Decision to accredit Bupa Mosman - Aged Care Quality › sites › default › files › ... · 2018-12-14 · Decision to accredit Bupa Mosman The Aged Care Standards and Accreditation

Decision to accredit

Bupa Mosman

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Bupa Mosman in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Bupa Mosman is three years until 28 March 2014. The Agency has found the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. This is shown in the ‘Agency findings’ column appended to the following executive summary of the assessment team’s site audit report. The Agency is satisfied the home will undertake continuous improvement measured against the Accreditation Standards. The Agency will undertake support contacts to monitor progress with improvements and compliance with the Accreditation Standards. Information considered in making an accreditation decision The Agency has taken into account the following: the desk audit report and site audit report received from the assessment team; and information (if any) received from the Secretary of the Department of Health and Ageing;

and other information (if any) received from the approved provider including actions taken

since the audit; and whether the decision-maker is satisfied that the residential care home will undertake

continuous improvement measured against the Accreditation Standards, if it is accredited.

Home name: Bupa Mosman Date/s of audit: 11 January 2011 to 12 January 2011 RACS ID: 0553 AS_RP_00851 v2.5

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Home and approved provider details

Details of the home

Home’s name: Bupa Mosman

RACS ID: 0553

Number of beds: 60 Number of high care residents: 56

Special needs group catered for: Extra Service

Street/PO Box: 18-20 Bardwell Road

City: MOSMAN State: NSW Postcode: 2088

Phone: 02 9969 2500 Facsimile: 02 9969 2723

Email address: Nil

Approved provider

Approved provider: Bupa Care Services Pty Ltd

Assessment team

Team leader: Margaret McCartney

Team member/s: Leah Asensio

Date/s of audit: 11 January 2011 to 12 January 2011


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Executive summary of assessment team’s report Accreditation

decision

Standard 1: Management systems, staffing and organisational development

Expected outcome Assessment team recommendations

Agency findings

1.1 Continuous improvement Does comply Does comply

1.2 Regulatory compliance Does comply Does comply

1.3 Education and staff development Does comply Does comply

1.4 Comments and complaints Does comply Does comply

1.5 Planning and leadership Does comply Does comply

1.6 Human resource management Does comply Does comply

1.7 Inventory and equipment Does comply Does comply

1.8 Information systems Does comply Does comply

1.9 External services Does comply Does comply

Standard 2: Health and personal care


Agency findings




2.4 Clinical care Does comply Does comply

2.5 Specialised nursing care needs Does comply Does comply

2.6 Other health and related services Does comply Does comply

2.7 Medication management Does comply Does comply

2.8 Pain management Does comply Does comply

2.9 Palliative care Does comply Does comply

2.10 Nutrition and hydration Does comply Does comply

2.11 Skin care Does comply Does comply

2.12 Continence management Does comply Does comply

2.13 Behavioural management Does comply Does comply

2.14 Mobility, dexterity and rehabilitation Does comply Does comply

2.15 Oral and dental care Does comply Does comply

2.16 Sensory loss Does comply Does comply

2.17 Sleep Does comply Does comply


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Executive summary of assessment team’s report Accreditation

decision

Standard 3: Resident lifestyle


Agency findings




3.4 Emotional support Does comply Does comply

3.5 Independence Does comply Does comply

3.6 Privacy and dignity Does comply Does comply

3.7 Leisure interests and activities Does comply Does comply

3.8 Cultural and spiritual life Does comply Does comply

3.9 Choice and decision-making Does comply Does comply

3.10 Resident security of tenure and responsibilities

Does comply Does comply

Standard 4: Physical environment and safe systems


Agency findings




4.4 Living environment Does comply Does comply

4.5 Occupational health and safety Does comply Does comply

4.6 Fire, security and other emergencies Does comply Does comply

4.7 Infection control Does comply Does comply

4.8 Catering, cleaning and laundry services

Does comply Does comply


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Assessment team’s reasons for recommendations to the Agency The assessment team’s recommendations about the home’s compliance with the Accreditation Standards are set out below. Please note the Agency may have findings different from these recommendations.

Name of home: Bupa Mosman RACS ID 0553 AS_RP_00857 v1.5 Dates of site audit: 11 January 2011 to 12 January 2011 Page 6

SITE AUDIT REPORT

Name of home Bupa Mosman

RACS ID 0553

Executive summary This is the report of a site audit of Bupa Mosman RAC ID 0553, 18-20 Bardwell Road MOSMAN NSW from 11 January 2011 to 12 January 2011 submitted to the Aged Care Standards and Accreditation Agency Ltd. Assessment team’s recommendation regarding compliance The assessment team considers the information obtained through audit of the home indicates that the home complies with: 44 expected outcomes Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Bupa Mosman. The assessment team recommends the period of accreditation be three (3) years. Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation.


