Anam Cara - Aged Care QualityAnam Cara RACS ID 5355 52 Lavarack Road BRAY PARK QLD 4500 Approved provider: The Uniting Church in Australia Property Trust (Q) Following an audit we

Anam Cara RACS ID 5355

52 Lavarack Road BRAY PARK QLD 4500

Approved provider: The Uniting Church in Australia Property Trust (Q)

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 7 December 2015.

We made our decision on 15 October 2012.

The audit was conducted on 3 September 2012 to 5 September 2012. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. This home is a 2012 Better Practice Award winner. Click here to find out more about their award.

Home name: Anam Cara Date/s of audit: 3 September 2012 to 5 September 2012 RACS ID: 5355

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Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

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

Expected outcome Accreditation Agency

decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal care

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

Expected outcome Accreditation Agency decision




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


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Standard 3: Resident lifestyle

Principle:

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


decision




3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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


decision




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

Anam Cara 5355


Introduction This is the report of a re-accreditation audit from 3 September 2012 to 5 September 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 Accreditation Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home. Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 3 September 2012 to 5 September 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team

Team leader: Erin Gorlick

Team member/s: Paula Gallagher

Approved provider details


Details of home

Name of home: Anam Cara

RACS ID: 5355

Total number of allocated places:

105

Number of residents during audit:

100

Number of high care residents during audit:

100

Special needs catered for:

Secure dementia specific areas

Street/PO Box: 52 Lavarack Road State: QLD

City/Town: BRAY PARK Postcode: 4500

Phone number: 07 3881 7881 Facsimile: 07 3881 7882

E-mail address: [email protected]


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

Number Number

Management 5 Residents/representatives 14

Nursing staff 14 Lifestyle staff 3

Support staff 3 Hospitality staff 6

Client services staff 2 Safety and maintenance staff 4

Allied health staff 4

Sampled documents

Number Number

Residents’ files 9 Medication charts 27

Summary/quick reference care plans

9 Personnel files 8

Other documents reviewed The team also reviewed:

Action plans

Activities calendars and documentation

Admission paperwork

Annual review guidelines

Audits tools and data results

Catering and food safety documentation

Chaplaincy documentation

Cleaning schedules

Comments and complaints register and documentation

Controlled drug register

Criminal record checks

Exceptional report events

Fire and evacuation documentation

Hazard substance register and risk assessments

Improvement log register and documentation

Infection control documentation

Mandatory reporting documentation

Material safety data sheets

Medication and pharmacy documentation

Meeting minutes


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Newsletter

Observation records

Pet care plans

Policy and procedures

Preventative and reactive maintenance documentation

Registration checks for registered nurses

Resident handbook

Self-assessment

Staff education and competency documentation

Staff information package and orientation program Surveys

Temperature monitoring charts

Weight records

Workplace health and safety documentation Observations The team observed the following:

Activities in progress

Charter of residents’ rights and responsibilities

Cleaning in progress

Coded entry and exit points

Colour coded cleaning equipment

Emergency evacuation plans displayed throughout

Emergency exits, lighting and paths of egress

Equipment and supply storage areas

Fire fighting equipment and inspection tags

Information storage areas

Interactions between staff and residents

Internal and external living environment

Medication delivery

Men’s shed

Midday meal service and delivery

No smoking signage

Notice boards and brochures

Outbreak and emergency kits

Personal protective equipment in use

Religious services

Resident and pet interactions

Secure suggestion boxes


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Staff using personal protective equipment

Storage of medications


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Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Residents/representatives and staff interviewed advised they are encouraged to discuss and contribute at meetings and they are satisfied with management’s responsiveness to suggestions. The organisation has a framework to identify, plan, implement, review and evaluate continuous improvement activities within the home. Staff, residents and representatives contribute to the improvement system through written improvement logs, resident and staff meetings, surveys, internal and external audits, hazard/incident alerts, data collection and analysis. A plan for continuous improvement is maintained by the Director of Nursing and is used to track improvements. Evaluation and monitoring of progress of improvement actions occurs via formalised meeting structures, integration of local plans within the framework of the strategic plan and residents and staff surveys. Examples of improvement initiatives related to Standard 1 Management systems, staffing and organisational development implemented by the home include:

As part of the process of implementing the Eden Alternative, Anam Cara has taken specific steps for attracting and retaining skilled staff. This has included the introduction of key elements aimed to honour and encourage staff members through empowerment, involvement, acknowledgement and growth. Management reported by ensuring staff members are empowered, involved, growing and acknowledged the home has maintained a high level of staff retention. The home received a better practice award nomination for this Eden principle.

