Decision to accredit Tricare Mt Gravatt Private Hostel...Decision to accredit Tricare Mt Gravatt Private Hostel The Aged Care Standards and Accreditation Agency Ltd has decided to

Decision to accredit

Tricare Mt Gravatt Private Hostel

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Tricare Mt Gravatt Private Hostel in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Tricare Mt Gravatt Private Hostel is three years until 4 June 2013. 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: Tricare Mt Gravatt Private Hostel Date/s of audit: 1 March 2010 to 2 March 2010 RACS ID: 5334 AS_RP_00851 v2.5

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Home and approved provider details

Details of the home

Home’s name: Tricare Mt Gravatt Private Hostel

RACS ID: 5334

Number of beds: 60 Number of high care residents: 35

Special needs group catered for: • n/a

Street/PO Box: 20 Agay Street

City: MOUNT GRAVATT

State: QLD Postcode: 4122

Phone: 07 3343 9254 Facsimile: 07 3343 8522

Email address: [email protected]

Approved provider

Approved provider: Tricare (Hostel) Pty Ltd

Assessment team

Team leader: Mariza De Feudis

Team member/s: Paula Gallagher

Date/s of audit: 1 March 2010 to 2 March 2010


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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.


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SITE AUDIT REPORT

Name of home Tricare Mt Gravatt Private Hostel

RACS ID 5334

Executive summary This is the report of a site audit of Tricare Mt Gravatt Private Hostel 5334 20 Agay Street MOUNT GRAVATT QLD from 1 March 2010 to 2 March 2010 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 Tricare Mt Gravatt Private Hostel. The assessment team recommends the period of accreditation be three 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.


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Site audit report

Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 1 March 2010 to 2 March 2010 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: Mariza De Feudis

Team member/s: Paula Gallagher

Approved provider details

Approved provider: Tricare (Hostel) Pty Ltd

Details of home

Name of home: Tricare Mt Gravatt Private Hostel

RACS ID: 5334

Total number of allocated places:

60

Number of residents during site audit:

53

Number of high care residents during site audit:

35

Special needs catered for:

n/a

Street/PO Box: 20 Agay Street State: QLD

City/Town: MOUNT GRAVATT Postcode: 4122

Phone number: 07 3343 9254 Facsimile: 07 3343 8522

E-mail address: [email protected]


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Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Tricare Mt Gravatt Private Hostel. The assessment team recommends the period of accreditation be three 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 two days on-site and gathered information from the following:

Interviews

Number Number

Facility Manager 1 Residents/Representatives 6

Clinical Manager 1 Administration Officer 1

Manager of Clinical Systems 1 Diversional Therapist 1

Accreditation Manager 1 Medical Officer 1

Recruitment/Training Co-ordinator

1 Maintenance Officer 1

Registered Nurse 1 Catering staff 4

Endorsed Enrolled Nurse 1 Cleaning staff 1

Care staff 3 Laundry staff 1

Sampled documents

Number Number

Residents’ files 9 Medication charts 8

Resident care plans 9 Personnel files 6

Residential care agreements

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Other documents reviewed The team also reviewed:

•••• Activities of daily living observations

•••• Activity calendars

•••• Audit data and survey results 2009 - 2010

•••• Audit Schedule 2009 and 2010

•••• Baseline assessment tools

•••• Behaviour monitoring charts

•••• Bowel management charts

•••• Buzzer response times


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•••• Care evaluation checklist

•••• Cleaning schedules

•••• Clinical incident data

•••• Clinical indicators reports

•••• Comments and complaints register and documentation

•••• Communication folder/diaries

•••• Competency assessments

•••• Continuous improvement logs and register

•••• Continuous improvement plan 2009

•••• Core skills competency booklets

•••• Daily kitchen record form

•••• Dietary needs assessments

•••• Duties lists

•••• Education attendance forms

•••• Employee orientation manual

•••• Equipment guidelines

•••• Fire declaration February 2010

•••• Fire evacuation plan

•••• Fire systems and equipment inspection and servicing logs

•••• Fluid balance charts

•••• Food safety program accreditation certificate October 2009

•••• Group activity attendance records

•••• Handover reports

•••• Hazard forms and register

•••• Hazard, incident and accident reports

•••• Health and safety monitoring chart

•••• Improvement forms folder

•••• Individual daily activity record

•••• Infection control guidelines

•••• Maintenance request folder

•••• Maintenance request sheets, schedule and servicing documentation

•••• Mandatory training program and competencies

•••• Material safety data sheets

•••• Memos

•••• Menu

•••• Minutes of meetings

•••• Monthly individual resident activity attendance sheets

•••• Pain monitoring charts

•••• Podiatry schedule

•••• Policies and procedures

•••• Position descriptions

•••• Preventative maintenance schedule

•••• Protective assistance assessments

•••• Quality assurance questionnaires

•••• Resident feedback log

•••• Resident lists

•••• Resident profile reports

•••• Residents dietary profiles

•••• Residents’ admission information package

•••• Residents’ information handbook

•••• Restraint monitoring charts

•••• Risk assessments and analysis records

•••• Roster variation book


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•••• Shower lists

•••• Staff availability diary

•••• Staff handbook

•••• Staff rosters

•••• Temperature records

•••• Training calendar and evaluation forms

•••• Training register

•••• Weight records

Observations The team observed the following:

•••• Activities in progress

•••• Advocacy brochures on display

•••• Assembly points with signage

•••• Colour coded cleaning equipment

•••• Designated smoking areas

•••• Emergency exits with signage

•••• Equipment and supply storage areas

•••• Fire detection alarm system and safety equipment

•••• Fire evacuation plan

•••• Fire exits, paths of egress and assembly points

•••• Hand washing facilities

•••• Interactions between staff and residents

•••• Kitchen area

•••• Laundry area

•••• Living environment internal/external

•••• Manual handling equipment and aids

•••• Meal services

•••• Medication administration

•••• Notice boards and information displayed in public areas

•••• Personal protective equipment

•••• Secure storage of resident files

•••• Sign in/out books

•••• Signage for infection control

•••• Spill kits

•••• Storage of medications

•••• Suggestion box


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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 home actively pursues continuous improvement by seeking feedback through comments and complaints, improvement forms, an ‘open door’ policy with management, residents/representatives and staff through surveys and by conducting a systematic review of processes through regular audits across the four accreditation standards. Continuous improvement activities are discussed, planned and reviewed at the home’s consultative committee, management level and as a standard agenda at all focus group meetings. Improvement action plans are fed back to the residents/representatives and staff at meetings and summarised in the home’s continuous improvement plan, along with expected completion dates. Evaluation and monitoring of improvements is conducted to ensure identification of results and impact on residents/representatives, staff and key stake holders. Staff and residents state they are encouraged to contribute to the homes continuous improvement activities. Management reported examples of recent improvements relevant to Standard One which included:

•••• The home reviewed and increased their level of care hours to meet the increased changing needs of residents as identified by clinical indicators. This resulted in extra care staff hours during peak times such as the morning and afternoon to assist with one-on-one showers, toileting programs and assist feeds. During the night shift the endorsed enrolled nurse hours have been increased to provide added support and to ensure residents’ needs are being met in a timely manner. Staff and residents indicated satisfaction with the new allocated hours provided and report a decrease in the call bell response times during these periods.

•••• The home has reviewed and updated their care system due to gaps identified during their internal auditing process. All of the updated assessment tools have been loaded on the home’s intranet system with headings and page numbers. Staff have been educated on changes to the care system and assessment tools. The care system now includes delegations to avoid any misinterpretation of what scope of practice the registered nurse and endorsed enrolled nurse holds, as defined in the Aged Care Act 1997 for high care residents. Management report the new system is working well.

•••• Management identified the need to complete a recruitment drive to reduce the use of agency staffing within the home. The home employed a number of new staff members resulting in reduction in the dependence on agency staff. This has improved continuity of care for the residents, improved communication regarding residents’ needs through higher standards of documentation and reduced the incidence of medication errors.


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1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard One, through subscriptions to aged care peak bodies, national bodies and subscriptions of relevant publications and journals from government and peak bodies. Policies and procedures are reviewed and updates are communicated to staff through meetings, newsletters, intranet and memos. Staff are kept informed of changes through a standard agenda at all focus group meetings, meeting minutes, policy updates and reviews, education sessions and memoranda; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices/newsletters. Systems are in place to inform residents/representatives of accreditation audits and ensure all staff have a current criminal record check which they have passed. Compliance with legislation is monitored through supervision of work practices, audits and staff competencies. 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 systems in place to ensure management and staff have the knowledge and skills to perform their roles effectively. An education program is developed based on the identification of staff training needs, mandatory requirements and resident clinical needs. The education program reflects identified training needs and staff have the opportunity to undertake a variety of internal and external training programs relating to the Four Accreditation Standards. Education sessions are evaluated by participants and by the observation of staff practice. Each staff member has an education record maintained by the home and mandatory training is checked and staff are required to participate. Ongoing knowledge and skill needs of staff are monitored through competencies, performance appraisals, analysis of data, and observation of practice. Staff report satisfaction with the training and development opportunities available to them at the home and demonstrate knowledge and skills appropriate for their roles. 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 Internal and external complaints mechanisms are explained to residents/representatives on entry to the home, usage is encouraged at resident meetings and via the residents’ information package, newsletters and brochures available at the home. Verbal complaints are passed onto the Facility Manager and where appropriate discusses issues raised by residents with the consultative committee. Comments and complaints are kept confidential,


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logged, evaluated and fed into the continuous improvement program where necessary; direct feedback or written responses communicate progress and actions to stakeholders. Staff are educated about the comments and complaints process during orientation and how to advocate for residents by assisting them to complete written forms where necessary. Residents/representatives raise their concerns or ideas at resident meetings, directly to staff and management, who operate an open door policy, or via the comments and complaints forms. Residents/representatives are satisfied that the issues that are important to them are dealt with appropriately. 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 The home has documented its commitment to quality throughout the service and the organisation’s vision, values, philosophy and objectives; these are outlined in organisational documents including the staff and resident information packages. 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 has systems in place to ensure there are sufficient and appropriately skilled and qualified staff. Staffing levels and skill mix are determined through acuity of residents’ care needs, number of bed occupancies, discussions with staff around workload considerations and take into account the layout of the home. The roster is modified in response to changes in resident needs with additional staff rostered when/or as required. A casual pool of staff/permanent part time are used to cover leave absences and agency staff employed if organisational staff not available. Staff are recruited against a position description outlining knowledge and skill necessary to perform the role, referee checks, and pre employment criminal checks. New staff receive an orientation program which includes all mandatory requirements prior to commencing shifts and are rostered with experienced staff to provide further on the job orientation and mentoring. Position descriptions and duty lists are available to direct staffs’ work practices and performance is monitored through competency assessed training, observation of practice, and annual performance appraisals. Residents/representatives are satisfied staff have the skills and knowledge required to meet their needs.