Site audit report Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 11 January 2011 to 12 January 2011 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team

Team leader: Margaret McCartney

Team member/s: Leah Asensio

Approved provider details

Approved provider: Bupa Care Services Pty Limited

Details of home

Name of home: Bupa Mosman

RACS ID: 0553

Total number of allocated places:

60

Number of residents during site audit:

48

Number of high care residents during site audit:

10

Special needs catered for:

Extra services

Street/PO Box: 18-20 Bardwell Road State: NSW

City/Town: MOSMAN Postcode: 2088

Phone number: 02 9969 2500 Facsimile: 02 9969 2723

E-mail address: [email protected]


Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Bupa Mosman. The assessment team recommends the period of accreditation be three (3) years. Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation. Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and the reasons for its recommendations are outlined below. Audit trail The assessment team (the team) spent two days on-site and gathered information from the following: Interviews

Number Number

General manager 1 Residents/representatives 13

Acting chief nurse 1 Recreational activity officers 3

Quality assurance manager 1 Physiotherapist 1

Registered nurses 4 Laundry staff 1

Care staff 5 Cleaning company manager 1

Administration officer 1 Cleaning staff 2

Chef 1 Maintenance officer 1

Catering staff 1

Sampled documents

Number Number

Residents’ care files (including assessments, progress notes, medical officers notes, family conference records, and other information) and care plans

7 Medication summary sheets, medication plans, and medication signing sheets

17

Resident files (for information systems review)

3 Nurse initiated medication consents

11

Weight charts 10 Patch application records 5

Initial wound assessment charts/wound treatment charts

11 Diabetic records (including blood glucose levels and parameters)

2

Bowel charts 6 Resident of the day checklists 9

Behavioural charts 2 Catheter care plans 3

Catheter specific urine output 2 Personnel files 5


record

Other documents reviewed The team also reviewed: ‘Admission’ assessment outline Allied health contact details Allied health professionals folder including allied professional logs Allied health professionals list Audit and checklist schedule and related documentation Cleaning log Close supervision charts Communication books Continence aid allocation records (pictorial) and additional usage registers Daily handover booklet (for assistants in nursing) Doctors communication folders including doctors request sheets Education calendar Education competencies Employee handbook Facsimiles to medical officers Food Safety program Handover sheets Hazard logs Indication and orientation documents Infection control report Job descriptions Letter from resident Local dentists contact details Lodged improvement logs Maintenance logs Medication management documentation including: staff sample signatures; medication

reviews; short term medication/interim signing sheets; PRN (as required) medication signing sheets; self medication assessment; drugs of addiction registers (schedule eight medications); medication refrigerator temperature logs; daily medications orders/communication form; and emergency medication stock records

Memorandum folder Menu Menu review ( November 2010) Minutes of meetings including: resident/relative meetings; medication advisory committee

meetings; recreation activity meeting; and various other meetings Monthly weight register Newsletters Optometrist lists Pain management folder including: aromatherapy treatment record; laser treatment

records; transcutaneous electrical nerve stimulation (TENs) records; and heat treatment records

Physiotherapy records including: physiotherapy classes programs; physiotherapy assessments; physiotherapy requests; exercise programs; physiotherapy care plans; and manual handling/mobility plans

Podiatry lists and debriefing records Policy and procedure manual Pressure ulcer monitoring forms Privacy policy manual


Recreational activity documentation including: individual resident activity plans; map of life assessments; birthday list; individual lifestyle activity attendance records; activity evaluation form; activity planning sheet; and activity evaluations

Recruitment policies and procedures Reportable and essential services logs Resident accident and incident reports Resident agreement Resident handbook Resident incident audit report (including medication incident data) Resident incident reports Resident list Resident walking schedule Residents’ information package Roster Simple procedures charts Speech pathology dietary reports Staff map of life chart Standard Bupa annual reassessments list Wound management registers Observations The team observed the following: Activities in progress Activity program on display Annual fire safety statement on display Brochures on display including complaints investigation scheme brochures and ‘Let us

help you’ brochures Charter of Residents’ Rights and Responsibilities on display Equipment and supply storage areas Fire safety equipment including, fire panel, detectors, exit signs, and evacuation plans Hairdressing salon Hand washing facilities and signage Interactions between staff, representatives, private carers and residents Key pad locks on doors Lifts between the floors Living environment (internal and external) Medication rounds Notice boards and signage (staff and resident areas) New South Wales Food Authority licence on display Nurse call bells Oxygen cylinder storage Photographs of residents Ping pong table Pressure relieving chairs in use Recent refurbishments Residents participating in lunch including staff assistance Spills kits and sharps disposal containers Staff clinical areas including medication trolleys, medication storage, wound management

