• entry to the facility through a single point of entry in view of staff

• security sensor lights

• security patrols at night

• alarmed doors and windows

• security screens where appropriate

• pagers connected to security system.

The amenity of the facility is not to be unacceptably compromised by the security level adopted.


0 = poor level of demonstrated building security, both active and passive e.g.. undetected entry to the facility possible through unlocked exits.

2 = controlled entry to the building but no alarm mechanisms in place.

3 = acceptable level of security provided and supported by the facility, such as screening where appropriate and some alarm mechanism.

4 = extensive internal security measures but limited ability to monitor external threats/conditions.

5 = extensive security measures in place including electronic and physical measures.



(c) Securable Site Perimeter Weighted Score: 2.0

This question addresses the ability of a facility to secure its perimeter in order to address any demonstrated or perceived risks to residents or staff in the normal operations of the facility.

The requirement for a secure perimeter or extent of security is essentially site specific and involves consideration of the location of the site, surrounding conditions (including hazards such as roads and bodies of water etc.), as well as the continuity of the perimeter security. Perceived risks to staff also requires consideration in situations such as secure access to car parking on site.

Sites located in open and remote areas may not require a secure perimeter providing no hazardous situations exist close to the facility, and there are no perceived risks from external intrusion.

Similarly the secure perimeter requirements may differ for a facility contained in a larger secured site. Secured courtyards may be the appropriate requirements.

The amenity of the facility is not to be unacceptably compromised by these measures.


0 = open and unsecured site, little or no control or monitoring of perimeter, where a securable site is required.

2 = some physical measures adopted to exercise control but are ineffective (i.e. no gates or sections of fence missing).

3 = some physical and electronic measures adopted to exercise control or monitoring of perimeter.

4 = high level of security appropriate to the site and residents, with minor deficiencies in the integrity of the security measures.

5 = high level of security appropriate to the site, that operates in such a manner as not to impinge inappropriately upon the movement and interactions of staff and residents, or a securable site is not required.



(d) Security Compatibility Weighted Score: 4.0

This question relates to the compatibility and appropriateness of the security in general with regard to evacuation requirements, circulation and emergency access needs.

The key issue is to ensure that the security measures employed to protect the site from perceived risks do not hinder the emergency evacuation and access needs. This incorporates the types of locking mechanisms on exits - both electronic and mechanical, and whether they are automated for release under an emergency evacuation situation.


0 = security totally incompatible with evacuation and other emergency procedures.

2 = most aspects of security incompatible with evacuation and other emergency procedures

3 = some aspects of security incompatible with evacuation and other emergency procedures, and most issues readily rectified with evacuation and other emergency procedures.

4 = security, generally compatible with minor non-conformances.

5 = security fully compatible with evacuation and other emergency requirements.

Documents

Aged Care Certification Guidelines - CH Groupchgroup.com.au/documents/Guidelines_Nov_2002.pdf · Commonwealth Department of Health and Ageing - Aged Care Certification ... and represents