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1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply The home has processes in place that ensure the adequate supply and quality of goods and equipment is available at all times. Key personnel are responsible for the regular ordering of goods including catering supplies, continence aids, chemicals, medical supplies, medications and other general goods through a preferred supplier list available to all staff. Processes ensure goods are checked on delivery, returned if incorrect or unsatisfactory in quality and stock items are regularly rotated. Storage areas are appropriate and secure when required. Equipment needs are identified with ongoing purchases and/or replacement occurring based on the overall capital expenditure budget. New equipment is trialled where possible before purchased with staff education and risk assessments conducted as required. Residents/representatives and staff are satisfied they have access to appropriate and adequate goods and equipment for the delivery of services to meet their needs. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply The home has processes in place to ensure appropriate information is managed in a secure and confidential way. Staff and resident information is stored in restricted areas in accordance with the privacy legislation to authorised personnel only. Service policy and procedures, legislative information, administrative and educational information is provided to staff, residents/representatives through written communication, electronic-mail, memoranda, newsletters, noticeboards, meeting agendas and minutes. An electronic and hard copy clinical management system is used to provide information in relation to resident care provision. Electronic information is secured by password access and data is backed up daily and stored off site to prevent the loss of important information. There is a system in place to archive material in a designated secure locked area with access limited to management and senior administration staff only. An external contract is in place for additional archiving and destruction of confidential files and documentation. Staff reported that they have access to information relevant to their position and stated that changes to residents’ current needs are communicated to them in a timely manner. 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 The organisation’s head office identifies and specifies services to be provided by external service providers. A service agreement is established between the organisation and all external providers for the provision of services such as fire and emergency, maintenance, pest control, chemical, medical and food supplies, servicing of equipment and allied health services. Contractors/appropriate service providers are required to provide relevant certificates/licences, current police certificates and work within the organisations workplace


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health and safety guidelines. Quality of service is monitored through audits and feedback from staff and residents. Head office in conjunction with management review the performance of external services to ensure quality service delivery is maintained and when requirements are not being met appropriate action is taken. Residents and staff report satisfaction with the quality of services sourced externally.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home actively pursues continuous improvement by seeking feedback through comments and complaints, improvement forms, an ‘open door’ policy with management; residents/representatives and staff through surveys and by conducting a systematic review of processes through regular audits across the four accreditation standards. Continuous improvement activities are discussed, planned and reviewed at the home’s consultative committee, management level and as a standard agenda at all focus group meetings. Improvement action plans are fed back to the residents/representatives and staff at meetings and summarised in the home’s continuous improvement plan, along with expected completion dates. Evaluation and monitoring of improvements is conducted to ensure identification of results and impact on residents/representatives, staff and key stake holders. Staff and residents state they are encouraged to contribute to the homes continuous improvement activities. Management reported examples of recent improvements relevant to Standard Two which included:

•••• Due to the increase in controlled drugs being used within the home to meet residents’ needs, the Clinical Manager identified the current drug safe was not large enough. The home purchased a new larger drug safe which allows for medications to be stored securely in accordance with state regulatory requirements.

•••• After the review and assessment of individual resident’s skin integrity, new specific pressure relieving cushions were purchased to assist in maintaining and improving skin integrity for residents. The new cushions are being used for residents identified as at risk of impairment to skin integrity consistent with their health. Management report satisfaction with the new pressure relieving equipment.

•••• To meet the specific needs of a resident the home purchased a sling for the full and standing hoist in an extra large size and an extra large shower chair. This was to promote the residents privacy and dignity during the use of the equipment and to allow choice depending on the resident’s daily strength and ability. Management reported the new equipment is working well for both the resident and staff.

•••• To assist in the reduction of behaviours and enhance safety of wandering residents the home has trialled a number of alert systems to inform staff when residents are attempting to exit the building. Wandering residents now wear a walk about alarm on their wrist which alerts staff when they are approaching or near an exit door. The alarm enables them to roam freely within the building reducing anxiety and behaviours while maintaining their personal safety.