equipment and clinical information resources Staff handover in progress Staff room Staff work areas including: offices; education room; utility rooms; kitchen and food

storage areas; laundry; and cleaners’ room


Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Management can demonstrate results of continuous improvement across the four Accreditation Standards. Staff and residents are encouraged to contribute to the home’s continuous improvement system using the improvement logs that are accessible in all parts of the home. Residents’ needs and preferences are included in the planning of continuous improvement activities. The home uses audits and meetings to monitor and evaluate the effectiveness of the improvements. Management receives support from Bupa Care Services with the management of continuous improvement. Staff interviewed indicated that management is responsive to suggestions for improvement and they receive appropriate and timely feedback. Recent improvements in relation to Accreditation Standard One include: The introduction of the new e-learning program is available for all employees to complete

on line, some are based on legislation and others concerning the person centered care approach. This has resulted in a standardised delivery approach and is flexible for staff to complete where and when it suits them.

Frequency of meetings has recently been restructured; some have increased from bi-

monthly to monthly and from monthly to bi-monthly. This is resulting in more effective use of time for both management and staff.

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s recommendation Does comply The home has a system for identifying relevant legislation, regulations and guidelines for monitoring compliance with these and in relation to the four Accreditation Standards. The home receives electronic updates from Bupa Care Services weekly and includes a timeframe of actions to complete. These updates are communicated to the relevant stakeholders through memoranda and staff meetings and any action required is taken. Staff are aware of recent changes and are asked to sign when they have received the information. Examples of the home’s system that demonstrates compliance with Accreditation Standard One includes that all residents/representatives were made aware of the Accreditation site audit and all employees have had police checks conducted.


1.3 Education and staff development: This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home demonstrated that staff have the knowledge and skills that are required for effective performance across the four Accreditation Standards. The home conducts orientation and induction sessions for new employees and uses a buddy system for new staff. Staff are offered internal and external education and are encouraged to take personal responsibility for their professional development. This includes the introduction of a new system of education by e-learning. This web-based, on line-training includes six mandatory e-learning programs. An annual education program is developed from input from staff, performance appraisals, identified needs and current issues in aged care. Management respond to the educational needs of staff when the needs of residents change. Staff interviewed are satisfied with the support and education provided by the home. Some recent examples of education relevant to Accreditation Standard One are bullying and harassment and communication skills. 1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s recommendation Does comply The home demonstrated that information about internal and external complaints’ mechanisms is accessible to each resident and/or his representative. Information about complaints’ mechanisms is included in the resident handbook and on brochures available around the home. Residents and staff are encouraged to make comments and complaints through the mechanisms available, regular meetings and the manager’s open door policy. Management receive comments and complaints verbally and in writing. These are actioned as necessary and in a timely manner. Residents/representatives interviewed are familiar with the complaints’ mechanisms at the home and residents are satisfied with the complaints’ mechanisms available to them. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s recommendation Does comply Management has consistently documented the home’s vision, values, philosophy and objectives information for stakeholders and these are on display and throughout the home’s documentation. For example, they are recorded in the employee handbook. Staff are informed of the organisation’s vision, values, philosophy, objectives and commitment to quality through the home’s staff recruitment, orientation and education processes.


1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s recommendation Does comply The home can demonstrate that there are sufficient staff with the appropriate knowledge and skills to perform their roles effectively. There is a system to ensure that identified numbers and types of staff are maintained including replacements for leave. Staffing levels and rosters are determined by resident needs and preferences and the home has a large pool of casual staff to cover permanent staff on leave. Performance of existing staff is evaluated through a variety of ways including competency assessments. The organisation also runs a staff awards program. New staff are provided with an organisational and site specific orientation and there is a system in place for two compulsory ‘buddy’ shifts for all new staff. Residents/representatives interviewed by the team generally expressed satisfaction with the responsiveness of staff and the adequacy of care. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply Management can demonstrate the home has suitable goods and equipment appropriate for the delivery of services. This includes processes in place to check on the quality of goods and to receive and review stocks to ensure they are appropriate and sufficient. The home assesses and monitors the quality of goods and makes changes where necessary. Residents/representatives advised that they are satisfied with the goods provided by the home to meet their needs. Staff reported that they have adequate supplies and equipment to perform their roles effectively. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply The organisation uses a wide range of methods to ensure that all stakeholders have access to current information on the processes and general activities and events of the home. These include newsletters, memoranda and minutes of meetings. Management and staff have access to accurate and appropriate information to help them perform their roles. This includes information in relation to management systems, health and personal care, resident lifestyle and the maintenance of a safe environment. Information is stored appropriately for its purpose and is retrievable in a timely manner suitable for its use. Residents/representatives interviewed by the team stated they are kept well informed in matters relevant and of interest to them.


