Decision to accredit The Oaks Nursing Home · Decision to accredit. The Oaks Nursing Home . The Aged Care Standards and Accreditation Agency Ltd has decided to accredit The Oaks Nursing

Decision to accredit

The Oaks Nursing Home

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit The Oaks Nursing Home in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of The Oaks Nursing Home is three years until 21 July 2012. 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 and approved provider details Details of the home Home’s name: The Oaks Nursing Home

RACS ID: 5462

Number of beds: 40 Number of high care residents: 40

Special needs group catered for: • Residents with dementia and other related disorders

Street/PO Box: 56 Locke Street

City: WARWICK State: QLD Postcode: 4370

Phone: 07 4661 6800 Facsimile: 07 4661 6816

Email address: [email protected]

Approved provider Approved provider: Darling Downs West Moreton Health Service District

Assessment team Team leader: Belinda Newley

Team member/s: William Tomlins

Date/s of audit: 28 May 2009 to 29 May 2009

Name of home: The Oaks Nursing Home RACS ID 5462 AS_RP_00857 v1.2 Dates of site audit: 28 April 2009 to 29 April 2009 Page 2

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

2.1 Continuous improvement Does comply Does comply 2.2 Regulatory compliance Does comply Does comply 2.3 Education and staff development Does comply Does comply 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


Executive summary of assessment team’s report Accreditation decision

Standard 3: Resident lifestyle


Agency findings

3.1 Continuous improvement Does comply Does comply

3.2 Regulatory compliance Does comply Does comply

3.3 Education and staff development Does comply Does comply

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

4.1 Continuous improvement Does comply Does comply

4.2 Regulatory compliance Does comply Does comply

4.3 Education and staff development Does comply Does comply

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

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.


SITE AUDIT REPORT

Name of home The Oaks Nursing Home

RACS ID 5462 Executive summary This is the report of a site audit of The Oaks Nursing Home 5462 56 Locke Street Warwick QLD from 28 April 2009 to 29 April 2009 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 The Oaks Nursing Home. The assessment team recommends the period of accreditation be 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 28 April 2009 to 29 April 2009. 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: Belinda Newley

Team member/s: Bill Tomlins

Approved provider details Approved provider: Darling Downs West Moreton Health Service District

(Queensland Health) Details of home Name of home: The Oaks Nursing Home

RACS ID: 5462

Total number of allocated places:

40

Number of residents during site audit:

40

Number of high care residents during site audit:

40

Special need catered for:

Residents with dementia and other related disorders

Street/PO Box: 56 Locke Street State: QLD

City/Town: Warwick Postcode:

QLD

Phone number: 07 4661 6800 Facsimile:

07 4661 6816

E-mail address: [email protected]


Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit The Oaks Nursing Home The assessment team recommends the period of accreditation be 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 spent 2 days on-site and gathered information from the following: Interviews

Number Number

Nurse unit manager 1 Residents 7 Clinical nurse consultant 1 Representatives 2

Clinical nurse 1 Supervisor operational services 1

Registered nurse 1 District workplace health and safety officer 1

Enrolled nurse- advanced practice 1 Workplace health and safety

officer 1

Care staff 5 Chef 1 Infection control resource person 1 Catering staff 2

Administration officer 1 Laundry staff 1 Activities officer 1 Cleaning staff 1 Manager operational services 1 Maintenance staff 1

Sampled documents

Number Number

Residents’ files 5 Medication charts 7 Care plans 5 Restraint authorities 7

Residential care agreements 4

Other documents reviewed The team also reviewed: • ‘Caring together’ diversional therapy assessment


• ‘Our Oaks Family” newsletter- Dec08/Jan09 and Mar/Apr09 • 28 day assessment planner • Abbey pain scale • Activity attendance records(group and individual) • Activity evaluation forms • Activity procedure folder • Annual licence certificate • Aromatherapy sign off sheet • Audit outcomes • Audit planner • Audit recommendations • Audits • Behaviour data tool • Benchmarking data report • Birthday list • Bowel management chart • Care plan review schedule • Catering cleaning schedule • Catheter change record • Cleaners duties list • Communion list • Community welfare directory • Controlled drug register • Daily activity sheets • Daily allocation sheet • Daily wound evaluation sheet • Diabetic record sheet • Dietary intake record • Diversional therapy new resident checklist • Diversional therapy time plan • Education calendar-2009 • Emergency phone numbers • Evacuation instructions • Evacuation map • Extra pad usage chart • Falls risk assessment • Fire competency assessment tool • Fire warden guidelines • Food receipt book • Food safety audits • Hand washing assessment • Have your say forms • Have your say register • Incident data • Incident forms • Incident reports • Key selection criteria • Laundry daily record • Mandatory training records • Massage list


• Medication incident report • Meeting calendar • Memorial service information • Menus • Mission, vision, strategic directions • Monthly activity calendar • New starter information sheet • Newsletter • Pain assessment • Pain observation tool • Palliative care end of life plan • Pastoral care contact list • Patient handling competency assessment • Police certificate • PRN medication response record • Proposed yearly activity calendar • Quality indicator notification form • Quality meeting minutes • Referee checks • Resident admission pack • Resident exercise care plan record • Resident handbook • Resident mobility list • Resident newspaper list • Resident religion list • Resident/relative meeting minutes • Rosters • Session evaluations • Staff survey • Staff survey action plan • Staff survey results • Subcutaneous narcotic syringe driver record • Temperature records – food/equipment • Tender submission • Thermometer calibration records • Training attendance sheet • Trend analysis report • Unpacked medication order forms • Volunteer handbook • Weekly activity planner- Cunningham wing • Weight graph • Weight list • Wing trial evaluation forms • Work order • Workplace incident report • Wound assessment Observations The team observed the following: • ‘Have your say forms’ on display


