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Arcare GlenhavenRACS ID: 1060

Approved provider: Arcare Pty Ltd

Home address: 93 Glenhaven Road Glenhaven NSW 2156

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 11 September 2021.

We made our decision on 10 July 2018.

The audit was conducted on 05 June 2018 to 07 June 2018. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: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 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 carePrinciple: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.




2.4 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 MetHome name: Arcare Glenhaven Date/s of audit: 05 June 2018 to 07 June 2018RACS ID: 1060 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




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 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




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

Home name: Arcare Glenhaven Date/s of audit: 05 June 2018 to 07 June 2018RACS ID: 1060 3

Audit ReportName of home: Arcare Glenhaven

RACS ID: 1060

Approved provider: Arcare Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 05 June 2018 to 07 June 2018 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

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

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 05 June 2018 to 07 June 2018.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Details of homeTotal number of allocated places: 120

Number of care recipients during audit: 65

Number of care recipients receiving high care during audit: 48

Special needs catered for: Dementia


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

Interviews

Position title Number

Cafe staff 2

Clinical Care Manager 1

General services manager 1

National catering manager 1

Chef 1

Catering staff 4

Laundry staff 2

Servery staff 2

Receptionist 1

Cleaning staff 3

Maintenance officer 1

Residence Manager 1

Registered nurse 4

Client service manager 1

Care staff 6

Nurse educator 1

Care coordinator 1

Care recipients and/or representatives 21

Sampled documents

Document type Number

Care recipients' files 16

Summary and/or quick reference care plans 16

Medication charts 10


Document type Number

Personnel files 6

Other documents reviewedThe team also reviewed:

Accident, incident and hazard documentation – staff and care recipient

Advocacy information

Annual fire safety statement of compliance

Application for residential care

Approved supplier list

Arcare Glenhaven brochure

Archive room and documentation

Behaviour Incidents register (electronic)

Building/floor plan

Care Plan review schedule

Care recipient and staff vaccination records

Care recipient and visitor sign in/out screen

Care recipient emergency evacuation documentation

Care recipient pre entry pack

Catering - 5 week rotating menu and daily menus in dining rooms, menu review report, catering feedback forms, special dietary information, dietary analysis summaries report, food safety plan, NSW Food Authority audit report March 2018, meal satisfaction questionnaire

Cleaning programs

Clinical documentation: progress notes, advanced care plans, behaviour monitoring charts, bowel charts, pain assessments and charts, clinical observation records, dietary forms, hospital referrals, wound charts, weight charts, physiotherapy plans, pathology reports, blood glucose charts, incident reports, line listings, pain charts

Comments and complaints documentation (including complaint forms, information on internal and external complaints mechanisms)

Continuous Improvement (CI) records (including CI plan/register, audit schedule, audit reports survey results, and associated documentation. Quality improvement form. Feedback forms. Trend data analysis

Corrective and preventative maintenance documentation

Education – program, staff compulsory and general training attendance records

Electronic communication systems: including email, purpose specific computer programs such as the care recipient clinical records system.

Emergency and disaster management response procedures

Environmental records

External service contracts and associated documents


Fire and essential services maintenance and testing records

Handbook - care recipient

Human resource records including codes of conduct, staff handbook, recruitment documentation, orientation and induction information, Police and statutory declaration register, probationary and performance appraisal procedure and guidelines, professional registrations and monitoring system, duty statements and work instructions, volunteer documentation, roster and staffing reports

Incident and accident/hazard reports, WH&S environmental safety inspections, chemical information, material safety data sheets (MSDS), manual handling instructions, risk assessments

Incident and hazard documentation

Infection control policies and procedures, infection surveillance program, infection incident reports, Influenza vaccination records including care recipients and staff; influenza outbreak management records

Information management documents including clinical policies and procedures, newsletters, communication books, diaries, memos, electronic clinical documentation program, emails,

Legislative information

Lifestyle management: lifestyle past history, leisure and spiritual assessments, activity plans, attendance records, consent forms, communication cue cards

Medication profiles and pharmacist reviews, charts and signing sheets, pharmacy reports, schedule eight medication books, staff signature records, therapeutic monitoring charts, incident reports.

Organisational membership of legislative body

Organisational monthly magazine Vol 2 Edition 5 May 2018

Organisational self-assessment

Physiotherapy assessment plan/charts, mobility plans, therapeutic folder (heat pack management

Policies and procedures, organisational flowcharts, planning documentation, vision, values and mission statements

Preferred supplier list

Regulatory compliance documentation

Reporting Register (electronic)

Resident/relative/visitor comment form

Social register (electronic)

Staff vaccination documentation

Temperature checks

The six 'Senses'

Various meeting minutes including staff, care recipient, influenza outbreak debriefing; workplace health and safety

Work Health and Safety materials.