1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s recommendation Does comply Management demonstrated external services are provided at a standard that meets the home’s needs and service quality goals. Bupa Care Services support Bupa Mosman by listing preferred suppliers and contact details on their intranet system. Processes are in place to ensure that all relevant individuals from external companies have current police checks. The performance of external services is evaluated by seeking feedback from residents/representatives staff and any other relevant stakeholders. Changes are made if the review of the external services is unsatisfactory or in response to the changing needs of residents. Residents/representatives and staff confirm that they are satisfied with the externally sourced services.


Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for details of the home’s continuous improvement system. The home presented evidence to demonstrate that the organisation actively pursues continuous improvement in relation to Accreditation Standard Two. Recent improvements in relation to Accreditation Standard Two include: The physiotherapy program has recently been restructured so that there are more regular

group exercises. This has resulted in more residents attending. Residents’ family case conferences are now conducted more frequently so the home can

communicate more effectively with all stakeholders and provide better care for residents. The system for residents’ continence management has recently been improved with the

night registered nurse now in charge of allocation and stock management. This has resulted in a more efficient use of stock and time for the assistants in nursing.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s recommendation Does comply The home has systems in place to manage regulatory compliance in relation to residents’ health and personal care. For a description of the home’s system for regulatory compliance refer to the expected outcome 1.2 Regulatory compliance. A recent example of the home’s system that demonstrates compliance with Accreditation Standard Two is the registered nurses registrations are up to date. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has an education and staff development system to provide staff with appropriate knowledge and skills to perform their roles effectively in relation to residents’ health and personal care. For details of this system refer to the expected outcome 1.3 Education and staff development.


Some recent examples of education relevant to Accreditation Standard Two include education on the administration of medication, mandatory reporting, and understanding behaviours. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply The home has systems in place to ensure residents receive appropriate clinical care. Systems include: medical officers’ reviews; registered nurse input into residents’ care delivery; and a program for the assessment of residents’ care needs. The home has verbal and written communication processes to inform nursing staff of residents’ care needs and to inform medical officers of residents’ care issues in need of review. This includes written handover reports readily available for staff. Residents are weighed and a urinalysis is completed each month as part of the resident of the day program. The frequency for monitoring residents’ blood glucose levels is determined in consultation with their medical officers. Other observations, such as neurological observations, are taken if the resident is identified to require them. Residents/representatives have opportunities for input into the residents’ care delivery. This includes family case conferences held for new residents six weeks following entry to the home. Residents/representatives expressed satisfaction with the care provided and their access to medical officers. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s recommendation Does comply Residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officers input when the need is identified. The home provides 24 hour registered nurse coverage including a registered nurse on each of the two levels during the day time and one registered nurse at night. The home currently provides specialised nursing care for residents such as catheter care, and diabetic management. Residents’ care plans reviewed include information on their specialised nursing care needs as required. The team’s observations and interviews demonstrated that the home has sufficient equipment and supplies to support residents’ specialised nursing care needs. Management advised that the home has access to supply company representatives should advice be required for residents’ specialised nursing care. A clinical care procedures manual is available for nursing staff with guidelines on nursing procedures. A registered nurse advised that the home has access to an acute post acute care service to provide treatments, such as intravenous antibiotics, to decrease the need for residents to stay in an acute care hospital. Resident/representative interviews indicated satisfaction with the nursing care provided. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s recommendation Does comply The home has systems to support residents to be referred to appropriate health specialists in accordance with their needs and preferences. The resident handbook records the care and services to which residents are entitled in accordance with legislative requirements. Interviews and documentation reviews demonstrated residents have been seen by other