• Activities in progress • Activity calendar on display • Assembly areas • Cleaner’s trolley • Colour coded linen skips • Comments post box • Controlled drug safe • Drug fridge • Equipment and supply storage areas • Exit lights • Filing and storage areas • Fire doors • Fire fighting equipment • Fire panel • Hand washing facilities • Hand sanitiser at entry to the home • Interactions between staff and residents • Internal and external living environment • Maintenance shed • Meal service • Medication administration • Personal protective equipment in use • Personal protective equipment on display • Spill kits • Storage of medications


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 The Oaks Nursing Home has a continuous improvement system that comprises of processes for the identification of improvement opportunities and the implementation, monitoring and evaluation of improvement solutions. A framework of audits, staff and resident meetings, ‘Have your say’ forms, staff and resident surveys, maintenance requests and incident reports assist the home to actively pursue continuous improvement. Feedback is provided through discussions with the originator of the suggested improvement, through staff and resident meetings and via staff memos. Staff and residents demonstrated an understanding of these processes and stated that they worked effectively. Residents indicated that management encouraged them to make suggestions for improvements with staff also indicating that they are encouraged by management to contribute ideas for improving service outcomes and that they assist residents to fill out forms if they want to make a suggestion. Examples of improvements relative to Standard One include:

• An improvement to the ‘have your say’ form to include a section on how the suggestion will benefit the residents, the staff or the home has resulted in better quality suggestions being received as some additions can now be made by the originator to demonstrate how the improvement may be implemented within the home.

• A computerised handover sheet containing all resident’s names and a column for each day allows information to be accumulated for the week. These are filed for up to two months and correlate with details contained within individual resident progress notes. This has improved communication of clinical information and has resulted in an improved continuum and quality of care for the residents.

• Mandatory training is now concentrated into one full day instead of being done over a longer period. This allows staff to be rostered for mandatory training and for records of attendance to be more accurately kept. Competencies for hand washing, manual handling and fire safety are also done on this day.

• Stores management has been improved by making it the responsibility of one person. This has been done by improving the method of storage with bins for each item, by allocating a larger area for storage and by having a communication book in the storeroom into which staff write requirements for the stores person to attend to each week.


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 There is a system in place to capture changes to relevant legislation, regulatory requirements, professional standards and guidelines. This system includes membership to organisations providing information on such changes, access to Internet websites, attendance at seminars and education sessions, and subscriptions to professional journals. Changes are monitored in the district office of the provider, by an aged care district committee or by the home itself through information transmitted to the home via Queensland Health circulars or by a monthly tele-link with an office of ageing in the approved provider’s head office. Changes are communicated to the appropriate staff throughout the home directly by the Nurse Unit Manager (NUM) and to all staff via the communication book. Recent changes to mandatory reporting and the new aged care funding instrument were followed by a series of training programs. Staff criminal record checks are conducted and residents and relatives had been notified of the forthcoming accreditation audit. Compliance with legislation is monitored through the audit process, surveys and supervisor observation of 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 recommendation Does comply The home has a range of strategies to ensure that staff have appropriate knowledge and skills, including incorporating these requirements in the key selection criteria at recruitment. The performance appraisal and development system identifies general educational needs, supported by information from the clinical indicators, ‘Have your say’ forms, incident reports and admissions of residents with specific care requirements all providing information from which an education calendar is developed. Some competency assessments also form part of the audit of staff skills that is commenced at orientation for new staff and is an ongoing process. The organisation offers a range of training opportunities for staff, both on site using senior and other local experts, suppliers, or off-site through other external providers. The home also subscribes to an external education provider to provide internal in-service program to all staff. Staff report management is responsive to their learning needs. Recent examples of education provided relevant to Standard One include accreditation – your role and responsibility, code of conduct, teamwork, situational leadership, customer satisfaction, and Aged Care Funding Instrument (ACFI) in practice. 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 has a comments and complaints system that captures comments, complaints and suggestions from residents, representatives, staff and other interested parties. Residents/representatives are informed about internal and external avenues of complaint on admission via the resident handbook, the residential care agreement, brochures, the home’s newsletter, notices displayed throughout the home, at resident meetings and through one-to-one discussions with staff and management. Comments/complaints forms (Have your say) are available and accessible to residents with a secure post box is located through a slot in the door of the manager’s office for those who wish to lodge a confidential complaint. Management register and act upon all complaints received and monitor progress towards resolution at monthly quality improvement meetings. Management provides feedback to the originator in writing, verbally or via the telephone on the progress of the investigation and the final outcome. Staff receive training to assist residents’ with lodging complaints either internally or externally. Surveys indicate that residents/representatives are familiar with the various ways to initiate a complaint/suggestion and reported they feel comfortable in expressing any issues of concern and stated that they are dealt with promptly and adequately. 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 documented the vision, mission and strategic directions of the home and these are displayed in the residents’ information book, the staff handbook and on the walls of the home and discussion of them forms part of the orientation sessions. Staff practices to achieve the intent of these statements form part of the performance appraisal and development discussion. 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 ensures appropriately skilled and qualified staff through its human resource procedures, which include key selection criteria linked to position descriptions at recruitment, reference checking, contracts of employment, performance and development system and the training and education program. Staffing numbers are determined by an organisation imposed occupancy formula but adjusted on a short-term basis by the Nurse Unit Manager in consultation with the campus Director of Nursing with regard to resident needs and staff workloads. New staff attend a comprehensive orientation in all mandatory areas at district and local level prior to or soon after commencing duty and are ‘buddied’ for a minimum three shifts or longer if required. A probation assessment is completed after twelve weeks