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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 and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Two, through subscriptions to aged care peak bodies, national bodies and subscriptions of relevant publications and journals from government and peak bodies. Policies and procedures are reviewed and updates are communicated to staff through meetings, newsletters, intranet and memos. Staff are kept informed of changes through a standard agenda at all focus group meetings, meeting minutes, policy updates and reviews, education sessions and memoranda; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices/newsletters. Compliance with legislation is monitored through supervision of work practices, audits and staff competencies. Residents at the home are provided with goods and services in line with requirements of the Aged Care Act 1997 Specified Care and Services. 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 systems in place to ensure management and staff have the knowledge and skill to perform their roles effectively. An education program is developed based on the identification of staff training needs, mandatory requirements and resident clinical needs. The education program reflects identified training needs and staff have the opportunity to undertake a variety of internal and external training programs relating to health and personal care. Education sessions are evaluated by participants and by the observation of staff practice. Each staff member has an education record maintained by the home and mandatory training is checked and staff are required to participate. Ongoing knowledge and skill needs of staff are monitored through competencies, performance appraisals, analysis of data, and observation of practice. Staff report satisfaction with the training and development opportunities available to them at the home and demonstrate knowledge and skills appropriate for their roles. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply The home has systems and processes in place to enable residents to receive appropriate clinical care. Residents receive an initial assessment and an interim care plan is developed to guide staff practice. A comprehensive assessment process occurs adopting a multidisciplinary approach where individualised nursing care plans are developed using baseline health assessments and a suite of focus assessment tools in consultation with residents/representatives. Care plans are formulated and reviewed regularly by registered


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nurses and changes in care needs and preferences are reflected in progress notes, activity of daily living summaries and the resident’s care plan. The Clinical Manager oversees the clinical system and staff remain informed of care requirements through hand over processes, communication diaries/folders, one to one discussion and case conferences. Monitoring of the clinical system occurs through observation of staff practices, scheduled audits, surveys and review of monthly clinical indicators. Residents/representatives are satisfied with the care that is provided and their involvement in care decisions. 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 with specialised nursing care needs are identified through assessment and reassessment processes in consultation with residents/representatives and other members of the health care team. Registered nurses develop and review care plans regularly or as residents’ needs change and specialised care is delivered in line with each resident’s prescribed needs and preferences. Complex specialised nursing care treatments such as diabetes management, complex wound care and catheter management are delivered by registered staff who demonstrate appropriate skills and qualifications to effectively identify and manage residents’ specialised nursing care. Referrals to allied health professionals occur as necessary and changes are documented and communicated to relevant staff in a timely manner. Staff receive education and have access to resources and equipment to enable residents’ specialised nursing care needs to be met. Residents/representatives are satisfied with the specialised 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 Residents have access to a range of health and other related services both on and off-site including but not limited to doctors, dentists, dieticians, physiotherapists, speech pathologists, mental health specialists, optometrists, podiatrists, audiologists and palliative care. Referral to appropriate health specialists occurs in a timely manner and is initiated by the Clinical Manager in consultation with residents/representatives and the treating medical officer. Residents are assisted to attend external appointments when necessary, appointments are diarised for future reference and feedback from health specialists is documented in progress notes to ensure resident’s needs are met. Care staff inform registered staff of changes to residents needs to enable timely review and referral. Residents/representatives indicate satisfaction with the assistance and choices given to access medical specialists and other health related services.


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2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply The home utilises a sachet system to safely and correctly manage residents’ medications. Registered nurses and endorsed enrolled nurses administer medications to residents and receive annual competency assessment and education to ensure knowledge remains current. Medication charts are reviewed by medical officers and pharmacy and include information such as photographic identification, special instructions and resident allergies. ‘As required’ (PRN) medications and variances are documented using a sticker system to ensure effectiveness is monitored. Processes are in place for the safe storage of medication, including controlled drugs with access to after hour’s emergency supplies if required. The medication management system is monitored through observation of staff practices, scheduled audits and review of monthly clinical indicators data and relevant issues and plans for corrective action are discussed at medication management meetings and individually with staff where indicated. Residents/representatives are satisfied with the management of medications and the assistance provided by staff. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply On entry, each resident’s history of pain is assessed by registered nurses and resident’s experiencing acute or new episodes of pain are commenced on pain monitoring charts to identify the need for further medical review. Verbal and non-verbal pain assessments are completed and care plans are developed in consultation with residents/representatives to guide staff practice. The physiotherapist and nursing staff offer a range of pain management strategies such as massage, gentle exercise, heat packs, repositioning, nerve stimulation equipment and analgesia. Registered staff manage residents’ complex pain requirements, including the frequency and effectiveness of the use of analgesia and pain relieving strategies. Amendments to pain management strategies are communicated to staff and staff are aware of indicators of pain and of the reporting requirements should residents display these. Residents/representatives are satisfied that pain is managed effectively and staff are responsive to residents changing needs. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply The home has processes to enable residents' palliative care needs and preferences to be identified, assessed and managed in consultation with residents/representatives and the treating medical officer. The terminal care needs and wishes of residents are identified on entry or as residents’ needs change and copies of advanced health directives and enduring power of attorney documents are located within the residents’ files for staff reference if applicable. Specialised equipment and access to palliative care advice is available to enable residents to be supported to remain in the home wherever possible; nursing and lifestyle staff, volunteers and religious representatives provide emotional, cultural and spiritual