ObservationsThe team observed the following:

Activities in progress

Aged Care Complaints Commissioner and advocacy information on display

Australian Aged Care Quality Agency re-accreditation audit notice displayed

Automatic door locking system

Cafe at the home – fully functioning located in foyer

Care recipient tablet computers

Care recipients/representative suggestion boxes

Charter of care recipients’ rights and responsibilities on display

Chemical storage and safety system including safety data sheets

Cleaning in progress (including use of equipment, trolleys and wet floor signage boards)

Courteous interactions between staff, care recipients, representatives and visitors

Dining environment during midday meal service, morning and afternoon teas including staff serving meals, supervision and assisting care recipients.

Education calendar and flyers

Electronic and hardcopy record keeping systems – clinical and administration

Emergency equipment including fire panel, fire safety equipment, emergency exits, emergency egress route diagrams, key pad locks

Equipment and supplies in use and in storage including manual handling equipment, mobility and pressure relieving equipment, chemicals, clinical and wound supplies

Equipment and supply storage areas

Fire indicator panel, firefighting equipment, sprinkler system, evacuation signs and diagrams, evacuation egresses

Food safety registration certificate and audit report

Hairdresser salon with hairdressers in attendance

Infection control resources including hand hygiene/washing facilities, colour coded equipment, personal protective equipment, sharps containers, spills kits, outbreak supplies, influenza promotion program

Information brochure stand in foyer

Information notice boards including Work, Health and Safety

Kitchen and kitchenette/servery areas

Laundry environment

Lifestyle equipment and resources

Living environment – internal & external

Medical officer rounds

Medication administration and storage

Notice boards for staff and care recipients containing care recipient activity programs and notices, staff and resident information, comments and complaints information


Nurse call system

Personal protective equipment

Safe chemical and oxygen storage

Secure storage of staff files, care recipients’ clinic files and confidential handover

Short group observation dementia unit lounge

Sign in sign out system (electronic)

Staff work practices and work areas including administrative, clinical, lifestyle, physiotherapy, catering, cleaning, laundry and maintenance

Tranquillity room

Vision, Mission and Philosophy Statements

Waste management practices

Water hydrants, pumps and sprinkler valves

Wound trolley and equipment


Assessment informationThis 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 developmentPrinciple: Within the philosophy and level of care offered in the residential care services, 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 improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team's findingsThe home meets this expected outcome

The continuous improvement program includes processes for identifying areas for improvement, implementing change, monitoring and evaluating the effectiveness of improvements. Feedback is sought from care recipients, representatives, staff and other stakeholders to direct improvement activities. Improvement activities are documented on the plan for continuous improvement. Management uses a range of monitoring processes such as audits and quality indicators to monitor the performance of the home's quality management systems. Outcomes are evaluated for effectiveness and ongoing monitoring of new processes occurs. Care recipients, representatives, staff and other personnel are provided with feedback about improvements. During this accreditation period the organisation has implemented initiatives to improve the quality of care and services it provides. Recent examples of improvements in Standard 1 Management systems, staffing and organisational development are:

The home opened in September 2017. It has fully implemented the Arcare group’s established systems and processes to cater for the needs of its care recipients.

All 70 staff have successfully completed a comprehensive one-week’s orientation training program delivered on site. This included but was not limited to the completion of online learning/education modules. The online system monitors staff completion and progress. In addition, the home has created a mentoring checklist sheet for each staff role at the home. Staff interviewed indicated that they were happy with the recruitment process, orientation program and ongoing education provided to them by the home.

Arcare aged care's the Six 'senses' program has been introduced. The organisation believes that the provision of 5-star support is shaped by the quality of the relationships and interactions between care recipients, staff and families. It is committed to supporting and valuing the well-being and contribution of all those involved in these relationships. This program outlines what clients, staff and families should experience in order for relationships to flourish, and 5-star support to be achieved. The program guides behaviour and approach and is used to evaluate outcomes and personal performance.

Arcare’s homes have adopted a dedicated assignments staffing model. The organisation believes that staff continuity is essential to providing quality care and hence operates a dedicated assignment system that promotes continuity and allows for deep and trusting relationships to develop between clients, staff and family.