before being made part of the permanent workforce and staff then participate in annual performance appraisals which are linked to the education plan. Rosters are done in consultation with staff to address the needs of residents, and staff stated that roster arrangements allow for them to complete their duties and attend to residents in a reasonable time. Residents/ representatives indicated they were satisfied with staff responses to requests for assistance. 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 There is a purchasing process in place for day to day operations and for capital items that ensures that there is always sufficient and appropriate goods and equipment to deliver the care and service required. New equipment requirements are suggested by staff on an ongoing ‘wish list’ at the time of preparing capital budgets and are trialled before purchase. Specialised health and personal care products, catering items and other housekeeping and cleaning materials are ordered by relevant staff via a purchase order system and stock is examined for fitness on receipt and rotated with remaining stock. There is a preferred supplier list to guide staff as well as service agreements in place with regular suppliers to indicate quality of goods and services required. There is a scheduled maintenance program in place to ensure ongoing reliability of equipment and infrastructure and a daily maintenance program to correct minor items needing attention. Residents and staff indicated that they were satisfied with the availability and appropriateness of the goods and equipment provided. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply There are systems in place to enable staff and management access to sufficient and reliable information for appropriate decision making. Staff files are stored in locked cabinets in the manager’s office and residents’ clinical files are in the nurse stations and accessible to those using the information. Staff indicated that the information necessary to perform their jobs is readily available and that regular staff briefings keep them informed on a whole range of relevant topics. Minimal records are archived on site with most stored off-site and redundant files destroyed according to the provider’s policy. Communication to residents or and representatives is via resident meetings, notes attached to monthly accounts, the home’s newsletter and by an open-door policy to all senior staff and residents/representatives commented positively on their access to information and staff. 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


Allied health services sourced external to the home but from within the provider organisation include dietitian, physiotherapy and speech pathology. Services such as pest control, chemicals, and fire equipment maintenance are sourced externally and managed through the policies of Queensland Health. External services are covered by the purchasing policies of the provider and service agreements are in place and managed from district office but with input from the user sites particularly at time of contract review and possible renewal. Performance is monitored according to the satisfaction of the residents’ and staff and as many suppliers have been providing the service for a long time residents’ indicated their satisfaction with the services provided.



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 The Oaks Nursing Home has a continuous improvement system that comprises of processes for the identification of improvement opportunities and the implementation, monitoring and evaluation of improvement solutions. A framework of audits, staff and resident meetings, ‘Have your say’ forms, staff and resident surveys, maintenance requests and incident reports assist the home to actively pursue continuous improvement. Feedback is provided through discussions with the originator of the suggested improvement, through staff and resident meetings and via staff memos. Staff and residents demonstrated an understanding of these processes and stated that they worked effectively. Residents indicated that management encouraged them to make suggestions for improvements with staff also indicating that they are encouraged by management to contribute ideas for improving service outcomes and that they assist residents to fill out forms if they want to make a suggestion. Examples of improvements relative to Standard Two include:

• New pressure relief mattress inlays have been purchased which need only to be switched on by the staff when a person lies on them. The mattress then self calculates the pressure required depending on the weight of the resident. These mattresses are less bulky than previous ones which means that the height of the bed changes very little so are safer for residents sitting on the edge. Staff and residents have given positive feedback with some residents wishing to purchase their own which they have been able to do at a favourable price through the home’s purchasing system.

• Electronic blood pressure machines have been purchased. Staff indicate that this has allowed more accurate and quicker assessment of residents in emergency situations and on a daily basis.

• As a result of a request coming from workshops set up after the staff survey, staff are now allocated to one of the four wings for a month and then rotated to another wing. Residents and staff are happy with the change. Management states that care routines are more consistent and staff supervision for on the job training is easier and more effective.

• The home has recently gained access to a visiting podiatrist who now does the high risk, more difficult jobs and the staff who have been specially trained continue to do the rest. This has been a difficulty for a long time and staff are happy to have the difficult jobs done by a professional.

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 There is a system in place to capture changes to relevant legislation, regulatory requirements, professional standards and guidelines. This system includes membership to organisations providing information on such changes, access to Internet websites, attendance at seminars and education sessions and subscriptions to professional journals. Changes are monitored in the district office of the provider by an aged care district committee or by the home itself through information transmitted to the home via Queensland Health circulars or by a monthly tele-link with an office of ageing in the approved provider’s head office. Changes are communicated to the appropriate staff throughout the home directly by the NUM and to all staff via the communication book. Recent changes to mandatory reporting and the new aged care funding instrument were followed by a series of training programs. Changes to legislation regarding the administration of drugs required a change to the medication policies for enrolled nurses. Compliance with legislation is monitored through the audit process, surveys and supervisor observation of 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 recommendation Does comply The home has a range of strategies to ensure that staff have appropriate knowledge and skills, including incorporating these requirements in the key selection criteria at recruitment. The performance appraisal and development system identifies general educational needs, supported by information from the clinical indicators, ‘Have your say’ forms, incident reports and admissions of residents with specific care requirements all providing information from which an education calendar is developed. Some competency assessments also form part of the audit of staff skills that is commenced at orientation for new staff and is an ongoing process. The organisation offers a range of training opportunities for staff, both on site using senior and other local experts, suppliers, or off-site through other external providers. The home also subscribes to an external education provider to provide internal in-service program to all staff. Staff report management is responsive to their learning needs. Staff report management is responsive to their learning needs. Recent examples of education provided relevant to Standard Two include pain identification and management, mental health – dementia and depression, fall prevention, responding to behaviours, and Huntington’s disease. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply


Residents care needs are assessed using a standard set of assessments (inclusive of risk assessments) on entry to the home and as residents clinical care needs change. Care plans are developed by registered nurses utilising information gathered from assessments which are evaluated three monthly or as required. Case conferences involving the resident and/or their representatives are held annually or as required to ensure they have input into the care provided. Daily care needs are evaluated, monitored and reviewed by the registered nurse through the handover processes at each change of shift and the review of progress notes. Care plan adjustments are made as required and in a timely manner. Communication and referral between external/internal medical and allied health professionals for residents’ individual care needs is appropriate and timely. Staff demonstrated an understanding of individual resident care needs and preferences and are satisfied with the communication processes utilised to inform them of resident clinical care changes. Residents/representatives confirm that the clinical care they receive is appropriate to their needs and preferences. 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 needs are identified in consultation with residents and other health professionals, using discharge summaries and other information available to them. Care plans identify and include the specialised nursing care needs of individual residents and are developed and reassessed by registered nurses. The delivery of specialised nursing care needs of residents’ is undertaken by registered nursing staff or endorsed enrolled nurses under the supervision of registered nurses with the exception of colostomy care which is undertaken by trained care staff. Care routines are structured to ensure specialised care needs are carried out in accordance with residents’ identified needs. A registered nurse is available for consultation and assessment at all times, with scheduled specialised nursing care requirements attended within required timeframes. The home accesses clinical expertise through effective working relationships with specialist external health services within the area if required, with trained resource personnel also onsite. Staff are provided with education sessions on clinical practices such as colostomy care, wound care and palliative care. Residents/representatives indicate they are satisfied that their specialised nursing needs are identified and met by appropriately qualified staff. 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 Residents’ allied health needs are identified on admission or as care needs change with referral to appropriate health specialists undertaken in a timely manner. A variety of health specialists are utilised by the home including physiotherapy, podiatry, dietician, speech pathology, occupational therapy and mental health with regular assessments undertaken for individual residents as required. A written or verbal


referral is initiated by registered nursing staff for non-urgent medical and allied health reviews. In urgent cases the registered nurse verbally refers to medical or allied health staff for review and further care instructions. The outcome of the referral (internal or external), including instructions for ongoing care, are documented appropriately and retained in residents’ records. Staff demonstrated an understanding of the circumstances to refer residents for re-assessment by other health specialists, are aware of the referral process and are satisfied that they are informed of outcomes resulting from referral. Residents/representatives indicate that residents are referred to appropriate health specialists in accordance with residents’ needs and preferences. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply Resident’s individual medication management needs are identified on entry to the home by the NUM. The home utilises a sachet pack compliance system for resident’s routine medications with ‘as required’ and short course medications supplied in their original packaging. Registered and endorsed enrolled nurses who have undertaken medication calculations exams and skill stations annually, administer medications. Registered nurses are responsible for the ordering of unpacked medications, notifying pharmacy of changes to residents’ medications and for the checking of sachets when delivered to the home weekly. An imprest system is available with the external pharmacy provider responsible for the monitoring of this. All medications including controlled and refrigerated drugs are stored and monitored appropriately. Processes are in place to monitor and evaluate the administration of variable dose/timed medication and ‘as required’ medication. A three monthly review of residents’ medications is undertaken by the resident’s treating doctor with an external pharmacist conducting reviews annually or as required. Evaluation of the medication administration system is conducted through the monitoring of internal medication incidents and internal auditing processes. Residents/representatives are satisfied that their medication is administered safely and correctly. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”.

Team’s recommendation Does comply A pain assessment is conducted on all residents during the initial assessment phase, with processes also in place to identify new or acute pain for all residents. The home utilises verbal and non-verbal assessment tools (dependent upon resident need) to assist in the assessment and identification of pain. The level of pain experienced, the potential for pain, identified triggers and management strategies are included in the resident’s care plan to guide staff. Strategies to manage pain involve a multidisciplinary approach and include pharmacological and non-pharmacological interventions. ‘As required’ medication provided for pain are administered and evaluated for effectiveness by registered nurses/endorsed enrolled nurses, with increased use prompting referral to medical officers for re-evaluation of treatment. Referal to allied health professionals is undertaken to guide the implementation of