Management identified the production process of the monthly newsletter consumed many hours of key personnel time during the printing and assembling stage and was not efficient. As a result the responsibility for the production of the home’s monthly newsletter has been allocated to the organisation’s disability employment initiative which specialises in commercial printing. Management reported this has resulted in a more efficient deployment of personnel and a better quality of production, while supporting and promoting internal services within the organisation.

To support the clinical nurses and the leisure and lifestyle coordinators in their leadership roles and improve interaction across the two groups, management sent designated key staff members on a management course. Management reported through attending the course, the clinical nurses/leisure and lifestyle coordinators have enhanced their leadership skills and have become empowered to be involved in facilitating residents/representative in decision making.


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1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The home has established systems to identify and ensure compliance with current legislation, professional standards and industry guidelines through corporate office, government and industry peak body membership. The information is disseminated to the Director of Nursing who updates policies or procedures, where required, and distributes relevant information through memoranda and meetings to staff for acknowledgement and action such as training. Where changes to legislation directly affect the day to day lives of the residents this is discussed at the residents community meetings. A spread sheet is used to record evidence of regulatory compliance such as police certificate checks for staff and volunteers. Systems to inform residents, their representatives and other stakeholders of complaints mechanisms are effective. Compliance with legislation is monitored through the audit process, staff and resident feedback and observation of staff work practices. 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Residents/representatives interviewed reported staff have sufficient skills and knowledge to attend to residents’ needs. The home’s education program ensures management and staff have the knowledge and skills to perform their roles effectively. Procedures include a comprehensive local and organisation orientation, mandatory training/competencies, self-directed learning packages, identified training needs and other development opportunities. There is a “buddy” system in place to support new staff through the induction and orientation process. An education calendar is developed and reviewed regularly using information collected through a response to residents changing needs, changes to legislation, opportunities for improvement, performance evaluations and training needs analysis. Education sessions are communicated to staff via education flyers placed on the staffroom notice board and/or nurses’ station and verbal notification. Records of attendance and training evaluation are maintained to ensure all staff have attended and attained mandatory and elective training. Staff interviewed report they receive appropriate education to enable them to perform their duties effectively. 1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Residents/representatives and staff interviewed reported they have access to internal and external complaints mechanisms and are satisfied with the way feedback is managed. The home has systems and processes to ensure each resident, representatives and other interested parties have access to internal and external complaints mechanisms and advocacy services. Information is provided in formal resident agreements, the resident


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handbook and during orientation to the home. Feedback forms and secure suggestion boxes, brochures and literature regarding external and internal complaints are available and accessible to residents/representatives throughout the site. A complaints register is maintained, by the Director of Nursing and written follow up is provided when requested and ensures confidentiality and anonymity where necessary. Staff are informed of the customer complaint and feedback process at orientation and via the employee guidelines. Management and staff advised they have access to external interpreter services for non-English speaking residents should the need arise. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The organisation has a documented mission statement, which includes their vision, values, philosophy, objectives and quality commitment. The organisation’s mission statement is published in a number of documents, including resident and staff handbooks and procedures manual. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome Residents/representatives interviewed are satisfied with the responsiveness of staff and that their level of skill is sufficient to meet residents’ needs. Management review staff hours and workload in line with changes in residents’ care needs to ensure there are sufficient and appropriately skilled and qualified staff. Rosters are planned in advance, which includes access to qualified staff 24 hours a day, with planned and unplanned leave filled by permanent part time staff members and/or agency staffing should the need arise. Recruitment and selection processes are managed by the organisation’s Human Resource Manager in conjunction with the Director of Nursing and include a corporate and local orientation program with associated buddy shifts. Duty lists, position descriptions and policies and procedures are available to direct staff work practices and performance is monitored through competency assessed training, observation of practice, and annual performance appraisals and mandatory training. Monitoring of appropriate registration and police certificate checking occurs to ensure appropriateness of staff appointed. Staff interviewed are satisfied they have sufficient time and appropriate skills to carry out their duties effectively.


