Published Decision Redistribution 10-10-2017 · 11 Edmund Street PORT BROUGHTON SA 5522 Approved provider: Barunga Village Incorporated Following an audit we decided that this home

Reconsideration Decision Barunga Village Incorporated RACS ID: 6074

Approved Provider: Barunga Village Incorporated

Reconsideration of decision regarding the period of accreditation of an accredited service under section 2.19(1)(a) of the Quality Agency Principles 2013.

Reconsideration Decision made on 10 October 2017

Reconsideration Decision An authorised delegate of the CEO of the Australian Aged Care Quality Agency has decided to vary the decision made on 26 March 2015 regarding the period of accreditation. The period of accreditation of the accredited service will now be 17 May 2015 to 17 January 2019.

Reason for decision Under section 2.69 of the Quality Agency Principles 2013, the decision was reconsidered under ‘CEO’s own initiative’.

The Quality Agency is seeking to redistribute the dates for site audits for a number of services that have demonstrated consistent and sustained compliance with the Accreditation Standards to achieve a more level distribution of the timing of accreditation site audits over a three year period. More information is available on our website at http://www.aacqa.gov.au/publications/news-and-resources/redistribution-of-aged-care-accreditation-program.

The Australian Aged Care Quality Agency will continue to monitor the performance of the service including through unannounced visits.

This decision is effective from 17 May 2015

Accreditation expiry date 17 January 2019

Barunga Village Incorporated RACS ID 6074

11 Edmund Street PORT BROUGHTON SA 5522

Approved provider: Barunga Village Incorporated

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 17 May 2018.

We made our decision on 26 March 2015.

The audit was conducted on 16 February 2015 to 18 February 2015. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Home name: Barunga Village Incorporated Date/s of audit: 16 February 2015 to 18 February 2015 RACS ID: 6074

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Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

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

Expected outcome Quality Agency

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1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal care

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


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2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


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Standard 3: Resident lifestyle

Principle:

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


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3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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


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4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


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Audit Report

Barunga Village Incorporated 6074


Introduction This is the report of a re-accreditation audit from 16 February 2015 to 18 February 2015 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide

quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that

it meets the Standards.

There are four Standards covering management systems, health and personal care, care

recipient lifestyle, and the physical environment and there are 44 expected outcomes such

as human resource management, clinical care, medication management, privacy and dignity,

leisure interests, cultural and spiritual life, choice and decision-making and the living

environment.

Each home applies for re-accreditation before its accreditation period expires and an

assessment team visits the home to conduct an audit. The team assesses the quality of care

and services at the home and reports its findings about whether the home meets or does not

meet the Standards. The Quality Agency then decides whether the home has met the

Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets:

•••• 44 expected outcomes


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Audit report

Scope of audit An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 16 February 2015 to 18 February 2015. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: Diane Mogie

Team member: Melanie Hulme

Approved provider details


Details of home

Name of home: Barunga Village Incorporated

RACS ID: 6074

Total number of allocated places:

52

Number of care recipients during audit:

52

Number of care recipients receiving high care during audit:

50

Special needs catered for:

People with dementia or related disorders.

Street: 11 Edmund Street State: SA

City: PORT BROUGHTON Postcode: 5522

Phone number: 08 8635 0500 Facsimile: 08 8635 2133

E-mail address: [email protected]


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

Interviews

Number Number

Management 7 Care recipients/representatives 7

Clinical/care/lifestyle 8 Volunteer 1

Hospitality and environmental staff

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Sampled documents

Number Number

Clinical assessments/care plans/progress notes

6 Medication charts 7

Lifestyle assessments/care plans/progress notes

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Other documents reviewed The team also reviewed:

•••• Audits/surveys

•••• Care recipient dietary information

•••• Clinical monitoring tools

•••• Colour coding systems and cleaning schedules

•••• Comments and complaints data

•••• Communication books, email alerts

•••• Contractor and visitor sign in/out register

•••• Drugs of dependency records

•••• Duty statements

•••• Electrical testing and tagging records

•••• Emergency procedure manual

•••• External contractor agreement

•••• Feedback forms

•••• Food safety plan, dietitian review

•••• Hazard and incident register and reports

•••• Infection control data

•••• Lifestyle attendance records and evaluations

•••• Lifestyle calendar

•••• Mandatory reporting register

•••• Memoranda and emails

•••• Menu


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•••• Missing persons register

•••• Modified dietary guide

•••• Pest control service records

•••• Plan for continuous improvement

•••• Police clearance register

•••• Policies and procedures

•••• Preventative and reactive maintenance documents

•••• Resident information pack

•••• Resident newsletters

•••• Risk assessments

•••• Safety data sheets

•••• Scheduled 4 & 8 licence

•••• Self-assessment

•••• Orientation and induction records

•••• Temperature monitoring records

•••• Training documentation and calendar

•••• Triennial fire safety certificate

•••• Various meeting minutes

•••• Work instructions

Observations The team observed the following:

•••• Activities in progress

•••• Care recipients and visitors using the cafe

•••• Charter of residents’ rights and responsibilities

•••• Chemical storage/spills kit

•••• Cleaning in progress

•••• Comments and complaints information on display

•••• Equipment and supply storage areas

•••• Fire suppression equipment and signage

•••• Infection control equipment

•••• Information noticeboards

•••• Interactions between staff and care recipients

•••• Living environment

•••• Short observation in activity room

•••• Smoking areas for care recipients

•••• Storage of medications/medication administration

•••• Suggestion boxes


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Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The home has a continuous improvement system to identify improvement opportunities and monitor performance against the Accreditation standards. The home has a Quality Improvement Committee to which each department within the home provides a regular report. This committee consists of a member of the Board of Directors and a representative from each department within the home. The home uses care recipient and staff meetings, internal and external audits, care recipient and staff surveys, ‘tell us what you think’ forms, service improvement reports, training and incident analysis and hazards to identify improvements. This information is documented in a continuous improvement plan which is aligned against the Accreditation Standards. Monitoring of improvements include information from service improvement forms, analysis of incidents and hazards, equipment trial forms, staff and care recipient feedback systems, audits and observations. Results show the home has an effective system to identify opportunities for improvement and monitor the effectiveness of improvements implemented. Care recipients and staff are satisfied that the organisation actively pursues continuous improvement. Improvement initiatives implemented by the home over the last 12 months in relation to Standard 1 Management systems, staffing and organisational development include:

•••• A quarterly review identified a gap in the quality management system and the current auditing process, which was manually completed, was time consuming and inconsistent. Information presented at an aged care conference led to several options being investigated before the ‘Moving on Audits’ electronic system was recommended. This system was trialled for three months from October 2013 and new procedures were implemented to ensure consistency in the auditing process. This included placing responsibility for the conduct of audits on departmental heads rather than different general staff members and the inclusion of a benchmarking tool to focus results. Staff said the new system has decreased the time taken to do the audits and they are now more comprehensive. The system has been implemented on an ongoing basis.

•••• An administrative meeting highlighted issues regarding the existing document management system not meeting the home’s needs. The current system did not have an effective version control process and staff did not have ease of access to documentation required to undertake their work. In response, management developed and implemented an electronic register of documents. All documentation within the home was reviewed and relevant documents were included on the new system. This includes links to all documents kept in a central folder on the home’s network, a search function and colour coded automatic alert when documents are due for review. The system is accessible at all computer terminals around the home and staff feedback has been positive with staff stating they have easier access to all the documents they require to perform their roles effectively.


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•••• Audit results identified that not all staff were completing mandatory training as required. Management discussed options and developed a whole day training program to replace the existing scheduled sessions which totalled six days. The new program consists of core training including fire and emergency, manual handling, infection control, dementia training and food safety and electives decided by the home and staff feedback. The program is run every two months to capture all staff and the electives are changed annually with the core modules remaining the same. Having a combined training also gives staff the chance to network across departments and therefore strengthens relationships and makes rostering easier for management. Staff feedback has been positive with staff reporting that it makes it easier for them to attend their manual training.

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The home has membership with peak industry bodies and professional organisations to receive updates. Updates are received via email and the information disseminated to staff through electronic notification systems, departmental meetings, training sessions and policies and procedures. Care recipients and representatives are informed through newsletters, letters and meetings. Legislative changes are actioned as required. The home monitors regulatory compliance through internal audits, staff feedback processes and the home’s electronic document management system. Results show the home’s processes are effective in monitoring and ensuring regulatory compliance. Staff said they receive regular updates and have access to up-to-date information. Examples of how the home meets regulatory compliance requirements in relation to Standard 1 Management systems, staffing and organisational development include:

•••• Police check register have been completed for staff and volunteers.

•••• Contracts with external service providers confirm their responsibilities under the relevant legislation, regulatory requirements and professional standards and include police checks for contractors visiting the home.

•••• Re-accreditation audit notification sent to care recipients and representatives in writing. 1.3 Education and staff development: This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home has systems in place to ensure management and staff have the ongoing knowledge and skills to perform their roles effectively. The home has an education program which is responsive to requests from staff and the needs of care recipients, including an orientation program for new staff and volunteers. Educational opportunities include e-learning, face-to-face, training sessions by external suppliers and other external education programs of benefit to the organisation. The program includes mandatory training days held every two months to capture all staff and staff attendance at education sessions is recorded and monitored. Monitoring processes include performance appraisals, audits, observations


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and staff requests. Staff are notified of education opportunities via staff room noticeboards and verbally from supervisors. Staff complete evaluations of training sessions as they attend. Staff interviewed expressed their satisfaction with the education available to them. Care recipients and representatives are satisfied staff have appropriate knowledge and skills. Examples of education and training provided for management and staff in relation to Standard 1 Management systems, staffing and organisational development include:

•••• Aged Care Roundtable Workforce Development Program

•••• Lee Care training 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome There are systems to ensure care recipients and their representatives have access to internal and external comment and complaint systems. Care recipients and their representatives are informed regarding how to lodge a comment or a complaint on entry and on an ongoing basis through the resident frequently answered questions, meetings, newsletters and external advocacy brochures and supported by staff advocacy. All comments, concerns and suggestions are recorded on the home’s electronic system and actioned according to the home’s procedures by the relevant member of the management team. Suggestion boxes are available throughout the home and confidentiality is maintained as required. Comment and complaint processes and care recipient satisfaction is evaluated through surveys, audits, care recipient meetings and feedback forms. Results show the home has systems to ensure care recipients and their representatives have access to internal and external complaints mechanisms. Staff demonstrated awareness of the home’s comments and complaints systems and information provided to care recipients. Care recipients are satisfied with the home’s internal complaints processes and they are aware of how to access external complaints mechanisms. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The home has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the home. The home includes this information in staff handbooks and in the care recipient pre-entry information. The home’s mission and value statement is displayed in brochures and documentation around the home. Staff interviewed are familiar with the home’s commitment to quality care, service provision and values.