non-pharmacologic pain management strategies such as transcutaneous electronic nerve stimulation (TENS) or aromatherapy. Other strategies utilised include repositioning, heat pad application and massage. Residents/representatives are satisfied that their pain is managed effectively and that staff are responsive to their changing needs and intervene so as maximise their comfort. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply Residents’ palliative care needs are identified on entry to the home, if appropriate or as the need is identified. Where applicable, copies of health care directives and enduring power of attorney documentation are kept on file for staff to access as required. Palliative care nursing requirements are entered into an individualised end of life care plan when the need is identified and is updated to ensure flexibility in the provision of care and to accommodate the residents’ and families’ changing needs. The home has equipment available within the home to support resident’s care during the palliative phase. Residents’ pain, comfort and spiritual needs are managed in consultation with the resident/representative, health care practitioners and pastoral care personnel, to provide physical, psychological, emotional, cultural and spiritual support to residents and their families. Staff demonstrated an awareness of the care needs and measures to provide comfort and dignity for terminally ill residents and support for their families. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply Residents’ nutrition and hydration needs including likes, dislikes and cultural requirements, allergies and assistive equipment devices required are identified on admission through the completion of a dietary assessment. The information gathered is used to develop the resident’s care plan and inform the kitchen, to ensure appropriate meals are provided to all residents. Strategies implemented to assist residents to maintain adequate nourishment include the provision of specialised eating utensils/assistive devices, assistance to eat and drink, provision of texture modified diets, dietary supplements and referral to dietitians and speech pathologists, as required. Residents are weighed on admission then monthly with variances trended and reviewed by the registered nurses. Unintended weight loss or gain is analysed for causative factors and prompts referral to allied health professionals if required. Other management strategies include the introduction of special diets and/or supplements by registered nurses in consultation with the resident’s medical officer and/or the monitoring of dietary/fluid intake with all changes communicated to relevant areas of the home within appropriate timeframes. Residents/representatives are satisfied with the quality and sufficiency of food and fluids provided.


2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply Residents’ skin integrity is assessed on entry to the home and on an ongoing basis with required interventions included in the resident’s care plan to guide staff. The potential for compromised skin integrity is also risk assessed on entry and three monthly or as required to ensure appropriate preventative strategies are implemented. These include pressure reducing/relieving devices, limb protectors, pressure area care, the use of emollient creams, assistance with personal hygiene, the provision of adequate nutrition/hydration and effective continence management. Incidents related to breaks in skin integrity are captured on incident reports and analysed for trends/triggers; with appropriate interventions implemented as required, including the development of wound management plans, with photographic evidence of healing progress. Regular evaluation of wounds is undertaken by registered nurses or endorsed enrolled nurses under the supervision of the registered nurse. Staff demonstrated an understanding of factors associated with risks to residents’ skin integrity and indicate that they receive education on maintenance of skin integrity, wound management and correct manual handling techniques. Resident/representatives indicate that residents’ skin condition is consistent with their general health. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Continence assessments are conducted on residents upon entry to the home with urinary and bowel monitoring charts commenced to identify patterns and trends. Residents’ individual continence programs are developed by the registered nurse and are detailed on care plans for care staff reference. Risk factors such as frequent urinary tract infections or constipation are also identified in the residents care plan with instruction to direct staff care. Continence link nurses review documented extra pad requirements and increased frequency of incontinence which prompts investigation and continence aid re-assessment once any possible causes are eliminated. Individualised bowel management programs are developed and include pharmacological and non-pharmacological interventions. Bowel patterns are monitored by registered nurses who respond by giving ‘as required’ medications to residents who exhibit constipation if other non-pharmacological interventions have failed. Residents/representatives are satisfied with the level of assistance and aids provided to manage their continence. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply


All residents are assessed for identified challenging behaviours on entry to the home after a settling in period or if identified prior. Monitoring is commenced to aid in the identification of triggers and effective management strategies. Care plans are developed in consultation with the resident and/or the representative to provide care staff with guidance in relation to ongoing management of residents’ with challenging behaviours; these care plans are evaluated every three months or as required. Pharmacological and non-pharmacological strategies are implemented including environmental and routine modification, diversion through activity, counseling, and medication review. Specialist advice is accessed to guide ongoing management of challenging behaviours through referral to external mental health and behaviour management advisory services. Staff have received education in the management of challenging behaviours and the effectiveness of strategies is discussed during handover processes. Residents/representatives are satisfied with the way challenging behaviours are managed within the home. 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 Each resident’s level of mobility, dexterity and falls risk is assessed during the admission phase initially by the registered nurse and then by the physiotherapist utilising where possible input from discharge summaries and residents/representatives. Assessment and observation is then used to identify and determine areas of need. A physiotherapy care plan, mobility plan and individualised exercise program is developed and provides care staff with information regarding how best to support residents’ mobility and dexterity levels. Care staff receive instruction in supporting residents with their active and passive exercises, with structured exercise programs such as chair Tai-chi included as part of the home’s activity program to ensure maintenance of residents current condition. Acute episodes such as falls or return from hospital will prompt re-evaluation of the resident’s mobility/dexterity needs. Appropriate aids to improve/maintain mobility and dexterity are available for residents to use and include; walkers, built up cutlery and plate guards. Residents/representatives are satisfied with the level of support and assistance provided to maintain optimum levels of mobility. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply Residents’ oral and dental status is identified on entry to the home through assessments with the level of assistance required to maintain oral and dental hygiene identified and included in the resident’s care plan to guide staff. Strategies to assist residents to maintain their oral and dental health include referral to the local hospital dental service or other relevant external health specialists, oral hygiene assistance, fluid maintenance and application of oral moisturisers. The local hospital dental service is accessed through referral by registered nurses and will visit residents within the home and repair dentures for residents with in appropriate timeframes. Texture