health and related services visiting the home including: physiotherapy, podiatry, optometry, a masseur, a psychogeriatrician, and speech pathology, pharmacy, and pathology services. Residents also have access to a dental technologist and an audiology service that will visit the home on request. Residents can choose to visit health services of their choice outside the home with assistance provided for their transportation by representatives, or escorts by the home’s staff if required. Resident/representative interviews indicated they are satisfied with the other health and related services which visit the home. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply Residents’ medication is managed safely and correctly through: the secure storage of medications; medication ordering and delivery systems; the regular checking of schedule eight registers; and medication reviews completed by an accredited pharmacist. Registered nurses administer residents’ medications using a medication packaging administration system or directly from the medication containers for medications which cannot be pre-packaged. The home has a system to assess residents who choose to self medicate, for their capability to do this. The team observed registered nurses administering residents’ medications following safe procedures. Residents’ medication summary sheets reviewed record current medical officers’ orders. Documentation used for administering residents’ medications includes residents’ medication allergies, and photographic identification. Nurse initiated medication lists are maintained. Eye drop containers are labelled with the dates of opening and the temperatures of the refrigerators used for the storage of medications are monitored. A supply of antibiotics is kept for emergency use. The home participates in a medication advisory committee meeting for the review of medication issues. Medication audits and medication incident reporting are completed. Residents/representatives interviewed are satisfied with the medication management the home provides. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply The home ensures all residents are as free as possible from pain through initial assessments of residents for pain, and the provision of care according to residents’ identified needs. Provision is made for the assessment of residents’ verbal and non-verbal pain. The home accesses residents’ medical officers and the physiotherapist when necessary for advice on pain management. The physiotherapist provides residents with laser treatments and TENs treatments when required. Other examples of strategies currently in use for residents’ pain management include: the administration of pain relieving medications including schedule eight medications and patches; exercises; heat applications; pain relieving cream applications; and massage therapy. The home has access to a local palliative care team for advice on residents’ pain management should this be required. Resident/representative interviews demonstrated that treatments are provided for residents with pain management needs and residents are as free as possible from pain.


2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply Management and nursing staff interviews indicated that the comfort and dignity of terminally ill residents is maintained through the identification of their needs at the time of the residents’ care needs changing. A template for a palliative plan of care is available for registered nurses to complete. Assistants in nursing interviews indicated that they provide care for terminally ill residents through supporting the residents’ physical and emotional care needs. This includes use of a palliative care kit and provision of mouth care. The home has access to a priest, ministers of religion, or a pastoral carer to provide support for terminally ill residents and their representatives when required. The home has access to a local palliative care team for advice when required. However, management and registered nurses advised that the residents’ medical officers are supportive and advice from the palliative care team has not been required in recent times. Resident/representative interviews indicated satisfaction with the care and support provided for residents at all stages of care delivery. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply The home has systems in place to provide residents with adequate nourishment and hydration through the assessment and documentation of residents’ dietary needs, and the communication of these needs to catering staff. Meals are cooked fresh on site following a four weekly rotating seasonal menu which is reviewed by a dietician. Provision is made for residents who require special diets, pureed meals, thickened fluids, assistance with meals, and dietary assistive devices. Fresh fruit is available for residents each day. Assistants in nursing provide residents with fluids at regular intervals, such as morning and afternoon teas, to ensure their hydration is maintained. Residents’ dietary and fluid intake is monitored through staff observations, and by recording residents’ weights. Registered nurse interviews indicated that strategies are put in place to support residents with weight loss such as providing dietary supplements when tolerated. The home demonstrated that a speech pathologist is accessed when needed to review residents with swallowing difficulties. Residents/representatives expressed satisfaction with the quantity and quality of the food and drink the home provides. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply The home has processes for maintaining residents’ skin integrity consistent with their general health including assessment processes. Residents have podiatry, hairdressing, and nail care provided according to their identified needs and preferences. Residents with skin integrity breakdown have wound care provided by registered nurses. Wound dressing charts are completed to record the healing of their wounds and the treatments provided. Assistants in nursing advised of strategies they practice for maintaining residents’ skin integrity, such as, the application of emollient creams, use of limb protectors, and providing pressure area care. The home has equipment to minimise the risk of skin trauma for residents including: water


chairs; alternating air flow mattresses; bedrail guards; and manual handling equipment. Residents/representatives interviewed are satisfied with the skin care and wound care provided. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Residents’ continence is managed through the initial identification of residents’ continence management needs, ongoing reviews and resident/representative feedback. A registered nurse oversees the distribution of residents’ continence aids. Assistants in nursing confirmed they are kept informed of residents’ continence aid needs and have access to adequate supplies of continence aids. Management advised that a representative from the continence aid supply company is available to provide staff with education on continence aids and their use. Assistants in nursing reported that they provide residents with regular toileting programs according to their identified needs. The home has strategies for residents’ bowel management including: the completion of bowel charts, providing exercises, high fibre diets, and the administration of medications for bowel management regularly or when the need is identified. Residents/representatives expressed satisfaction with residents’ continence management. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply The home has systems to manage the needs of residents with behaviours of concern. The home completes behaviour charts to identify residents’ behaviours and strategies to meet the residents’ needs. Behavioural management strategies are also identified in consultation with residents’ medical officers as needed. The home has access to a psychogeriatrician to review residents in the event of this being required. Management reported that residents with wandering or absconding behaviours are transferred to accommodation on the upper level when required. The home has close supervision charts to monitor the whereabouts of residents with wandering behaviours if necessary. Management advised that no residents currently have chemical restraint. The use of bedrails for residents is monitored. The organisation provides a policy for restraint management to guide staff. Nursing staff advised of behavioural management strategies in place including: talking and listening to residents; and residents being cared for by the staff they trust. Interviews with a recreational activity officer demonstrated that residents with dementia are supported to participate in the various recreational activity programs held. Residents/representatives are satisfied with the care provided for residents with behaviours of concern. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply Residents are supported to achieve optimum levels of mobility and dexterity. A physiotherapist who visits the home each week completes assessments, and develops individual exercise programs for all residents. Physiotherapy aides provide residents with exercises according to the physiotherapist’s instructions. Assistants in nursing also