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support when required. Staff receive education and use organisational and external resources such as the palliative care team to ensure the comfort and dignity of terminally ill residents. Review of documentation indicates terminally ill residents’ comfort and dignity is maintained and representative satisfaction with approaches to resident care. 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 requirements are identified through the initial and ongoing assessment and review processes and resident dietary requirements forms and care plans are developed to reflect residents’ dietary needs and preferences. Residents’ body weight is regularly monitored through monthly profile reports and unplanned weight loss or gain is recorded with referrals made to the medical officer, speech pathologist and/or dietician. Strategies recommended are implemented and include assistance with meals, provision of specialty and texture modified diets, dietary supplements and increased monitoring of weights and food/fluid intake. The seasonal menu utilised at the home receives dietician review, provides choice and variety and accommodates residents’ needs and preferences. Staff receive information to ensure residents are provided with adequate nourishment and hydration, demonstrate an awareness of individual resident’s needs and special preferences and provide appropriate diets, fluid consistencies, dietary aids and assistance. Residents/representatives are satisfied with the quantity and quality of food and fluid received. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply The skin care needs of residents are identified during assessment and reassessment processes and interventions used to maintain skin integrity are recorded in the care plan. Consultation occurs with residents/representatives and other health professionals, skin tears and wounds are reported, monitored and trended and healing progress is evaluated and documented on wound management and simple dressing charts. Wound and skin care products are utilised and equipment such as mattresses, sheepskins, cushions and limb protective devices are available to maintain, protect or improve residents’ skin. Manual handling equipment is provided to support the safe transfer and mobility of residents and staff receive education in relation to wound management, the maintenance of skin integrity and manual handling to ensure effective care deliverance. Residents/representatives are satisfied with the care received in relation to skin integrity.


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2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Residents’ urinary and bowel management needs are assessed on entry to the home and are monitored on an ongoing basis. Strategies such as programmed toileting, bowel management programs, catheter care regimes, dietary modification, hygiene assistance and use of medications and continence aids are recorded, implemented and evaluated for effectiveness. Urinary tract infections are monitored and data is analysed for causative factors and improvement opportunities. Audits are conducted regularly and action plans are developed when required. Staff trained in continence management monitor the use of continence aids, receive education to promote residents’ optimum level of continence and demonstrated an awareness of individual resident’s specified requirements. Residents/representatives report that staff respect privacy and dignity when providing continence care and confirm continence needs are met. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply Residents identified with challenging behaviours are assessed on entry or when needs change and a plan of care is developed using a multidisciplinary approach to effectively manage and care for these residents. Focused assessment tools are used to identify contributing factors relating to residents’ behaviour patterns, techniques used to manage behaviours are documented in care plans and interventions are evaluated regularly for effectiveness. Incidents of significance are reported, documented and discussed to enable analysis, proactive action and if necessary referral. Staff are educated on appropriate methods for managing residents with challenging behaviour and demonstrated knowledge of resident’s individual routines, preferences and strategies to promote positive care outcomes. The team observed care staff interacting calmly and respectfully with residents exhibiting challenging behaviours and residents/representatives confirmed that residents with challenging behaviours are managed effectively. 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’ needs in relation to mobility and dexterity are identified in the initial and ongoing assessment process and those identified as having mobility and/or falls risk are reviewed and assessed by a visiting physiotherapist. Care plans and activity of daily living summaries guide staff practices and are reviewed by registered nurses and/or the physiotherapist regularly. Exercise programs are implemented to encourage residents’ ongoing mobility and dexterity and equipment and aids are available to support resident’s mobility and dexterity requirements. The home monitors falls using an electronic clinical database system and generates monthly individual resident profile reports and clinical indicators reports to ensure regular review and discussion of incidents occurs. Staff receive ongoing information in


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relation to residents’ mobility and dexterity needs through handover processes, progress notes and communication diaries and guide residents in the appropriate and optimal use of mobility and dexterity aids. Residents are assisted to mobilise within their individual capacity and preference and are satisfied that optimum levels of mobility and dexterity is achieved. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply The oral and dental needs of residents are assessed on entry to the home and includes assessment of residents’ preferences relating to their oral health care. Care plans and activity of daily living summaries are in place to guide staff practice and effectiveness of care is reviewed regularly and as care needs change. Resources such as mouth care products are available to meet residents’ oral hygiene needs. Changes to care are communicated through nursing handover, communication diaries, progress notes and care plans. Referrals to dental services are facilitated by the home where indicated and a denture repair service is available to visit the home. Staff demonstrate knowledge of individual residents’ oral care needs and residents/representatives confirm they are satisfied with the assistance provided in relation to oral and dental health. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Residents’ sensory needs are assessed on entry to the home and when there are indicators of change. Hearing and optical services are accessed and/or provided to residents in response to identified needs. Care plans and activity of daily living summaries are developed to guide staff practice in relation to identified sensory needs, including strategies to address changes and programs for the maintenance of sensory aids. Strategies are reviewed in line with a three monthly review schedule or as needs change and care plans record the use of hearing aids and glasses and interventions to address communication deficits. Staff assist residents to manage their sensory deficits where needed and ensure effective management of sensory aids. Residents/representatives are satisfied with the support provided to manage sensory loss and maintain sensory aids. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Information about residents’ usual sleep patterns, settling routines and personal preferences is collected through initial and ongoing assessment and review processes. Strategies to promote adequate sleep and rest are developed in consultation with residents/representatives and consider identified normal sleep patterns. Care plans define a range of specific interventions based on individual needs and include pharmacological and non-pharmacological interventions such as the use of one to one time to reduce anxiety, positional changes, toileting assistance and environmental modification. Sleep monitoring