modification of meals is provided where oral and dental health or swallowing is compromised. Staff are provided with education on oral hygiene safety for those residents with impaired swallowing capacity. Residents/representatives are satisfied with the level of support provided to assist them with the maintenance of oral hygiene and their access to dental health services. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Residents’ sensory losses are identified on entry to the home and information to support residents with sensory loss through a comprehensive assessment that incorporates the five senses. Information gained is incorporated in the resident’s care plan and includes reference to the use of assistive devices, where appropriate. Audiology and optical services are provided and accessed as required to address identified concerns. Staff receive training on the management of sensory aids (including correct insertion techniques and battery changes for hearing aids and cleaning of lens). Condiments are available on dining tables for residents with impaired sense of taste, with care staff using these as appropriate. Care staff and diversional therapy staff implement various strategies/assistive devices that may include modification of the resident’s environment, communication books/boards, routines and alteration/assistance with activities of daily living. Residents/representatives are satisfied that staff are aware of and sensitive to sensory losses and provide assistance and support as required. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Residents’ initial assessment includes identifying any aids/habits that have previously been utilised in assisting residents to achieve natural sleep patterns. Information gathered is included in the resident’s care plan to guide staff care. Night routines maintain an environment that is conducive to sleep and factors that may compromise sleep such as confusion, incontinence, pain, temperature variances and noise are identified and addressed to promote sleep. Prolonged disruption to sleep prompts reassessment of the residents needs. Non-pharmacological interventions such as provision of food and warm drinks, repositioning/massage and relaxing music are provided for residents if wakeful. Pharmacological intervention is available as prescribed by the resident’s medical officer. Residents/representative are satisfied that they are assisted to achieve natural sleep patterns by staff at the home.


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 The Oaks Nursing Home has a continuous improvement system that comprises of processes for the identification of improvement opportunities and the implementation, monitoring and evaluation of improvement solutions. A framework of audits, staff and resident meetings, ‘Have your say’ forms, staff and resident surveys, maintenance requests and incident reports assist the home to actively pursue continuous improvement. Feedback is provided through discussions with the originator of the suggested improvement, through staff and resident meetings and via staff memos. Staff and residents demonstrated an understanding of these processes and stated that they worked effectively. Residents indicated that management encouraged them to make suggestions for improvements with staff also indicating that they are encouraged by management to contribute ideas for improving service outcomes and that they assist residents to fill out forms if they want to make a suggestion. Examples of improvements relative to Standard Three include:

• With an increase in activity officers hours, activities in the secure wing are now more individually targeted. This has seen one resident taking ownership of a part of the garden and growing tomatoes and corn. Other residents also have special activities more suited to their previous lives and staff report a more calm atmosphere in the whole unit.

• Scheduled hours have been allocated from the collocated hospital’s social worker to the home enabling time to be given to some new residents who have found it difficult to settle on admission, and to others who have recently lost family members or are suffering grief for some other reason. Management reports that this has been effective especially as the social worker is not part of the home’s regular staff and residents feel more able to share confidences with them.

• The home has recently gained access and support from an indigenous health worker which is useful for assistance with indigenous residents from time to time and also with the training of staff in cultural matters.

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


There is a system in place to capture changes to relevant legislation, regulatory requirements, professional standards and guidelines. This system includes membership to organisations providing information on such changes, access to Internet websites, attendance at seminars and education sessions and subscriptions to professional journals. Changes are monitored in the district office of the provider, by an aged care district committee or by the home itself through information transmitted to the home via Queensland Health circulars or by a monthly tele-link with an office of ageing in the approved provider’s head office. Changes are communicated to the appropriate staff throughout the home directly by the NUM and to all staff via the communication book. The home has educated staff on changes relating to reportable assaults and has systems and processes in place to ensure the same occurs. Compliance with legislation is monitored through the audit process, surveys and supervisor observation of 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 recommendation Does comply The home has a range of strategies to ensure that staff have appropriate knowledge and skills, including incorporating these requirements in the key selection criteria at recruitment. The performance appraisal and development system identifies general educational needs, supported by information from the clinical indicators, ‘Have your say’ forms, incident reports and admissions of residents with specific care requirements all providing information from which an education calendar is developed. Some competency assessments also form part of the audit of staff skills that is commenced at orientation for new staff and is an ongoing process. The organisation offers a range of training opportunities for staff, both on site using senior and other local experts, suppliers, or off-site through other external providers. The home also subscribes to an external education provider to provide internal in-service program to all staff. Staff report management is responsive to their learning needs. Staff report management is responsive to their learning needs. Recent examples of education provided relevant to Standard Three include the ageing process, indigenous culture, grief and loss and elder abuse. 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 Emotional support is provided to residents and representatives upon entry to the home by all staff. An admission kit is provided to all residents prior to entry to the home with the NUM providing emotional support and orientation to the residents and families and upon arrival at the home. Care plans outlining emotional support needs are developed in consultation with resident and/or their representative after a settling in period at the home and are utilised by staff on a daily basis to ensure the emotional well being of the residents. Responses to critical changes in the resident’s emotional need such as change of environment or family crises are managed by the care staff and/or the


activity officer within the home. The home has access to ministers of religion/pastoral care staff to assist residents’ with emotional support needs. Families are encouraged to be involved in all aspects of the residents’ life within the home. Residents/representatives are satisfied with the level of support and consideration provided by staff and management to meet their emotional care needs and preferences. 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’ capabilities, interests and wishes are assessed on admission with care plans developed that promote choice and independence within the initial assessment period. Staff encourage residents to maintain independence through maintaining flexibility in care routines, ensuring assistive aids are accessible, allowing residents the time to complete activities of daily living and modifying and setting up the environment to ensure residents can attend to their own tasks as much as they are able. Assistance with financial independence is maintained through a petty cash account system at the home, with accounts sent to residents or their authorised representatives monthly. Residents are encouraged to maintain their friendships and links with the community by accessing local clubs and to develop new friendships within the home. Residents/representatives are satisfied with the assistance provided to maintain their level of independence and to participate in and attend personal and group activities as they wish. 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 Resident’s individual needs relating to privacy, dignity and confidentiality are identified in entry to the home through the assessment and orientation process. Individual wishes are documented into the care plans and reviewed as necessary. Strategies are implemented by care staff to ensure that residents’ privacy and dignity are maintained while entering residents’ rooms and conducting personal care for resident. Residents’ confidential information is stored in secure locations in each section of the home. Staff confirmed the strategies they use to maintain resident’s privacy and dignity and apply these. Residents/representatives indicate that staff respect their privacy, dignity and confidentiality when caring for them. 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