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1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome The home has processes to ensure there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the standards and the residential care service’s philosophy and objectives. The home’s recruitment processes ensure staff with appropriate qualifications and skills are recruited and management undertake regular performance appraisals. The home provides orientation and induction to new staff which includes an induction pack and checklist and position descriptions. The home ensures there is coverage by a registered nurse or a suitably qualified enrolled nurse and the site manager is on call. Training is provided both on a scheduled and ad hoc basis and includes competency training. The home monitors staff through feedback, appraisals, staff and care recipient surveys, audits and observation. Results show the home’s processes are effective in ensuring sufficiently qualified and skilled staff are available to meet care recipients’ needs. Staff interviewed reported they have enough time to complete their duties and have access to training and information needed to effectively perform their role. Care recipients and their representatives are satisfied with the numbers and skills of staff to deliver care services. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The home has systems and processes to ensure appropriate stocks of goods and equipment needed for quality service delivery. The home has a comprehensive asset register, imprest system and electronic system for the scheduled and ad hoc maintenance records. Stock is ordered weekly and any suggestions or identified needs are reported in the monthly quality meetings. The home uses scheduled servicing and maintenance reports, audits and feedback from staff and care recipients to monitor levels and fitness for service and identify needs. Results show the home reviews and maintains sufficient stock levels of goods and equipment to meet the home’s needs. Staff, care recipients and representatives interviewed said they are satisfied there are adequate and appropriate stocks of goods and equipment to deliver quality care and services. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The home has effective information management systems in place. Care recipient information is stored on the computerised care management system, is regularly reviewed, updated and includes effective communication to staff of changes to care recipient information. Staff information, policies and procedures and other corporate information is kept on the home’s electronic system and relevant information is readily accessible to staff


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around the home. Staff have different levels of access according to their position and information is stored, archived and disposed of securely to ensure confidentiality and privacy is maintained. Care recipients and representatives are provided information via letters, newsletters and through care recipient meetings. Monitoring, reporting and addressing of issues occur through one-on-one feedback, various meetings, surveys and audits. Results show that staff have access to sufficient information to perform their roles effectively and staff interviewed stated they are satisfied with the home’s management of information. Care recipients and representatives are satisfied care recipients have access to relevant information to assist them to make informed decisions about their care and lifestyle.

1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome The home has systems to ensure that externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals. The home identifies needs through care recipient and staff suggestions, meetings and audit processes. Options are researched, a risk assessment performed and prospective providers are consulted with. Each contracted provider is required to sign a contract that stipulates requirements for police checks and outlines specifications for work provided. Contracts are kept on the home’s electronic system and reviewed as defined under the individual terms and conditions. The home monitors the service provided by the contracted providers through feedback, staff and care recipient surveys, hazard and incident forms, maintenance records and meetings as well as through the audit process. Results show external services provided are meeting the residential care service’s needs. Care recipients, representatives and staff reported satisfaction with externally sourced services.


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Standard 2 – Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. The home generates continuous improvement initiatives through analysis of clinical data, incidents, audits, observation, staff and care recipient feedback. This information is analysed for trends. Care recipients and staff are aware of the continuous improvement program and are satisfied the home actively promotes and improves care recipients’ physical and mental health. Examples of Improvement initiatives implemented by the home over the last twelve months in relation to Standard 2 Health and personal care include:

•••• Audit results, from the new auditing system, showed a high number of medication signature omissions per month. A subsequent nurses’ meeting identified that interruptions from other staff and care recipients as well as phone calls during the medication round contributed to the omissions. Management implemented ‘Do not disturb’ aprons to be worn during medication rounds as well as the clinical nurse coordinator taking phone calls during this time. After trialling this system, it was found the registered nurse couldn’t be contacted in the case of an emergency if conducting the medication round. As a result a review of the whole medication management system was instigated. Management implemented a new system of nightly audits, benchmarking and incident reporting if omissions occurred two or more times in a single shift. Additionally staff education was conducted and audit data has shown a consistent reduction in signature omissions from March 2014 to January 2015.

•••• A nurses’ meeting identified not all care recipients’ assessments were completed prior to receiving equipment to meet their care needs. It was also identified staff were not tracking equipment used for care recipient needs. Management created an asset and inventory system to log and track all equipment and a new process was developed to ensure assessments are completed prior to equipment being allocated to care recipients. Maintenance log and track all equipment, clinical staff assess care recipients and complete a checklist that includes assessments completed, in order for the equipment to be supplied. An evaluation demonstrated an increase in assessments completed prior to allocation of appropriate equipment. Management said this system has also decreased the amount of equipment ordered. Staff and care recipients have provided positive feedback and the project has been implemented on an ongoing basis.