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charts are used for residents identified as having disturbed sleep patterns and referral to medical officers occurs for residents identified with prolonged sleep disturbances. Staff facilitate individual resting routines and flexible settling/rising times and minimise environmental factors impacting on residents’ ability to sleep. Residents/representatives are satisfied with the home’s approach to maintaining natural sleep and rest patterns and with the assistance received from staff during times of sleep disturbances.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home actively pursues continuous improvement by seeking feedback through comments and complaints, improvement forms, an ‘open door’ policy with management; residents/representatives and staff through surveys and by conducting a systematic review of processes through regular audits across the four accreditation standards. Continuous improvement activities are discussed, planned and reviewed at the home’s consultative committee, management level and as a standard agenda at all focus group meetings. Improvement action plans are fed back to the residents/representatives and staff at meetings and summarised in the home’s continuous improvement plan, along with expected completion dates. Evaluation and monitoring of improvements is conducted to ensure identification of results and impact on residents/representatives, staff and key stake holders. Staff and residents state they are encouraged to contribute to the homes continuous improvement activities. Management reported examples of recent improvements relevant to Standard Three which included:

•••• A request by the residents indicated they would like to have animal therapy introduced into the activity program. As a result of the residents request the Diversional Therapist brings her dog to work on a daily basis. Residents were observed interacting with the dog during a morning activity while the team was on site. Residents reported satisfaction with the introduction of the dog into the home’s environment.

•••• As a result of feedback from residents around the level of activities being provided at the home, management purchased and introduced an electronic gaming device. Residents meeting minutes indicated residents enjoy the interaction and participation levels the gaming device offers.

•••• To increase residents’ ability to access the community on a more regular basis the home is utilising the service of a shared transport arrangement with a local retirement village’s bus. The transportation arrangement allows residents to develop and maintain friendships with resident from the retirement village and within the community. Residents and management indicated satisfaction with the use of the bus for community outings.

•••• With the recruitment of a new Diversional Therapist in October 2010 the monitoring and evaluation systems of the activity program were reviewed, this has resulted in a new form being developed to capture the individual attendance of residents to activities. The Diversional Therapist reported the form is easier to use and provides a quick glance reference for each individual.


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3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Three, through subscriptions to aged care peak bodies, national bodies and subscriptions of relevant publications and journals from government and peak bodies. Policies and procedures are reviewed and updates are communicated to staff through meetings, newsletters, intranet and memos. Staff are kept informed of changes through a standard agenda at all focus group meetings, meeting minutes, policy updates and reviews, education sessions and memoranda; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices/newsletters. Systems are in place to ensure reportable assaults are reported and managed in accordance with regulatory requirements. Compliance with legislation is monitored through supervision of work practices, audits and staff competencies. 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 systems in place to ensure management and staff have the knowledge and skill to perform their roles effectively. An education program is developed based on the identification of staff training needs, mandatory requirements and resident clinical needs. The education program reflects identified training needs and staff have the opportunity to undertake a variety of internal and external training programs relating to resident lifestyle and the “Eden model” of moving decision making for care and lifestyle closer to the people best able to determine this for example: residents, relatives and care staff. Education sessions are evaluated by participants and by the observation of staff practice. Each staff member has an education record maintained by the home and mandatory training is checked and staff are required to participate. Ongoing knowledge and skill needs of staff are monitored through competencies, performance appraisals, analysis of data, and observation of practice. Staff report satisfaction with the training and development opportunities available to them at the home and demonstrate knowledge and skills appropriate for their roles. 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 Processes are in place to identify residents’ emotional support needs on entry to the home and on an ongoing basis. Prior to entry, prospective residents and their families are greeted and interviewed by the Clinical Manager, receive a tour of the home and are given opportunity to discuss concerns and have their enquiries addressed. Residents are provided with a resident handbook and receive orientation to the environment, services, staff and


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other residents. Regular review processes identify emotional changes or concerns experienced by residents and strategies used to support residents are discussed and documented in care plans and progress notes. Initial and ongoing social and emotional support is provided by the Diversional Therapist, management, nursing staff, volunteers and spiritual groups and residents are encouraged to personalise their environment to increase comfort levels. Residents/representatives expressed satisfaction with the emotional support provided on entry and on an ongoing basis to enable them to adjust to their altered lifestyle within the home. 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 The home has systems in place to support and assist residents to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service. Residents’ preferences and abilities are assessed on entry by the Registered Nurse, the Diversional Therapist and where necessary by the Physiotherapist. Risks are identified and staff assist residents to achieve maximal independence, pursue activities of preference and maintain friendships and connections and demonstrate an awareness of individual resident’s preferences and limitations. Residents with special needs are provided with appropriate equipment and support with provision made to access the community for services, appointments, events, shopping and social visitation. Residents/representatives are satisfied with the assistance received in maintaining personal independence and friendships within and outside the home. 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 has processes in place to recognise and respect each resident’s right to privacy, dignity and confidentiality. Residents/representatives are provided with information about their rights on entry and on an ongoing basis, with strategies implemented to ensure that residents’ privacy and dignity are maintained during care routines. Staff and volunteers receive information relating to confidentiality on employment and have access to policy and procedures relating to privacy and dignity. Residents’ personal information is stored securely; and processes are in place to ensure archiving and destruction of confidential information. Residents reside in single rooms with en-suited bathrooms and the home has a number of internal and external private dining, entertainment and sitting areas to maximise privacy. Staff demonstrate strategies to maintain residents’ privacy and dignity and interact with residents respectfully, sensitively and discreetly. Residents/representatives are satisfied that staff are courteous, respectful of privacy and treat them with dignity when care and services are being provided.