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1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome Residents/representatives and staff interviewed are satisfied with the availability, suitability of goods and equipment. The home follows the organisation’s central purchasing procedures to ensure appropriate stocks of goods and equipment are available for quality service delivery. Stock control including levels, labelling, secure storage, rotation and other practices ensure the home can verify the safety, working order and useability of appropriate goods and equipment. The maintenance department oversees the corrective and preventative maintenance program to ensure equipment is identified, maintained, repaired, or replaced as required. Regular audits are undertaken to ensure goods and equipment are maintained at sufficient levels. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome Residents/representatives interviewed reported sufficient information is provided and residents’ personal and private information is managed sensitively and appropriately. The home has processes to guide the effective collection, use, storage and destruction of information in accordance with regulatory requirements. Staff receive information relevant to their specific roles through policies and procedures, care plans, memoranda, e-mail, electronic calendar notification, at handover and during meetings. Electronic information is secured by individual password access and systems are in place for the automatic back up of all information stored electronically on the organisation’s server. Security of confidential information is maintained and all staff sign a code of conduct as part of the recruitment process. There is a system to archive material and for appropriate destruction of files and documentation. Residents/representatives are provided with information when moving into the home, in meetings, on notice boards, newsletters and by verbal reminders from staff. Staff interviewed advised us they have access to sufficient information to perform their role. 1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome Staff and residents interviewed are satisfied with externally sourced services provided by the home. Processes ensure all externally sourced services are provided in a way that meets the organisation’s needs and service quality goals. Processes at head office include formal service agreements with suppliers and service providers, which contain reference to relevant legislation and guidelines. A preferred suppliers’ list is available for staff. In conjunction with head office, the home reviews the performance of external services to ensure quality service delivery is maintained. External service providers are given the opportunity to improve their service and or take appropriate action if required. Quality of service is monitored through


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input by management, maintenance department, staff and residents’ feedback and annual reviews of performance are conducted


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes. Examples of improvement initiatives related to Standard 2 Health and personal care implemented by the home include:

In response to feedback from an internal clinical audit that identified medications such as for indigestion relief and eyes drops were not dated, management implemented a label ‘Opened On’ to indicate when the product was opened and the use by date once opened. Management and staff reported the use of the label provides a clear guideline for staff and is in line with better practice.

Due to inconsistencies noted between the multiple copies of resident dietary profiles when a change occurs, management have ceased the use of paper based dietary profiles and initiated using an electronic data system for all dietary profiles. The data system allows the registered staff and/or allied health professional to amend individual residents’ dietary profiles on-line without delay. The data system allows all departments and relevant staff to access residents’ current and correct information to ensure residents receive their correct nutrition and hydration requirements.

Feedback from the residents ‘Gym satisfaction survey’, indicated residents wanted a greater variety of exercises, longer and more frequent exercise sessions and different types of exercise equipment. The exercise group ‘gym’ assists residents to maintain and/or strengthen movement control and balance. In response to residents’ requests management, in conjunction with the physiotherapist, purchased additional equipment such as but not limited to, soft foam balls, rhythm ribbon sets and a chime ball (a ball containing a bell inside for vision impaired residents). A variety of different exercise programs have been rostered on alternating fortnights. Residents reported satisfaction with the newly implemented equipment and programs.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes. In relation to Standard 2 Health and personal care, a register is used to record evidence of regulatory compliance such as staff’s professional registrations with systems to ensure


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appropriately qualified staff are in place. Compliance with legislation is monitored through the audit process, staff and resident feedback and observation of staff work practices. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s 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 systems and processes. In relation to Standard 2 Health and personal care, examples of training and education undertaken by staff include:

Wound management

Sensory loss

Sharps and body fluid exposure

Poor balance and unsteadiness 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Appropriate clinical care is delivered to residents’ by qualified staff following a process of assessment and care planning. On entry to the home registered staff develop an interim care plan for individual residents to guide staff practice. The interim care plan remains in place during a period in which standardised focused assessments are completed to formulate in individual care plan for each resident. Resident/representative input is sought prior to release of the care plans and annual case conferences ensure ongoing consultation. Care plans are displayed in the resident bath room and are reviewed at specified intervals. Care plans and residents needs are communicated to staff through handover, electronic media, progress notes and unit/house meetings. Incidents and key clinical indicators are recorded on a data base and reported to key clinical staff weekly and trended monthly. Further to these reports the systems is evaluated through audits, surveys, comments and complaints and observation of staff practice. Residents/representatives are satisfied residents’ receive appropriate clinical care reflecting both health needs and preference. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Registered staff identify specialised nursing care needs through ongoing assessment and observation. In consultation with appropriate health specialist, medical officers and resident/representatives, individual specialised nursing care plans are developed to guide staff interventions; specialised care plans are reviewed at regular interval or as required in


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response to residents’ changing health. Action plans are developed for those residents with an acute change in health and are reviewed as frequently as required; residents on action plans are identified though the use of a coloured dot in progress notes. The home has a working relationship with external specialists, universities and hospital based acute care service who will attend the home to support staff in the delivery of complex clinical nursing care through education and clinical consultation. Self learning assessment packages are available for specialised nursing care needs and staff complete regular competencies in these areas. Residents are satisfied with the specialised nursing care provided by the staff at the home. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome Residents are assisted to access external medical specialists and allied health professionals. Focused assessments highlight previous history of allied health involvement in resident care and ongoing need for specialist health services to maintain optimum resident health. Referrals to specialists, some of whom visit the home, are arranged by registered staff. These include a speech pathologist, pathology services, a podiatrist and an occupational therapist. Residents also have access to complementary therapies, including aromatherapy and reflexology. Allied health professionals document directly in to the resident chart; alternately staff ensure specialist reports and interventions are reflected in resident care plans and updated information is communicated to staff. Care plans are reviewed in consultation with allied health specialists at specified timeframes and in response to changing resident health needs. Residents/representatives are satisfied with residents’ access to appropriate health specialists in response to individual needs and preferences 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Residents’ medication needs are identified on entry to the home and documented on care plans and medication charts. Residents’ medication is administered by registered staff from multi dose packs or from the original packaging for items such as eye drops and insulin. Staff have access to an imprest stock of routinely prescribed medications and processes for the administration of as required (PRN) medications. Medical officers review medication charts at specified intervals and external pharmacists conduct medication reviews annually. Registered staff are aware of procedure related to administration and storage of medications and controlled drugs. Medication incidents and audit results are documented and trended to evaluate staff practices and ensure safe and correct administration. Residents choosing to self medication are assessed in consultation with the treating medical officer and residents have a choice between local and contracted pharmacists. Medications were observed to be stored safely and securely across the home. Residents/representatives are satisfied with the medication management provided by the home.


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2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome Resident pain is assessed using a variety of assessments including focused assessments, non verbal assessments and seven day observation charts. Information recorded is used to develop care plans that include both pharmaceutical and non pharmaceutical interventions, triggers and previous history of pain. Care plans are developed in consultation with residents/representatives, medical officers, allied health professionals and staff. Effectiveness of interventions, including use of as required medication, is monitored and evaluated on an ongoing basis. Residents experiencing unresolved and complex pain are referred to the hospital based acute care service for further review and intervention. Residents/representatives are satisfied residents’ pain is managed effectively by qualified staff 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome The home has processes to ensure palliating residents’ comfort and dignity. The home has a palliative care pathway reflecting cultural, spiritual and clinical decisions documented by staff in consultation with residents/representatives and medical officers. Advanced health directives are kept on file and identified through colour coded spines on resident charts. Case conferences are held to ensure a forum for open communication and support during end of life care. Strategies to ensure resident comfort and dignity include mouth care, eye care, aromatherapy and subcutaneous infusion devices for delivery of pain relief. The chaplain conducts education sessions on grief and loss and an annual memorial service is held with staff and families invited to participate. The home has established working relationships with specialist palliative care services based at local hospitals and have palliation advisors on staff who provide expert advice, education and support during end of life care. Representatives are satisfied with the home’s approach to end of life care and say comfort and dignity is reflected in care provided. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Residents receive adequate nourishment and hydration following assessed the formulation of a dietary profiles. Profiles are forwarded to the kitchen through an electronic data base program and used to ensure appropriate meals and drinks are provided. The data base allows individual preferences and changes to be immediately reflected in drinks and meals lists. Care plans include modified diets, aids used to encourage and support independence and the level of assistance required from staff. Weight is monitored monthly and reviewed at specified times. The home has a three stage diet action plan to address weight loss; in consultation with medical officers the action plan indicates appropriate interventions and monitoring. Visiting allied health personnel document in the resident chart, with care plans