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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 findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of regulatory compliance being met by the home in Standard 2 Health and personal care include:

•••• Nurses registrations are monitored for currency.

•••• The home has a current licence for storage and possession of Schedule 4 and Schedule 8 drugs.

•••• Specialised nursing care is carried out by qualified staff according the Quality of Care Principles.

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. Examples of education and training provided for management and staff in relation to Standard 2 Health and personal care include:

•••• Understanding the person with dementia - Alzheimer’s Australia session

•••• Medication Management

•••• Pain Management 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients receive clinical care that is appropriate to their individual needs and preferences. Care recipients’ individual health and personal care needs are identified from clinical and risk assessments and information provided from clinical monitoring. This information assists in completing a detailed care plan to guide staff in care recipients’ care needs and updates of care requirements are recorded in the progress notes. Monitoring of clinical care occurs through regular care reviews, handover meetings, electronic messaging system, regular staff meetings and audits. Results show there are effective systems in place to monitor care recipients’ clinical care. Staff said they have access to up-to-date information to guide them in individual care recipients’ care needs. Care


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recipients and representatives are satisfied with the level of consultation provided to care recipients and care recipients’ care needs are met. 2.5 Specialised nursing care needs This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Care recipients receive specialised nursing care from appropriately qualified nursing staff according to their identified needs and preferences. Clinical nursing staff assess care recipients to identify specialised care required and review specialised nursing needs on an ongoing basis through consultation with health specialists and staff. Specialised care needs are documented in care plans, medication charts and staff provide care in accordance with these documented requirements. Monitoring processes include regular care reviews, handover processes, staff meetings, clinical audits and reporting mechanisms through the Quality Improvement meetings. Results show care recipients’ specialised care is identified and monitored effectively by registered nursing staff. Care recipients and representatives are satisfied with the level of consultation to care recipients and with the specialised nursing care provided. 2.6 Other health and related services This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients are referred to appropriate health specialists when required. Care recipients are referred as required to identified specialists, and regular reviews occur to identify any further health issues requiring attention. Care requirements are updated in line with allied health and specialist recommendations, in consultation with care recipients and their representatives. Care is coordinated and provided by a wide range of health specialists, these include physiotherapists, speech pathologists, podiatrists and dietitians. Monitoring occurs through regular care reviews, handover meetings, electronic messaging system, regular staff meetings and audits. Results show care recipients who require referral to health specialists are identified and referred appropriately. Staff said they have access to information provided from specialists to assist staff in the delivery of care. Care recipients and representatives are satisfied with the level of access care recipients have to other health and related services. 2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome There are systems to ensure care recipients’ medications are delivered by qualified staff and managed safely and correctly. There are identified processes for assessing, managing and monitoring care recipients’ individual medication needs and these are documented and evaluated regularly by clinical and medical staff. Medications are kept in secure storage and


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drugs of dependence are stored as per legislative requirements. There are systems to ensure nurse initiated medications are administered correctly and ‘as required’ medications are monitored for effectiveness. Staff wear ‘do not disturb’ vests to assist in the efficient delivery of medications and staff said this has assisted staff in administering medications in a timely manner. Monitoring occurs through audits, pharmacy and medical reviews, medication advisory committee, regular staff meetings, review of medication incident data, education and observation. Results show medication management is monitored and follow up actions are completed. Staff said they have access to regular supplies of medication to support care recipients’ medication requirements. Care recipients and representatives said they are satisfied that care recipients’ medication is managed safely and correctly. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome The home has systems to asses all care recipients are as free as possible from pain. Pain assessments are undertaken on entry to the home and reviewed in consultation with the nursing and medical staff and the physiotherapist. Assessments include assessing care recipients with cognitive deficits regarding their levels of pain. A plan is developed, implemented and evaluated regularly as needs change. Interventions include medication, positional changes, exercise regimes, wax baths, heat packs and massage and these interventions are monitored by nursing and allied health staff. Monitoring of care recipients’ pain management occurs through regular care reviews, allied health and medical reviews, regular staff meetings and observation. Results show care recipients are assessed and monitored and there are effective systems in place to support care recipients’ pain management. Staff said they have access to specialised equipment to deliver pain relief medications effectively. Care recipients and representatives said care recipients’ pain is managed effectively. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients receive appropriate palliative care that maintains their comfort and dignity during the terminal stages. Clinical nursing staff meet with care recipients and their representative to discuss end of life wishes and an end of life pathway care plan is completed. Equipment is available to support care recipients’ comfort and care needs and emotional support is provided and care recipients have access to rosary beads and a bible. Other individual requests by care recipients and their representatives are accommodated including hospitality services provided. Pastoral services are available and arranged according to care recipient’s preferences. Monitoring occurs through care recipient and representative feedback mechanisms, handover sessions, clinical monitoring processes and staff feedback. Results show care recipients are supported in their care needs and pain management at the end stages of their life. Staff said they have access to medical staff and equipment to support care recipients’ care needs. Representatives are satisfied with the way the home maintains care recipients’ comfort and dignity.