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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 has systems in place that encourage and support residents’ participation in a range of activities of interest to them. Residents’ past and current interests are identified on entry through the resident lifestyle profile and information is transferred to the lifestyle component of the resident care plan. The activities program is developed in consultation with residents/representatives, is provided five days a week and consists of a variety of one to one and group activities including special events provided by the Diversional Therapist and dedicated volunteers. The program receives regular evaluation from review of participation rates, observation and resident feedback. Monthly activity programs are provided to residents/representatives and are displayed on noticeboards throughout the home. Staff have access to a range of resources and materials to enable them to assist residents with the program on weekends if requested. Residents/representatives indicate that they are satisfied with the leisure activity program offered by the home. 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 Residents are encouraged and supported to participate in community, spiritual and cultural events and residents informed the team they are satisfied their cultural and spiritual needs are supported. Information regarding residents’ interests, beliefs, language and cultural background, spiritual and end of life wishes is collected during the entry process and is used to develop care plans and guide staff in attending to residents’ individual needs. Religious, cultural and days of significance are celebrated and residents’ family are encouraged to attend the home and join in celebrations. Visiting ministers of religion conduct church services weekly on site, as well as offering one to one spiritual guidance if required. The home has access to resources, interpreters and cultural specific materials to assist in meeting residents’ needs and preferences. Residents/representatives are satisfied with the home’s approach in fostering and valuing their individual interests, beliefs and backgrounds. 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 processes to support residents’ choice and decision making in relation to the care and services they receive, while providing consideration to the rights of others. Individual care and lifestyle preferences are identified through assessment and review processes and information regarding residents’ alternative decision-makers and advanced health directives is documented and accessible to staff if required. Each resident/representative receives information about internal and external complaints mechanisms, advocacy services and their rights and responsibilities on entry and on an


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ongoing basis. Residents are enabled to participate in decisions and exercise choice through one to one consultation with staff and management, satisfaction surveys, resident meetings and the comments/complaints process. Staff support residents’ choice and decision making in the planning and provision of care, and encourage active involvement regarding aspects of care and services received. Residents/representatives confirm they are enabled to exercise choice and are satisfied with their involvement in decision making. 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 Residents/representatives are supplied with written and verbal information regarding service provision prior to entering the home. The documents provided at the pre-admission interview and tour contain information about the terms and conditions of their tenure, fees and charges, extra services, dispute resolution and residents’ rights and corresponding responsibilities. Key personnel ensure there is a shared understanding of the terms of the agreement and ongoing information regarding changes to fees and charges is provided. Networks with aged care industry groups ensure there is current information about specified care and service obligations, accommodation fees and charges. Residents/representatives are aware of their rights and responsibilities and are satisfied that their tenure at the home is secure.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home actively pursues continuous improvement by seeking feedback through comments and complaints, improvement forms, an ‘open door’ policy with management; residents/representatives and staff through surveys and by conducting a systematic review of processes through regular audits across the four accreditation standards. Continuous improvement activities are discussed, planned and reviewed at the home’s consultative committee, management level and as a standard agenda at all focus group meetings. Improvement action plans are fed back to the residents/representatives and staff at meetings and summarised in the home’s continuous improvement plan, along with expected completion dates. Evaluation and monitoring of improvements is conducted to ensure identification of results and impact on residents/representatives, staff and key stake holders. Staff and residents state they are encouraged to contribute to the home’s continuous improvement activities. Management reported examples of recent improvements relevant to Standard Four which included:

•••• An improvement log from kitchen staff identified the finish on the kitchen cabinets was not a wipeable surface and created difficulties during the cleaning process. The cabinets were removed and replaced with stainless steel providing a wipeable surface reducing the risk of cross contamination within the kitchen area. Management report the new surface meets the requirements of the homes food and safety program.

•••• The home has re-developed and established new evergreen plants and shrubs throughout the grounds to provide an environment which residents and representatives are able to enjoy and to utilise for privacy during visits. Residents were given an opportunity to suggest plants for the gardens. Minutes of meetings indicate satisfaction from residents/representatives on the improved grounds.

•••• As the result of a staff suggestion in regards to the health and safety of residents on the upper level floor wandering into the kitchen area, the home installed a retractable waist high barrier on the entrance to the kitchen. The new barrier allows residents to see what is happening within the kitchen area while maintaining their safety. Management and staff report the new system ensures a safer working environment.