encourage residents to complete various exercises and to undertake walks. The team observed residents being assisted by staff to mobilise with the use of manual handling belts and mobility aids. Exercise groups and activities involving exercises are included regularly in the recreational activity programs. Instructions on residents’ transfer and manual handling needs are located in residents’ wardrobes. Residents are provided with mobility aids to assist with walking in accordance with their needs and the home’s corridors have handrails. Strategies for residents’ falls prevention and management include: referrals to the physiotherapist; use of floor sensor mats to monitor residents’ movements; and the use of hip protectors. The home also completes safety and falls’ risk assessments for residents. Resident/representative interviews indicated residents are supported to exercise and maintain their mobility and dexterity levels. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply New residents’ oral and dental health needs are identified and care plans are completed when the need is identified. Residents’ ongoing oral and dental care needs are monitored through staff observations and resident/representative feedback. Residents have access to a visiting dental technician. The home has contact details for external dentists for residents to access in accordance with their needs and preferences. Assistants in nursing reported that they provide residents with oral care including assistance with denture care, teeth cleaning and mouth swabs when indicated. Residents/representatives did not identify any issues with the oral and dental health care provided by the home. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply The home manages residents’ sensory loss needs through the identification of residents’ hearing, vision and other sensory loss needs, staff practices, and the equipment available. An optometrist has visited the home recently to complete vision assessments for a number of residents. Audiology services can be organised to visit the home or are arranged externally to attend to residents’ hearing loss needs. Assistants in nursing advised of strategies they use to assist residents with vision loss and that residents are provided with talking books when required. A recreational activity officer reported that a local library visits the home to supply large print books as needed. They also reported that large print numbers are available in the bingo kit. Observations demonstrated that a clutter free environment is generally provided. A masseur visiting the home provides sensory stimulation through the massage they provide for residents. The recreational activity program includes foot and hand massage by the recreational activity officers. Residents/representatives are satisfied with the care provided by the home for residents’ sensory loss needs. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply The home assists residents to achieve natural sleep patterns through assessments which include the choice of bed times and rising times, care planning and the availability of staff support at night. Residents have access to call bells in their rooms and ensuite bathrooms to


call for staff assistance at night if required. The home is staffed with one registered nurse and three assistants in nursing at night. Strategies available to support residents to achieve natural sleep patterns include: warm drinks and/or snacks at night as required; provision of pressure relieving equipment; and night sedation as per medical officers’ orders if necessary. All residents have one bedded rooms to assist in providing a quiet living environment conducive to sleep. Residents report that the home is quiet at night and they sleep well. Residents’ representatives interviewed do not identify any problems with residents achieving natural sleep patterns.


Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for details of the home’s continuous improvement system. The home presented evidence to demonstrate that the organisation actively pursues continuous improvement in relation to Accreditation Standard Three. Recent improvements in relation to Accreditation Standard Three include: A sports day has been introduced each Wednesday which encourages residents to take

part on ping pong, bowls and walking. This has been a success with many residents attending.

A recreational activity officer reports that the home has recently purchased a new ping

pong table to improve the equipment available for residents’ activity programs. Nail painting as been introduced once a week for residents who request it, some of the

residents who had participated were interviewed by the team and they expressed satisfaction with this introduction.

French lessons have been introduced at Bupa Mosman and those residents attending

commented that they are enjoying it. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s recommendation Does comply The home has systems in place to manage regulatory compliance in relation to resident lifestyle. For a description of the home’s system for regulatory compliance refer to the expected outcome 1.2 Regulatory compliance. Recent examples of the home’s system that demonstrates compliance with Accreditation Standard Three includes ensuring resident agreements comply with current legislation and the home has processes in place for mandatory reporting that complies with current legislation.