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2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients receive adequate nourishment and hydration. Assessment processes including a malnutrition risk assessment are conducted on entry to identify care recipients’ nutritional and hydration needs. Each care recipient’s dietary needs, food textures and requirements are communicated to the kitchen and detailed menu planner is completed to guide staff. Care recipients are regularly weighed and referral to identified specialists is conducted if required. Monitoring occurs through regular care reviews, review of care recipients’ weights, audits and feedback from allied health specialists and staff. Results show care recipients are regularly monitored and referred to allied health specialists to support their nutritional and hydration needs. Observations shows staff assist care recipients who require supplements. Care recipients and representatives are satisfied with the home’s approach in meeting the care recipients’ nutrition and hydration needs. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients’ skin integrity is consistent with their general health. Assessment processes including a risk assessment are conducted on entry by clinical nursing staff to identify care requirements to maintain care recipients’ skin integrity. This information is detailed in care plans, including identification of pressure relieving equipment, treatments such as moisturising creams and other strategies such as positional changes and nutritional supplements. Wound assessments are performed to guide staff in relation to treatments identified and regular reviews are conducted by clinical nursing staff. Monitoring occurs through regular care reviews, weekly reviews of wounds by registered staff, medical reviews and monitoring of the incidence of skin tears. Results show staff have access to equipment to support care recipients’ skin integrity. Staff said they have access to a regular supply of wound care products and care recipients and representatives are satisfied with the care provided to maintain care recipients’ skin integrity. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients’ continence is managed effectively Care recipients’ individual continence needs are assessed by clinical nursing staff and a detailed history is taken on entry. Care plans identify individual levels of independence, assistance required and dietary needs as required. The continence nurse and clinical nurse consultant monitor and assess continence aids required and relay this information to relevant staff. Monitoring of the incidence of urinary tract infections is conducted and reported thorough the Quality Improvement meetings. Further monitoring occurs through regular care reviews, monitoring of medications, regular handover and staff meetings, reviews with medical officer and audits. Results show care recipients are supported in their continence


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management and monitoring systems are effective. Staff said they have access to regular supplies of continence aids to support care recipients’ continence needs. Care recipients and representatives are satisfied that care recipients’ continence needs are met. 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The home has systems to ensure the needs of care recipients with challenging behaviours are managed effectively. Individual assessments and behaviour monitoring is conducted to identify triggers and strategies to assist with care recipients’ behaviour management and care needs. Care plans identify strategies and interventions to assist staff in managing challenging behaviours. Planned strategies and interventions are implemented and include lifestyle activities and equipment to support safety such as sensor mats. The home has a specialised secure unit to provide a safe environment for care recipients who are identified with a cognitive impairment and a minimal restraint policy in place. Care recipient incidents are reviewed monthly and reported through the Quality Improvement meetings. Further monitoring occurs through regular care reviews, behaviour monitoring processes and consultation with medical staff. Results show there are effective systems to identify and support care recipients’ behaviour management. Staff are aware of strategies to support individual care recipient’s behaviour management. Care recipients and representatives are satisfied with the home’s approach to managing causes which prompt challenging behaviours. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome The home has systems to ensure optimum levels of mobility and dexterity are achieved for all care recipients. Assessment processes including functional assessments are conducted by clinical nursing staff and physiotherapists and individual mobility and transfer plans are completed. Exercise classes and mobility aids are provided to assist care recipients’ independence and improve mobility and balance. Falls are monitored monthly by clinical nursing staff and analysed for trends. Monitoring occurs through trending of incidents, observation, audits, feedback and evaluation from allied health specialists and staff. Results show care recipients are supported to maintain and improve their mobility and dexterity. Staff said they have access to mobility aids to support care recipients’ mobility needs. Care recipients and representatives are satisfied with the home’s approach to optimise care recipients’ mobility and dexterity.

2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients’ oral and dental health is maintained.


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Oral health assessments are conducted on entry and on an ongoing basis to identify individual oral and dental care needs. Care plans provide individual oral and dental hygiene strategies and care recipients are assisted to attend dental services as required. There are identified staff who monitor replacement of tooth brushes. Monitoring occurs through regular care reviews, nutrition and pain monitoring processes, medical reviews, consultation with allied health practitioners and the feedback process with staff, care recipients and representatives. Results show care recipients’ oral and dental needs are identified monitored and are effectively managed. Staff said they have access to oral equipment to support care recipients’ oral and dental health care. Care recipients and representatives are satisfied that care recipients’ oral and dental health care is maintained. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients’ sensory losses are identified and managed effectively. Assessment processes are in place to identify any sensory loss and care needs required in relation to hearing, vision, touch, taste and smell. Care plans identify strategies and aids to support and improve sensory loss. Activities are promoted to enhance sensory enjoyment. A visiting optometrist and audiologist visit the site to support care recipients’ sensory function in relation to sight and hearing. Staff monitor and assist care recipients with maintaining and fitting aids to support sensory function. Monitoring occurs through regular care reviews, observation, care recipient and staff feedback and medical and allied health reviews. Results show care recipients’ sensory needs are identified monitored and are effectively managed. Staff are aware of care recipients who require specialised aids to support their sensory loss. Care recipients and representatives are satisfied care recipients’ sensory losses are identified and managed appropriately. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome There are systems in place to assist care recipients to achieve normal sleep patterns. Clinical nursing staff complete an assessment on entry to the home to identify care recipients’ natural sleep patterns, preferred settling times and routines. Individual care plans are formulated and include rising and settling times and comfort interventions. Monitoring of care recipients’ sleep disturbance occurs through regular care reviews, medication reviews, audits, observations and feedback from staff and care recipients. Results show care recipients’ individual needs are identified and they are supported in achieving a normal sleep pattern. Staff are aware of care recipients’ individual needs to support their sleep management. Care recipients and representatives are satisfied care recipients are assisted to achieve a normal sleep pattern. .