•••• As a result of a complaint from a residents representative in regards to the extreme hot and cold temperatures within the dining areas during the summer and winter months the home has installed an air conditioning unit in both dining areas. The installation of the air conditioning units has resulted in comfortable internal temperatures and management have received positive feedback from residents/representatives


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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 and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Four, through subscriptions to aged care peak bodies, national bodies and subscriptions of relevant publications and journals from government and peak bodies. Policies and procedures are reviewed and updates are communicated to staff through meetings, newsletters, intranet and memos. Staff are kept informed of changes through a standard agenda at all focus group meetings, meeting minutes, policy updates and reviews, education sessions and memoranda; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices/newsletters. Systems are in place to ensure certification and other environmental requirements are met. The home has a food safety plan in place in accordance with legislation. Compliance with legislation is monitored through supervision of work practices, audits and staff competencies. 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 systems in place to ensure management and staff have the knowledge and skill to perform their roles effectively. An education program is developed based on the identification of staff training needs, mandatory requirements and resident clinical needs. The education program reflects identified training needs and staff have the opportunity to undertake a variety of internal and external training programs relating to the physical environment and safe systems. Education sessions are evaluated by participants and by the observation of staff practice. Each staff member has an education record maintained by the home and mandatory training is checked and staff are required to participate. Ongoing knowledge and skill needs of staff are monitored through competencies, performance appraisals, analysis of data, and observation of practice. Staff report satisfaction with the training and development opportunities available to them at the home and demonstrate knowledge and skills appropriate for their roles. 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 environment of the home provides residents with safe and comfortable access to clean internal and external areas, with appropriate furniture sufficient for residents. Residents are accommodated in single rooms with an en-suite and are encouraged to have their own furnishings to personalise their room. Internal/external walkways are free of trip hazards,


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designated storage areas for equipment and mobility aids are provided and garden areas are maintained to ensure safety. Maintenance and cleaning schedules are in place and are adhered to by staff. Additional maintenance requirements are reported by staff or residents and are attended to by the Maintenance Officer or external contractors in a timely manner. Security measures are in place to ensure overnight security in the home and staff have access to emergency telephone numbers in the event of a security breach. The comfort and safety of residents is monitored through resident feedback and environmental audits with identified improvements being actioned in a timely manner. Resident/representative feedback indicates residents feel safe and comfortable in all areas of the home. 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 has a workplace health and safety system in place to ensure that a safe working environment is maintained that meets regulatory requirements through the risk management committee and service improvement meetings, regular audits of the environment for safety aspects, hazard/risk management processes, incident and hazard reporting and staff education. Staff receive education on the home’s safety requirements at orientation and through the annual mandatory training program. Maintenance programs are in place for equipment and building and these are monitored for completion. Material safety data sheets are available in all work areas and chemicals are stored securely. Spills kits are available and accessible for staff. Staff accidents and incidents are reviewed, trended and analysed then reported and discussed at management level then through focus group staff meetings. Staff indicated awareness of the reporting processes of safety issues and how to perform their roles in a safe manner. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s recommendation Does comply The home has policies and procedures to guide staff practices in the event of a fire, security and other emergency. Management and/or the senior staff member on duty are responsible for responding to and co-ordinating staff in the event of an emergency. A resident list is maintained at reception and is located at the fire panel; the list includes residents’ mobility requirements. An external provider ensures maintenance of fire safety systems and equipment is carried out in accordance with legislative requirements. Evacuation plans are clearly displayed; emergency exits are clearly marked, free from obstruction and are suitable for the mobility level of the residents. Mandatory fire safety training is provided to staff at orientation, yearly and as required. Monitoring of fire safety systems occurs through the home’s preventative maintenance program and inspection by external bodies; issues identified are resolved in a timely manner. Staff and residents demonstrate knowledge of fire, security and other emergency procedures including their role in the event of an alarm, emergency or evacuation.


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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 in place across clinical, catering, cleaning and laundry services. The Clinical Manager is responsible for overseeing the home’s infection control program. This program consists of policies/procedures including an outbreak management plan and access to government guidelines. The home has processes in place to collect and analyse infection data and identify infection trends. Staff have mandatory training in relation to infection control measures at commencement and on an ongoing basis. Residents are administered flu vaccinations if this is their preference, with the program also offered to staff. Current processes are in place to monitor the effectiveness of infection control program in all areas of the home, including the kitchen, cleaning services and laundry through audits, temperature checks and competencies/questionnaires. Processes are in place to guide staff in the correct disposal of sharps, clinical waste and the management of spills. Personal protective equipment and hand washing facilities are available for staff use. Staff demonstrated awareness of the colour-coded equipment, the use of personal protective equipment and general principles used 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 The home provides catering, cleaning and laundry in a way that enhances residents’ quality of life and the staff’s working conditions. Catering services are provided to meet residents’ dietary needs and preferences as identified on entry to the home and when changes occur. A six weekly rotating menu that is seasonally adjusted is planned and reviewed with residents input then reviewed by a dietician to ensure nutritional value prior to implementation. Catering staff use safe food handling practices and daily equipment temperature checks and kitchen cleaning schedules are completed as planned. The on site laundry provides services for resident’s personal laundry and all other linen in the home. Cleaning of residents’ rooms and communal areas is completed in accordance with the cleaning duty lists and schedules. All staff receive education on and are instructed in the use of personal protective equipment, general cleaning equipment and chemicals. Mechanisms are available for residents/ representatives to provide feedback about hospitality services. Residents/representatives indicated satisfaction with the provision of catering, cleaning and laundry services at the home.

Documents

Decision to accredit Tricare Mt Gravatt Private Hostel...Decision to accredit Tricare Mt Gravatt Private Hostel The Aged Care Standards and Accreditation Agency Ltd has decided to