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reflecting alterations to interventions. Residents/representatives are satisfied with the meals and drinks provided by the home and the interventions employed to maintain adequate nutrition and hydration. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The potential for compromised skin integrity is assessed and preventative strategies are implemented as appropriate, including assistance with personal hygiene, regular pressure area care and repositioning, the use of aids/equipment such as air mattresses and continence aids, skin/limb protectors, and the use of moisturising creams. Wound care is documented on treatment sheets; chronic or long term wounds are documented on separate focused treatment sheets and include photos for effective ongoing review of healing. Incidents of skins tears, rashes and infections are documented and trended and interventions implemented where appropriate. Residents/representatives report satisfaction with the quality of skin care available and the access to external specialist provided by the home. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome Assessments are undertaken to establish continence needs and plan interventions for residents. Individualised care plans are developed and include strategies such as toileting programs, continence aids and the use of aperients. A designated staff member reviews additional pad usage and the appropriateness of continence aid in consultation with staff and coordinates ordering to ensure supply for residents. Specialised care needs, including catheter care, are met by nursing staff and documented on specialised care plans. Staff receive education on continence management and document relevant information to ensure ongoing care planning and management. Continence program effectiveness is monitored on a daily basis by care staff who report changes to registered nurses for follow up. Staff said prunes are available every day as well as fresh fruit and water. Residents/representatives are satisfied with the continence management delivered by the home 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The home has a process of assessment, consultation and care planning and care provision for the management of residents with challenging behaviour. Behaviour assessments and monitoring provides information for the identification of triggers for behaviour and successful intervention which are then included in care planning. Staff were knowledgeable about individual residents, any triggers for behaviours and strategies used to manage these behaviours while assisting residents to maintain abilities and interests. The home has two secure houses which provide a safe environment for residents to wander. Relevant authority


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is attained for each type of restraint required by a resident and are reviewed regularly by registered staff, medical officers and representatives. Residents/representatives state they are satisfied with the way staff manage challenging behaviours 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome The home assists residents to maintain optimum mobility, dexterity and independence. The home has a physiotherapist who provides assessment and therapy planning for new residents and reviews the assessment of residents whose condition has changed. Care plans are implemented by therapy assistants and staff during daily care provision. A range of equipment is available to assist in maintaining residents’ mobility and dexterity, including adjustable beds and mobility aids. Occupational therapists review residents for safe use of equipment, limb function and dexterity. Falls prevention strategies include the completion of risk assessments, the use of hip protectors and sensors mats and the promotion of a ‘No falls month’. Residents who have several falls have an action plan developed which includes prompts to complete a physical and environmental review and implement strategies and equipment to decrease risk. Residents said they were satisfied with the program and assistance they receive from staff. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome On entry to the home residents’ oral and dental health is assessed and care plans developed designed to maintain oral and dental health. Registered staff assess residents’ dental needs and develop care plans which include strategies such as regular mouth care, lip care and referral to specialist dental services. Staff are trained to ensure toothbrushes are replaced at appropriate intervals and staff practices prompt optimal resident oral health. The home has the facilities to have residents’ dental need addressed on site and coordinates visits to external dental specialist in consultation with medical officers and residents/representatives, with all interventions documented in the resident chart. Residents/representatives are satisfied with the oral and dental care provided by staff and the support to access external specialists. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Assessments are used to develop care plans used to guide staff practices and include strategies to promote maintaining independence. Sensory loss is included in the care plan, which is reviewed at specified intervals and as needed, with referrals made when appropriate. The home conducts clinics on site with residents’ seen by a variety of allied health professionals and coordinates visits to external specialists including audiologists,