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Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement systems and processes. In relation to Standard 3 Care recipient lifestyle, care recipient meetings and surveys are used to identify preferences and needs. Feedback is recorded and evaluated from all lifestyle activities. Staff contribute to lifestyle improvements through surveys and specific lifestyle training. Staff encourage and support care recipients and representatives to provide feedback and suggestions. Examples of recent improvements implemented by the home in the last 12 months in relation to Standard 3 Care recipient lifestyle include:

•••• In response to a suggestion at a care recipient meeting, the diversional therapist developed a new activity designed to involve recycling of materials at the home. A craft project involving building a miniature Lady Rose Cathedral was commenced using recycled materials, including used pill cups. Care recipients’ mobility and dexterity was matched to tasks that included building the structure and painting ‘stained glass windows’. The finished project was displayed in an Adelaide cathedral and the care recipients were taken on a bus trip to view it. Care recipient feedback was very positive with another project undertaken to build a miniature St Nick’s Castle.

•••• Staff in the specialised support unit suggested there could be more care recipient interaction and quiet time in the afternoon to mitigate challenging behaviours and reduce mandatory reporting. In October 2014, the home implemented quiet time in the afternoon, this incudes one-to-one interaction with staff. To improve and facilitate interactions with care recipients, management has developed a photo history book containing a page for each care recipient with photos and information regarding their life history for staff. It is also used to help form individual activity plans for care recipients. An evaluation was completed and this showed mandatory reporting has decreased from 2013 to 2014.

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 care recipient lifestyle”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.


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In relation to Standard 3 Care recipient lifestyle, the home has systems for identifying and accessing relevant legislation, regulations, and professional standards relating to care recipient lifestyle. Management update staff via all staff communications, electronic updates and policy changes. Staff said they are aware of regulatory requirements including privacy, maintaining confidentiality and compulsory reporting of assaults. Examples of regulatory compliance being met by the home in Standard 3: Care recipient lifestyle include:

•••• Policies and procedures and registers for reporting and recording of elder abuse

•••• Accommodation agreements, processes and policy

•••• Privacy policies to protect the use of care recipient information 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. In relation to Standard 3, Care recipient lifestyle, management ensure staff have the knowledge and skills required for effective performance in their roles. Stakeholder feedback and observations monitor staff skills and knowledge in relation to care recipient lifestyle needs. Examples of education and training provided for management and staff in relation to Standard 3 Care recipient lifestyle includes:

•••• Mandatory reporting: reportable incidents and preventing elderly abuse

•••• Wellness and Leisure - Diversional Australia National Conference 3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome Care recipients receive support in adjusting to life in the new environment and on an ongoing basis. Care recipients are provided with a tour of the home and they are introduced to a ‘buddy’ care recipient to assist them in settling into their new environment. Lifestyle and care plan assessments identify care recipients’ individual emotional needs and support networks. Care and lifestyle staff, volunteers and ministers of clergy support care recipients’ emotional needs and assist them to maintain relationships, recognise significant days and celebrations. Family, friends and community groups are encouraged to visit care recipients. Monitoring occurs through surveys, staff observation and verbal feedback from care recipients, staff and representatives. Results show there are effective systems in place to support care recipients’ emotional needs. Staff demonstrated examples of providing emotional support to care recipients. Care recipients and representatives are satisfied that care recipients’ emotional needs are met.