Information about residents’ social interests, (both past and present) capabilities, level of independence, communication skills and significant relationships is collected on entry to the home and is reviewed as needs change. The care plan is developed using information gained and includes social and emotional goals, interests and strategies to achieve these is reviewed three monthly by the diversional therapist in consultation with registered staff. The activities program is developed in consultation with residents through information provided via resident meeting forums and evaluation results of past events. A monthly activity calendar is available to residents/representatives with it provided to them monthly in large print or displayed throughout the home with the diversional therapy/care staff also informing residents on daily basis. Resident representatives are encouraged to participate in any activities within the home. Residents/representatives are satisfied with the activities offered and the support provided by staff and volunteers to enable them to participate in activities of interest to them. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s recommendation Does comply The cultural and spiritual needs of all resident’s are assessed on entry to the home by the Chaplin and Diversional Therapist and communicated to staff through care plans and progress notes. Church services are conducted and individual spiritual needs are met by visiting ministers and pastoral care volunteers. Spiritual and cultural days of significance are celebrated within the home with memorial services held three times per year in memory of past residents. The individual beliefs and customs of residents are observed and known by staff. Staff access culturally specific support services and have access to cultural resources to assist in communication with residents from diverse cultural backgrounds. Residents/representatives indicate that they are satisfied that their cultural and spiritual needs are being met at the home. 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 The home has a process to support residents’ choice and decision making in relation to the care and services they receive. Residents are able to have input into and exercise choice about care and services at the home through ongoing one-to-one consultation with staff and management, care conferences, resident meetings, satisfaction surveys and the comments/complaints process. Residents’ individual care and lifestyle routines are identified through the assessment and review processes and reflect the residents’ choices and decisions for activities of daily living. Identification of residents’ authorised representatives such as an enduring power of attorney are located in residents’ administration and care records. Residents/representatives


indicated that they are able to exercise choice and make decisions regarding the care and services they or their relative receive. 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 established within the home to ensure that residents’ are provided with a copy of a resident handbook, agreement and explanation of these documents prior to entry to the home. The information provided includes residents’ rights and responsibilities, fees and charges, security of tenure details, internal and external complaint mechanisms and the care, services and routines provided at the home. Any need for changes in the care needs or environment is discussed with the resident and/or their representative in a case conference prior to any change occurring. Management have an open door policy and meet with residents/representatives to ensure that any concerns or issues are addressed appropriately. Residents/representatives are satisfied they have security of tenure within the home and are aware of their rights and responsibilities and feel confident to raise any concerns with management.


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 The Oaks Nursing Home has a continuous improvement system that comprises of processes for the identification of improvement opportunities and the implementation, monitoring and evaluation of improvement solutions. A framework of audits, staff and resident meetings, ‘Have your say’ forms, staff and resident surveys, maintenance requests and incident reports assist the home to actively pursue continuous improvement. Feedback is provided through discussions with the originator of the suggested improvement, through staff and resident meetings and via staff memos. Staff and residents demonstrated an understanding of these processes and stated that they worked effectively. Residents indicated that management encouraged them to make suggestions for improvements with staff also indicating that they are encouraged by management to contribute ideas for improving service outcomes and that they assist residents to fill out forms if they want to make a suggestion. Examples of improvements relative to Standard Four include:

• Because the cleaners are part of the operational services staff from the collocated hospital and because they are changed often it was hard to include them in the communication loop. A communication book is now situated in the cleaners’ room and information recorded in the nurses’ station book is also passed onto the cleaners. This is assisting in making them feel part of the home’s team and has improved communication overall.

• With the retirement of the workplace health and safety officer a new person has been appointed. The previous person was part of the operational services staff and as such not a direct report of the home’s manager. The new workplace health and safety officer is an endorsed enrolled nurse which makes it easier for the home’s manager to roster time to be spent on safety aspects. They are also able to influence their colleagues more easily as part of the same team.

• The meals for the home are prepared in the kitchen of the collocated hospital and transported to the home in hot boxes. The new chef who was appointed four months ago now visits the home at least once a week at the midday or evening meal to talk with residents about the meal. Residents are now having more input, the chef is getting to know residents by name, and residents are much happier both with being listened to and with the meals themselves.