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optometrists and speech therapists. Residents/representatives are satisfied with the range of specialists sourced by the home and the access to external specialist of their choice. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Clinical assessments identify residents’ sleep patterns and individual needs for settling in the evening. Residents are encouraged to maintain their usual bed time and have rest breaks through the day if they choose; staff maintain flexibility in daily routines allowing residents to choose individual sleep requirements. Residents have single rooms unless they choose to share with a spouse; residents’ are able to arrange the environment to assist comfortable sleep including use of curtains, temperature control and having doors/windows open or closed. Medications to assist with sleeping are prescribed at the discretion of the resident’s medical officer and as required medication is monitored for effectiveness and frequency of use. Staff use non pharmacological strategies such as offering drinks, extra blankets and pillows and toileting residents. Residents say the home is quiet at night and they are able to achieve restful sleep.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes. Examples of improvement initiatives related to Standard 3 Resident lifestyle implemented by the home include:

Part of the home’s ‘Eden principles’ initiative is to find meaningful opportunities for residents, families, staff and volunteers to reduce loneliness, helplessness and boredom. Using the principle ‘changing the way we think’, the home encouraged participation in a community project to help orphaned possums. The project required volunteers to make woollen possum pouches. The project was promoted through the home’s monthly newsletter and resulted in a group of residents forming a knitting group, with knitters making the possum pouches. Resident feedback indicated they enjoyed participating in a worthwhile community project and one resident reported as a result they were provided with an opportunity to hold a baby possum

Through observation the Leisure and Lifestyle Coordinator identified residents enjoyed being involved in food preparation, as well as the social occasion of special meals. As a result, regular theme nights have been added to the activity calendar. Residents are encouraged and supported to assist with the meal preparation for social and community events. Management feedback and review of the house meeting minutes indicated residents and their representatives had provided positive feedback in regards to the themed meals.

To promote empowerment and transparency for residents and their representatives regarding activities within the home, management called for an expression of interest for a community forum representative to be on the ‘Steering Group’ (Management meeting group). A resident’s representative was chosen and appointed as the Community Forum Chairperson. Their role is to attend the steering group meetings and report back to the residents’ community meetings, ensuring residents have sufficient knowledge, skills, information, resources and support to make appropriate and informed decisions on current affairs which affect them. Management reported the role of the community forum representative has improved the communication process and empowered residents to raise issues as required.


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3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes. In relation to Standard 3 Residents’ lifestyle, there is a system to manage the mandatory reporting of assaults to the police and Department of Health and Ageing in accordance with regulatory requirements. Compliance with legislation is monitored through the audit process, staff and resident feedback and observation of staff work practices. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s 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 systems and processes. In relation to Standard 3 Residents’ lifestyle, examples of training and education undertaken by staff include:

The ‘Eden Alternative’

Culture awareness

Legal training (Elder abuse, Confidentiality)

End of life care pathway 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home has processes to ensure each resident is supported in adjusting to their new environment. Staff and management welcome and orientate residents and their families to the home. Residents’ emotional care needs are identified during the initial assessment period and care plans identify strategies to guide staff in supporting residents. New residents receive documentation and a resident handbook detailing the homes processes and key personnel available to them, including ministers and advocates. Residents are introduced to other residents, encouraged to personalise their rooms and to participate or observe activities of interest to them. Those residents who do not like to mix in large groups are supported to engage in individual activities of their choice and receive one on one interaction with lifestyle staff and volunteers. Residents report satisfaction in adjusting to the home’s environment and the emotional support offered by the staff at the home.


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3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome Residents’ individual needs are met through a process of assessment and care plan development guiding staff in the delivery of care. There are processes to assist residents to maximise their independence through the implementation of assistive equipment and intervention by allied health staff. Care plans are developed to support residents to achieve maximum independence and participate in the life of the community. Residents are encouraged to visit the local neighbourhood and support local initiatives and community events. Staff and volunteers support residents in the development and maintenance of friendships and the home’s environment provides areas away from common areas for resident use. Residents/representatives are satisfied with the assistance provided by staff at the home to maintain residents’ independence. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome The home has process and practices to ensure each resident’s privacy and dignity. On entry to the home, residents are provided with information about privacy and confidentiality which is contained in the resident handbook. Staff and management have an awareness of privacy and confidentiality considerations when attending to resident care needs and providing shift handover. Residents’ personal, clinical and financial information is stored in a secure manner protecting residents’ confidentiality. Staff ensure dignity and confidentiality by knocking on doors and requesting permission to enter and referring to residents by their preferred names. Management monitors compliance through observation of practices, audits and satisfaction surveys. Residents stated satisfaction with staff attention to respecting privacy, dignity and confidentiality. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome Residents’ past and current interests are identified through interview and completion of social profile assessment. Individualised lifestyle therapy care plans are developed in consultation with the resident/representatives and reflect the resident’s physical and cognitive abilities and identified interests. The home’s activity program includes general group and individual one-to-one activities. Activities calendars are provided to residents, sent to representatives via electronic mail, posted in resident communal areas and are communicated to residents by activities and care staff. Programs are evaluated by review of participation rates, surveys and feedback at resident meetings. The activity program is assisted by registered volunteers who provide support with activities within and outside the home and assist in providing a weekend program of gardening and social gatherings. Residents/representatives are satisfied