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3.5 Independence This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service. Care recipients’ lifestyle preferences, interests and abilities are identified during the care and lifestyle planning process and reviewed regularly. Physiotherapy assessments identify strategies to support independence including mobility aids required. Care recipients are encouraged and supported to participate in group activities, and maintain links with family, friends and community groups. The home supports care recipients’ independent outings with family, friends and groups within the local community. Monitoring occurs through staff observation, planned lifestyle reviews, allied health reviews, surveys and verbal feedback. Results show care recipients are supported to maintain links with the community and maintain friendships. Staff support individual care recipients to maintain their independence at the home and in the community. Care recipients and representatives are satisfied the home assists care recipients’ to maintain their independence 3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Care recipients’ rights to privacy, dignity and confidentiality are recognised and respected. Care and lifestyle plans identify care recipients’ privacy and dignity needs and requests. Shared lounges and private lounge areas are available. Staff support care recipients’ privacy, dignity and confidentially by knocking on doors before entering and not entering when ‘do not disturb signs’ are placed on care recipients’ room door. Staff sign a confidentiality declaration on commencement of employment and ensure care recipients’ information is stored securely. Monitoring of care recipients’ rights to privacy, dignity and confidentiality occurs through observation of staff practice, feedback processes at regular lifestyle reviews, consultation with families, surveys and audits. Results show there are effective systems in place to support confidently and privacy and dignity for care recipients. Care recipients and representatives are satisfied that care recipients’ privacy, dignity and confidentiality is maintained. 3.7 Leisure interests and activities This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome There are systems in place to ensure care recipients are encouraged and supported to participate in a wide range of activities of interest to them. A lifestyle assessment including a lifestyle history is obtained from care recipients or their representatives on entry to the home. This information includes past and present lifestyle interests and lifestyle plans are developed to identify care recipients’ lifestyle needs and preferences. Care recipients’


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interests, ability to participate, cultural and spiritual needs and physical ability are assessed as part of this process. Activities are developed to meet individual care recipients’ lifestyle needs and group sessions are tailored to meet the needs and preferences of care recipients. A wide range of activity programs are included in the lifestyle calendar. Monitoring occurs through evaluation of participation records, activities evaluations, feedback at care recipients’ meetings, audits and surveys. Results show care recipients have access to a wide range of activities. Staff are aware of individual care recipients’ wishes in relation to their lifestyle needs and preferences. Care recipients and representatives are satisfied that care recipients have a wide range of activities in which they can participate according to their preferences. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome There are systems in place to ensure care recipients’ individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. Through initial and ongoing assessments care recipient’s individual cultural and spiritual preferences are identified. Care recipients are assisted to maintain their individual religious beliefs and spiritual support is provided through individual visits from ministers of the clergy and church services are held on site. Monitoring occurs through feedback from staff and ministers, feedback from care recipients at lifestyle meetings and surveys. Results show there are effective systems in place to support care recipients’ cultural and spiritual needs. Staff provided examples of care recipients’ individual needs in relation to their cultural and spiritual needs. Care recipients and representatives are satisfied care recipients’ individual interests, religious and cultural needs are met. 3.9 Choice and decision-making This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome There are systems in place to ensure each care recipient or their representative participate in decisions about the services the care recipient receives, and are enabled to exercise choice and control over their lifestyle while not infringing on the rights of other people. Care and lifestyle assessment processes identify care recipient preferences for activities of daily living, leisure and lifestyle choices, civic interests and details of persons nominated to provide advocacy. Care recipients have access to advocacy agencies and external complaint mechanisms, these are discussed and displayed. Monitoring occurs through surveys, care recipients meetings and feedback processes from care recipients and representatives. Results show there are effective systems in place to support care recipients’ right to exercise choice and control over their life decisions. Staff provided examples regarding care recipients’ right to exercise choice and control over their individual choices in relation to lifestyle and care decisions. Care recipients and representatives are satisfied care recipients’ have the right to exercise choice and control according to their needs.


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3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome The home has systems to ensure care recipients understand their rights and responsibilities and security of tenure. Care recipients and their advocacy representative are provided with a preliminary enquiry pack and fact sheets with detailed information to assist them in making an informed decision. Care recipients and representatives are offered a one-to-one meeting with the Director of Nursing or Business Manager to assist in the understanding of the resident agreement, which includes information regarding rights and responsibilities, fees and charges and security of tenure. Monitoring of care recipients’ rights and responsibilities is conducted through meetings with care recipients and their advocates and through feedback processes. Results show care recipients’ are advised of their rights in relation to security of tenure and there are effective systems in place to ensure this information is provided. Staff are aware of processes and provide this information to all parties. Care recipients and representatives are satisfied that care recipients feel secure in their tenure and are assisted to understand their rights and responsibilities.


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Standard 4 – Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement systems and processes. In relation to Standard 4 Physical environment and safe systems, the home has a corporate schedule for auditing and reviewing compliance with the Accreditation standards. Care recipient, representative and staff feedback, preventative and routine maintenance registers, hazard and incident data and cleaning, laundry and catering records are used to gather information. Care recipients and staff are aware of the continuous improvement program and are satisfied that the organisation actively promotes continuous improvement. Examples of recent improvements implemented by the home in the last 12 months in relation to Standard 4 Physical environment and safe systems include:

•••• Following an infection control conference attended by the Education/Safety Coordinator and the Hospitality Services Manager in September 2014, microfibre mops were purchased and trialled. New cleaning procedures, in line with conference recommendations were developed and uploaded and an electronic all staff message was sent out to inform staff. Training from the supplier was provided for staff and management have implemented the microfiber mops across the home. Staff provided feedback regarding the new equipment and said the new mops cleaned better and there was less strain on their shoulders.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of regulatory compliance being met by the home in Standard 4 Physical environment and safe systems include:

•••• Food safety plan and council audit

•••• Infection control policy

•••• Asbestos register

•••• Triennial fire certificate


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4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. In relation to Standard 4, Physical environment and safe systems, management ensure staff have the knowledge and skills required for effective performance in their roles. Management monitor attendance to education sessions to ensure annual staff attendance, understanding, and competency. Examples of education and training provided for management and staff in relation to Standard 4, Physical environment and safe systems includes:

•••• Emergency management planning

•••• Food safety

•••• Asbestos management

•••• Preventing and managing bullying and harassment 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 care recipients’ care needs". Team’s findings The home meets this expected outcome The home has systems to ensure it provides a safe, clean and comfortable environment that is consistent with care recipients’ care needs. The home has a mixture of single and shared rooms with ensuite and includes a secure specialised memory support unit, hairdresser and café. The home provides clean, safe and well maintained communal living, which consists of several dining areas, quiet indoor lounge areas and outdoor areas where care recipients and their families can relax. The home has ducted air conditioning with some care recipient rooms having split systems, care recipients are able to furnish their own rooms with personal furniture and rooms are lockable via keys to ensure security. The safety and comfort of care recipients is guided by policy and procedures in consultation with the care recipient and/or representative, clinical staff and medical officers. The living environment is monitored through workplace inspections, incident and hazard reporting, recording and trending of data, audits, preventative and corrective maintenance and observation. Results show internal audits are conducted on a regular basis and identify areas requiring action and staff are informed through meetings, electronic information and ongoing training. Staff are aware of their roles in assisting to maintain a safe and comfortable environment and processes to report hazards or incidents. Care recipients and representatives are satisfied with the safety and comfort of the home.


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4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome The home has systems and processes to ensure a safe working environment that meets regulatory requirements. Policies and procedures to guide staff practice are contained in the home’s document management system, Quality Improvement meetings are held monthly and work health safety is a standing agenda item at all staff and care recipient meetings. Staff are invited to comment on draft or reviewed policy and are informed of changes via an electronic notification system. Staff are provided with mandatory training and ad hoc training that meets the home’s needs and compliance is ensured through observation, feedback, performance appraisal and audit processes. Monitoring to ensure a safe working environment is conducted through regular workplace safety inspections, trending of incident and hazard data, meetings and audit processes. Results show staff have input into the home’s work health and safety system through reporting mechanisms and work safety is discussed at staff meetings. Staff are aware of safe work practices, receive training and are aware of their role in creating a safe work environment. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome The home has systems for detecting and acting on fire, security and other emergency risks and incidents. Fire detection and suppression equipment is regularly maintained through regular inspections by an external contractor. The home has a current triennial fire certification and compliance with legislative requirements are maintained through the organisation’s policies and procedures. Fire panels, maps, fire detection and suppression equipment and evacuation instructions are located throughout the home and in care recipient rooms. The home has processes to ensure information is securely stored including secure filing and archive systems and the home has keyed locks and keypads to ensure the environment is secure. The home has a business continuity plan and monitoring of fire, safety and security is conducted through auditing processes, internal and external independent inspections and care recipient, representative and staff feedback. Results show equipment and systems are well maintained and the site has emergency contingency plans in place. Staff complete annual fire safety and emergency training and fire drills. Staff said emergency procedures, security and work safety are regularly discussed at meetings. Care recipients said they know what to do on hearing an alarm and feel safe in their home. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has systems to ensure an effective infection control program is in place. There are policies and procedures in place to guide staff in infection control processes, including outbreak management. Staff have access to infection control equipment, receive education on infection control and are offered a vaccination program by the home. Care recipients are


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also offered a vaccination program and there are systems for the management of pest control. Staff have access to a food safety plan to guide their practice and cleaning staff use a colour coded system to prevent and control the risk of infection. Clinical staff monitor current infections, identify and analyse data and trends and these are discussed at the Quality Improvement meetings. Other monitoring processes include observation of staff practice and hand washing audits. Staff said they attend the annual education program in relation to infection control and have access to infection control resources to reduce the risk of infections. Care recipients and representatives are satisfied with staff practice at the home to minimise the incidence of infection. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome The home has systems to ensure hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment. A dietitian reviewed menu is in place and current nutrition and hydration care plans are provided to the kitchen, via a ‘meals list’, to ensure care recipients’ needs and preferences are met. Preparation, cooking and serving of meals is done on-site, food is ordered weekly and date rotation system for stock is in place. Duty statements and cleaning schedules direct the cleaning of care recipient rooms and communal areas. The home has a five day on-site laundry service for all linen, towels and personal clothing, including a labelling service to reduce lost clothing. Care staff launder as needed on weekends. Monitoring of hospitality services is conducted through feedback, menu planning meetings, satisfaction surveys, consultation, maintenance records and internal and external auditing processes. Results show hospitality systems and services are effective, meet staff needs and care recipients and representatives are satisfied. Staff said they have access to appropriate training and equipment and the services provided by the home are effective. Care recipients and representatives said hospitality services provided by the home meet care recipients’ individual needs and preferences and they are able to provide feedback.

Published Decision Redistribution 10-10-2017 · 11 Edmund Street PORT BROUGHTON SA 5522 Approved provider: Barunga Village Incorporated Following an audit we decided that this home

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