3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has an education and staff development system to provide staff with appropriate knowledge and skills to perform their roles effectively in relation to resident lifestyle. For details of this system refer to the expected outcome 1.3 Education and staff development. A recent example of education relevant to Accreditation Standard Three is the activity staff attended education at a diversional therapy college for training on activities for residents. 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s recommendation Does comply The home has systems to ensure each resident receives support in adjusting to life on entry to the home and on an ongoing basis. Systems include providing potential and/or new residents and their representatives with the relevant information to assist them to identify that the home will meet their needs. Processes are also in place to assist new residents to settle into the home through the identification and support of their physical and emotional needs. Staff interviewed advised that they support new residents with a welcome, introducing themselves, and orientating the residents to the home. Recreational activity programs include one-to-one support for residents. A pastoral carer attending the home each week is also available to support residents. Residents/representatives interviewed generally expressed satisfaction with the initial and ongoing support and care provided. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s recommendation Does comply Residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home according to their personal preferences and general health. The home provides an environment in which representatives and visitors are welcome to visit. Private dining areas are available for residents to use if required for entertaining guests or for special celebrations. Residents’ independence is fostered in ways including, but not limited to: residents having personal items in their rooms; newspaper readings; telephones, and computers and televisions in their rooms. The home also provides grab rails in the bathrooms and other equipment to support residents’ independence. A recreational activity officer advised that polling representatives attend the home to assist residents to vote. A library service visits the home and the recreational activity program includes regular bus outings. Assistants in nursing interviewed indicated they encourage residents to do as much as they can to maintain their independence. Residents/representatives expressed satisfaction with the support provided for residents to maintain their independence.


3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s recommendation Does comply The home recognises and respects each resident’s right to privacy, dignity and confidentiality through the identification of residents’ care needs, and staff practices. For example, residents’ preferred names are identified on entry to the home and are used by staff. The resident agreement and resident handbook include information on the home’s support for the privacy of residents’ personal information. The resident agreement includes consent from residents or their representatives for the use of residents’ photographs within a specified manner. The employee handbook provides staff with information on the need to maintain the confidentiality of residents’ personal information. Staff interviewed described strategies for maintaining respect for residents’ privacy, confidentiality and dignity including, but not limited to: knocking on doors and closing doors when providing treatments in residents’ rooms. Management interviews indicated that processes are in place for the archiving of residents’ files and for the destruction of confidential information. Computerised information is password protected. Residents/representatives interviewed expressed satisfaction with the way staff respect and maintain residents’ privacy, confidentiality and dignity. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s recommendation Does comply The home encourages and supports residents to participate in a variety of leisure interests and activities. Assessment processes include the identification of residents’ interests and activities of interest to them, and residents have individual activity plans developed. Recreational activity officers are employed to provide recreational activity programs seven days a week. Activity programs are on display as well as individual copies being available for residents. The activity program includes, but is not limited to: sports days, happy hours, ladies high teas, bingo, art classes, French lessons, sing a longs, and various games. A men’s group is also reported to be available. Interviews with a recreational activity officer indicated that the recreational activity programs cater for residents’ various levels of physical and cognitive capabilities. Attendance records are completed to record residents’ participation in activities including one-to-one activities. Outlines on the activities available are maintained to guide staff. Evaluations of activities are completed periodically. Residents/representatives interviewed are satisfied with the activities provided and the bus outings available. Residents also advised that they can undertake individual activities or their choosing in their rooms when preferred. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s recommendation Does comply The home demonstrated that new residents’ individual interests, customs, beliefs and cultural needs are identified and documented during the initial assessment period. The home holds special celebrations for Australian cultural and religious days. For example, special celebrations have been held for ANZAC Day, Melbourne Cup, Easter, and Christmas. Roman Catholic and Anglican Church services are held in the home. A recreational activity


officer reported that a pastoral carer also attends the home for half a day each week. The recreational activity officer reported that residents’ birthdays are celebrated on the day of their birthday with a cake and singing happy birthday. Management and staff interviews indicated that spiritual support is arranged for terminally ill residents as required. The home does not currently identify any residents to have linguistically diverse needs. Residents/representatives interviewed are satisfied that adequate support is provided for residents’ cultural and spiritual 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 recommendation Does comply Residents and/or their representatives are enabled and encouraged to participate in decisions about the care and services provided. The home informs residents/representatives of choices available and their rights through the resident agreement, and the resident handbook. Examples of residents’ choices for care and services include: choice of participation in activities; choice of medical officer; choice of personal items in rooms; choices in activities of daily living; and choice of meals. Mechanisms through which residents/representatives can have input into the care and services provided include: resident/relative meetings, family case conferences, and comments and complaints mechanisms. The general manager also has an ‘open door’ policy. Most residents/representatives expressed satisfaction with their choices and control over the care and services provided within the home. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s recommendation Does comply Processes are in place to provide potential and new residents and/or their representatives with information on security of tenure and their rights and responsibilities. A resident agreement, to be read in conjunction with the resident handbook, is offered to new residents and/or their representatives for signing. These documents provide information including, but not limited to, reasons for moving beds; management of bonds; termination of the agreement; fees; an initial 14 day cooling off period; and details of the care and services to which residents are entitled. The resident handbook also includes the Charter of Residents’ Rights and Responsibilities which is also on display in the home. Management reported that residents are encouraged to seek financial advice prior to signing the agreement. Management also advised that residents are not transferred to alternative rooms unless consulted about the room moves. Resident/representative interviews indicated that residents feel secure in their tenure in the home and generally understand their rights and responsibilities.


Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply Refer to expected outcome 1.1 Continuous improvement for details of the home’s continuous improvement system. The home presented evidence to demonstrate that the organisation actively pursues continuous improvement in relation to Accreditation Standard Four. Recent improvements in relation to Accreditation Standard Four include: Introduction of a ‘memorable dining experience’ has been implemented at the home.

Tablecloths, placemats, menus on each table are now part of the everyday dining room experience and the room is set up like a restaurant. A bain marie has been purchased. This allows breakfast and lunch to be served by the staff to the residents where they can choose what they would like. As a result residents can smell the food on each floor and can have control over their portion size. Feedback from residents interviewed was positive about the new system.

Bruch in the sunshine has recently been introduced at Bupa Mosman. At the weekend,

relatives are invited to attend and share a brunch with the residents on the rooftop courtyard. The team received may positive comments from residents, staff, and representatives about the improvement. It provides an opportunity for residents to enjoy food outside of the usual location and with others.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s recommendation Does comply The home has systems in place to manage regulatory compliance in relation to the physical environment and safe systems. For a description of the home’s system for regulatory compliance refer to the expected outcome 1.2 Regulatory compliance. Recent examples of the home’s system that demonstrates compliance with Accreditation Standard Four includes routine checking and testing of fire fighting equipment and fire alarm systems and a current license for the food services. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has an education and staff development system to provide staff with appropriate knowledge and skills to perform their roles effectively in relation to the physical environment


and safe systems. For details of this system refer to the expected outcome 1.3 Education and staff development. Some recent examples of education relevant to Accreditation Standard Four are infection control and manual handling. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s recommendation Does comply Residents confirm they are satisfied that the home provides a safe and comfortable environment to live in and is consistent with their needs. The home is clean and well maintained with a number of indoor and outdoor communal areas for residents/representatives to use. There are a variety of processes in place to ensure the environment is clean and safe, for example, a prevention maintenance program, cleaning schedules and access to call bells. The home regularly monitors the environment to ensure it is consistent with residents’ care needs and has recently undertaken a large refurbishment project. Air conditioning units are throughout the home to ensure temperature control. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply Management can demonstrate it is working to provide a safe environment that meets regulatory requirements. The home has systems in place to regularly monitor and improve health and safety, for example, risk assessments and the use of incident and hazard forms which are acted on accordingly. Training and information is provided to all staff to ensure that safe practices are conducted. An occupational health and safety meeting is held regularly to ensure hazards are acted upon in a timely manner. Staff interviewed confirmed they are satisfied with the way the home provides a safe working environment. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s recommendation Does comply The home has procedures in place for detecting and acting on fire, security and other emergency risks. Staff understand these procedures and are required to attend training twice a year. A professional company is used by the home to carry out the necessary equipment and environmental checks. For example, the company completes fire extinguisher checks, exit light checks, and sprinkler inspections alongside the weekly checks that the maintenance officer conducts. The home minimises the risk of fire, security and other emergency risks by a variety of methods such as the management of electrical equipment. Resident/representative feedback about the security of the home was positive.


4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply Management demonstrated that there is an effective infection control program in place. The home has a central point of responsibility for the program and an infection control policy manual to guide staff in all areas of infection control. Training is provided for all staff on a regular basis and there is adequate equipment in place. For example, hand washing and spill kit facilities are available on all floors, to assist staff to maintain appropriate measures to reduce the chance of infections. The home has a food safety program in place and staff practice is consistent with the Australian government guidelines as demonstrated by the successful completion of the New South Wales food authority audit. The home regularly monitors and reviews its program through audits, trend analysis and a review of staff practices. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s recommendation Does comply The home has policies and procedures in place to ensure that hospitality services are provided in a way that enhances the quality of life of residents and the staffs’ working environment. The home offers a choice in menus and takes into account resident preferences and needs. Laundry of personal items of clothing is conducted on site and linen is routinely collected and delivered. There is a regular cleaning schedule in place that ensures all areas of the home are routinely cleaned which includes the spring-cleaning of rooms. Infection control systems ensure that all hospitality services are of a good standard. Residents interviewed expressed satisfaction with the hospitality services provided to them. Representatives interviewed also expressed satisfaction with the catering, laundry and cleaning services.

Documents

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