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residents are encouraged and supported to participate in activities and leisure interests of meaning 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". Team’s findings The home meets this expected outcome Residents receive care specific to their individual interests, customs, beliefs and cultural background. Information is gathered at entry and ongoing by registered staff, the chaplain and lifestyle therapists and used to develop an individual care plan. The home is regularly visited by representatives from a variety of denominations, with services being held weekly. Residents’ who are unable to attend services are visited in their rooms and spiritual support is available for palliative residents as needed. The chaplain conducts annual memorial services open to staff, resident and representatives. Culturally specific events are celebrated based on the resident mix and residents’ representatives are encouraged to attend. Residents are satisfied they receive care supportive of their spiritual and cultural needs. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home supports residents in making decisions regarding their health and care. At entry the home collects information related to enduring power of attorney and advanced health directives. This information is kept on file and communicated to staff through a colour coded system in the resident chart. Consultation on choice and decision-making is on-going and includes resident surveys, resident meetings, comments and complaints and through the annual case conferences. Resident preference is documented with regards to hygiene, grooming, sleep patterns and routine. Registered staff assess residents’ ability to make decisions and identify alternative decision makers on relevant documentation. Staff support residents’ rights to make decisions during interactions. All care plan entries start with an ‘I’ statement and are based on information collected. Residents are aware of their rights and responsibilities and have access to information relating to advocacy and complaints. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Residents have security of tenure and understand their rights and responsibilities. All residents are offered a residential care service agreement on admission and a resident handbook outlining residents’ security of tenure, residents’ rights and responsibilities and all the services and associated fees/charges provided within the home. The client services officer outlines the home’s philosophy of care to new and prospective residents during an entry interview. Staff meet with residents and their representatives for consultation prior to


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any room changes. Residents are aware of their rights and responsibilities and feel secure living in the home.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes. Examples of improvement initiatives related to Standard 4 Physical environment and safe systems implemented by the home include:

In response to a suspected outbreak at the home, management revised the home’s standard operating procedures for outbreaks. This resulted in the implementation of a specific task/duties list to guide hospitality cleaning staff, improved outbreak signage and the development of specific outbreak management boxes to ensure access to appropriate resources. For example, four bedroom, one cleaning and one master outbreak boxes are available. Management reported education on the new procedures and resources was provided to staff. No outbreaks have occurred at the home since the implementation of the new process.

To enhance the outdoor environment and provide sun protection for residents, a grant was obtained and a gazebo erected over the external courtyard between Allanaha and Shevaun house. Management and staff reported residents/representatives now utilise the area more frequently. During the re-accreditation audit residents were observed to be sitting outside under the gazebo.

In response to resident feedback the outdoor area utilised for the evening barbeques can become very hot and uncomfortable, management installed large outdoor ceiling fans to the area. Management reported residents and staff have provided positive feedback in response to the fans being installed.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes. In relation to standard 4 Physical environment and safe systems, there is a system to maintain workplace health and safety requirements, monitoring of emergency and fire systems and to ensure food safety. Compliance with legislation is monitored through the audit process, staff and resident feedback and observation of staff work practices.