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 There is a system in place to capture changes to relevant legislation, regulatory requirements, professional standards and guidelines. This system includes membership of organisations providing information on such changes, access to Internet websites, attendance at seminars and education sessions, and subscriptions to professional journals. Changes are monitored in the district office of the provider, by an aged care district committee, by the home itself and transmitted to the home via Queensland Health circulars, by meetings of the district committee and by a monthly tele-link with an office of ageing in the approved provider’s head office. Changes are communicated to the appropriate staff throughout the home directly by the NUM and to all staff via the communication book. Staff criminal record checks are conducted and residents and relatives had been notified of the forthcoming accreditation audit. Recent food safety legislation, ongoing workplace health and safety changes and new legislation regarding fire safety have been implemented and accompanied by training programs where necessary. Compliance with legislation is monitored through the audit process, surveys and supervisor observation of work practices. 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 a range of strategies to ensure that staff have appropriate knowledge and skills, including incorporating these requirements in the key selection criteria at recruitment. The performance appraisal and development system identifies general educational needs, supported by information from the clinical indicators, ‘Have your say’ forms, incident reports and admissions of residents with specific care requirements all providing information from which an education calendar is developed. Some competency assessments also form part of the audit of staff skills that is commenced at orientation for new staff and is an ongoing process. The organisation offers a range of training opportunities for staff, both on site using senior and other local experts, suppliers, or off-site through other external providers. The home also subscribes to an external education provider to provide internal in-service program to all staff. Staff report management is responsive to their learning needs. Staff report management is responsive to their learning needs. Recent examples of education provided relevant to Standard Four include fire safety, manual handling, infection control – influenza outbreak, fire panel instruction and incident investigation and reporting. 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 The home has 40 beds all on the ground level, all single with a shared en-suite. Eight of the rooms are within a secure unit. Dining and lounge areas are appropriately furnished to the needs of the residents, adequately placed around the facility for easy access, and residents were observed to be able to move about the facility and garden in comfort and safety. Covered areas and other seating outside provide pleasant and accessible places in the garden to sit. Entry to the home is via swipe cards at all times and these have also been issued to residents’ representatives (but these cards have defined time and limited site access authority). Except for the front door the whole area is securely fenced and security is present on the whole campus 24 hours a day. The environmental audit process ensures that any hazards are identified and eliminated, and the scheduled and corrective maintenance programs maintain the equipment and infrastructure in a safe and working condition. Residents/representatives indicated that they were satisfied with the cleanliness of the home and that it provided a safe and comfortable environment.

4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply The home’s management demonstrates its commitment to providing a safe working environment that meets regulatory requirements through its monitoring systems and its education program. The workplace health and safety officer reports monthly to the quality team meeting, and safety is a standing agenda item at every staff meeting. Monthly audits of the internal and external environment and of the use of chemicals are carried out. Staff are introduced to safe working practices through the initial orientation, during their buddy shifts, during normal working times by observation of supervisory staff, and by annual mandatory training programs. There are corrective and preventative maintenance programs to ensure equipment and infrastructures are kept in a safe working condition. New equipment is risk assessed and trialed prior to purchase and staff are trained in its safe use. Personal protective equipment is provided for use in appropriate situations and staff were observed to be using it in those situations. Staff indicated that they are given opportunities to input into the safety program and that management encourages their ideas and acts promptly on them. 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


Procedures have been established and staff are trained and understand the processes to follow in the event of fire or other emergency. Training sessions are conducted annually and training records indicate that all staff have completed their annual statutory fire training requirement. Fire drills are carried out annually with observers from the local fire service. Fire detection and fighting equipment such as smoke and heat detectors, fire blankets, smoke and fire doors, sprinkler system, exit lights, and fire extinguishers are maintained on a regular basis. Evacuation signs are displayed throughout the building, and the assembly areas are signed and easily accessible. A certificate of maintenance regarding fire is held. Security is present on site twenty four hours a day. All doors have swipe card access and relatives and staff carry cards but these are restricted in access as appropriate. Residents are notified of the safety procedures to follow when they enter the home and through resident meetings and all stated that they feel safe, and believe that staff are competent to handle any emergency that might arise. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply The home has an effective infection control program monitored by an infection control resource person and overseen by the Clinical Nurse Consultant, with processes in place to collect and analyse infection data for trends and ensure the ongoing safety of residents and staff. The home has outbreak management guidelines that are utilised if an outbreak occurs. Staff receive training and competency assessment in relation to infection control measures (such as hand washing) at orientation and then annually at mandatory training and also demonstrate an awareness of the outbreak, spills and waste management systems. Residents are administered flu vaccinations annually if this is their preference, with a program also offered to staff. The effectiveness of infection control measures in all areas of the home, including the kitchen, cleaning services and laundry are monitored through regular audits, cleaning schedules and temperature monitoring where appropriate. The home provides adequate hand washing facilities, sharps containers, spill kits and personal protective equipment for staff. Processes are in place to effectively manage waste, pest control and food hygiene. Staff demonstrated awareness of the colour-coded equipment, the use of personal protective equipment and the principles they utilise to prevent cross infection. 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 Catering services are provided to meet residents’ dietary needs and preferences that are identified on admission and an ongoing basis. Meals are prepared in the kitchen of the collocated hospital and transported by hot boxes to the home. Meals are served mainly in the two dining rooms but residents may wish to have their meal served in



their room for a particular reason. Residents’ have input into the menu via daily feedback to their carers or the catering staff, to the chef who visits weekly or through resident meetings and annual surveys. The menu is a four-weekly rotating menu and provides choice at all meals, including a choice of two hot meals at the midday meal. The kitchen and the home’s serving kitchenettes have monitoring systems to ensure that food is stored at the correct temperature; stock is dated and rotated, and food is served within safe temperature ranges. Cleaning schedules are used to ensure residents’ rooms, common areas and service areas are cleaned seven days a week. All laundry is done at the hospital laundry with personals being collected daily and returned once a week. Staff demonstrated knowledge of the importance of infection control principles to their roles, knowledge of chemicals used and the needs of individual residents. The home monitors the effectiveness of hospitality services through resident/relative feedback and regular environmental and infection control audits and identified deficiencies are actioned in a timely manner. Residents’ stated they are satisfied with the catering, cleaning and laundry services provided by the home.

Documents

Decision to accredit The Oaks Nursing Home · Decision to accredit. The Oaks Nursing Home . The Aged Care Standards and Accreditation Agency Ltd has decided to accredit The Oaks Nursing