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4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. In relation to standard 4 Physical environment and safe systems, examples of training and education undertaken by staff are listed below:

Food safety

Outbreak management

Fire and evacuation training

Workplace health and safety 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s findings The home meets this expected outcome Residents/representative interviewed advised they are satisfied with the safety and comfort of residents’ living environment. The home’s management are actively working to provide a safe and comfortable environment consistent with residents’ care needs. Residents are accommodated in single rooms with private en suites. Residents are encouraged to take ownership of their environment by personalising their room. The home is secure, clean, clutter and odour free and provides a variety of private seating areas available to residents and their families. Preventative maintenance schedules are in place and any additional maintenance requirements are reported by staff or residents and are attended to by the maintenance department and/or external contractors in a timely manner. Restraint is utilised for some residents and authorisation and monitoring undertaken. Security measures are in place to ensure overnight security in the home. Monitoring of the living environment is conducted through the audit process, staff and resident feedback and observation. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome In conjunction with a centralised workplace health and safety team, the home is actively working to provide a safe and secure working environment that meets regulatory requirements. Processes include quarterly committee meetings, regular area inspections of the environment for safety aspects, hazard/risk management processes, investigation and analysis of staff incidents and staff education. New and existing staff undertake annual compulsory education including workplace health and safety, manual handling, the use of equipment, infection control, hand washing and fire evacuation. Maintenance programs are


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in place for equipment and buildings and these are monitored for completion. Material safety data sheets are available in work areas and chemicals are stored securely as per regulations. Spills kits are available and accessible for staff. Staff accidents and incidents are reviewed, analysed then discussed at the continuous quality improvement meetings to ensure effectiveness of intervention. Staff interviewed demonstrated an awareness of how to report accidents, incidents and hazards and perform their roles in a safe manner. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome The home has processes to provide an environment and safe systems of work that minimise fire security and emergency risks. External providers ensure maintenance of fire safety systems and equipment is carried out in accordance with legislative requirements. Evacuation plans are clearly displayed; emergency exits are clearly marked, free from obstruction and are suitable for the mobility level of the residents. Mandatory fire and emergency training is provided to all staff on commencement of employment at a local level, as well as through organisation orientation and on annual basis. Staff attendance at these sessions is monitored and recorded to identify non-attendance. In addition, a self-directed learning package and questionnaire sheet are completed by all staff. Emergency procedure charts are in place to guide staff in emergency situations and resident evacuation lists are updated and accurate. Residents are advised of their role in a fire on entry to the home, through residents meetings and in the residents’ handbook. Staff interviewed demonstrated an awareness of emergency procedures and their individual roles and responsibilities in the event of a fire, security and other emergencies. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has infection control processes to guide staff in practices which comply with documented policies and guidelines. Infection reports are collected and reviewed monthly and discussed at relevant meetings. Staff are provided with education at orientation and annually. Colour coded equipment is used in clinical, cleaning, laundry and kitchen areas to minimise cross infection. Staff receive training in food handling and temperature monitoring of food during preparation and serving. Outbreak management is documented and outbreak kits and equipment are available to all staff. Infections are identified on care plans and treatment records so staff can allow for changes to processes during wound care and hygiene. Residents are satisfied with the infection control management and practices of the staff


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4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome Residents/representatives interviewed reported satisfaction with the home’s catering, cleaning and laundry services. A six-weekly menu is provided in consultation with the dietician, speech pathologist and resident feedback. Catering services are provided via a central kitchen and meals are plated at the local site in accordance with residents’ preferences, choice and dietary requirements, such as residents’ supplements, texture modified food and modified eating utensils. A data process has been established to allow real time updating of resident information, ensuring residents’ catering needs are met; a dietician and/or speech pathologist are consulted in relation to the residents’ special dietary needs, when necessary. Cleaning services are provided by on site staff with a central cleaning crew responsible for extra cleaning duties. Cleaning schedules ensure all residents’ rooms, communal areas and external areas of the home are cleaned systematically. All laundry services are completed off site five days a week, with allocated days for collection and delivery of residents’ personal clothing. Residents’ clothing is labelled on entry to the home in line with procedures for the prevention of lost items. Mechanisms are available for residents/representatives to provide feedback about hospitality services through comments and complaints, feedback surveys and residents meetings.

Documents

Anam Cara - Aged Care QualityAnam Cara RACS ID 5355 52 Lavarack Road BRAY PARK QLD 4500 Approved provider: The Uniting Church in Australia Property Trust (Q) Following an audit we