1.2 Regulatory complianceThis 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”.


The home has a system to identify relevant legislation, regulatory requirements and guidelines, and for monitoring these in relation to the Accreditation Standards. The organisation's management has established links with external organisations to ensure they are informed about changes to regulatory requirements. Where changes occur, the organisation takes action to update policies and procedures and communicate the changes to care recipients, their representatives and staff as appropriate. A range of systems and processes have been established by management to ensure compliance with regulatory requirements. Staff have an awareness of legislation, regulatory requirements, professional standards and guidelines relevant to their roles. Relevant to Standard 1 Management systems, staffing and organisational development, management are aware of the regulatory responsibilities in relation to police certificates and the requirement to advise care recipients and their representatives about re-accreditation site audits; there are processes to ensure these responsibilities are met. For example, compliance with regulatory requirements is monitored through processes including registers to monitor currency of registrations and certificates, audits and monitoring attendance at mandatory training.

1.3 Education and staff developmentThis expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.


The home's processes support the recruitment of staff with the required knowledge and skills to perform their roles. New staff participate in an orientation program that provides them with information about the organisation, key policies and procedures and equips them with mandatory skills for their role. Staff are scheduled to attend regular mandatory training; attendance is monitored and a process is available to address non-attendance. The effectiveness of the education program is monitored through attendance records, evaluation records and observation of staff practice. Care recipients and representatives interviewed are satisfied staff have the knowledge and skills to perform their roles and staff are satisfied with the education and training provided. Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include Arcare policies and procedures, legislation, mandatory reporting and information technology.

1.4 Comments and complaintsThis expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".


There are processes to ensure care recipients, their representatives and others are provided with information about how to access complaint mechanisms. Care recipients and others are supported to access these mechanisms. Facilities are available to enable the submission of confidential complaints and ensure privacy of those using complaints mechanisms. Complaints processes link with the home's continuous improvement system and where appropriate, complaints trigger reviews of and changes to the home's procedures and


practices. The effectiveness of the comments and complaints system is monitored and evaluated. Results show complaints are considered and feedback is provided to complainants if requested. Management and staff have an understanding of the complaints process and how they can assist care recipients and representatives with access. Care recipients/representatives and other interested people interviewed have an awareness of the complaints mechanisms available to them and are satisfied they can access these without fear of reprisal.

1.5 Planning and LeadershipThis expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".


The organisation has documented the home's vision, philosophy, objectives and commitment to quality. This information is communicated to care recipients, representatives, staff and others through a range of documents. Organisational strategic and other plans work towards ensuring that the home achieves the organisation's vision, philosophy, objectives and commitment to quality. The organisation structure and a range of committees are ensuring that the home is supported and that its performance is monitored.

1.6 Human resource managementThis 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".


There are systems and processes to ensure there are sufficient skilled and qualified staff to deliver services that meet the Accreditation Standards and the home's philosophy and objectives. Recruitment, selection and induction processes ensure staff have the required knowledge and skills to deliver services. Staffing levels and skill mix are reviewed in response to changes in care recipients' needs and there are processes to address planned and unplanned leave. The home's monitoring, human resource and feedback processes identify opportunities for improvement in relation to human resource management. The home believes that staff continuity is essential to providing quality care and hence operates a dedicated assignment system to ensure this. Registered nurses are available 24 hours a day to supervise care staff and manage specialised nursing care needs. Staff are satisfied they have sufficient time to complete their work and meet care recipients' needs. Care recipients/representatives interviewed are satisfied with the availability of skilled and qualified staff and the quality of care and services provided to the care recipient.

1.7 Inventory and equipmentThis expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".


The home has processes to monitor stock levels, order goods and maintain equipment to ensure delivery of quality services. Goods and equipment are securely stored and, where appropriate, stock rotation occurs. Preventative maintenance and cleaning schedules ensure equipment is monitored for operation and safety. The home purchases equipment to meet


care recipients' needs and maintains appropriate stocks of required supplies. Staff receive training in the safe use and storage of goods and equipment.

Staff interviewed stated they are satisfied they have sufficient stocks of appropriate goods and equipment to care for care recipients and are aware of procedures to obtain additional supplies when needed.

Care recipients/representatives interviewed are satisfied with the supply and quality of goods and equipment available at the home.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The home has systems to provide all stakeholders with access to current and accurate information. Management and staff have access to information that assists them in providing care and services. Electronic and hard copy information is stored securely and processes are in place for backup, archive and destruction of obsolete records, in keeping with legislative requirements. Key information is collected, analysed, revised and updated on an ongoing basis. Data obtained through information management systems is used to identify opportunities for improvement. The home regularly reviews its information management systems to ensure they are effective. Staff interviewed stated they are satisfied they have access to current and accurate information. Care recipients/representatives interviewed are satisfied the information provided is appropriate to their needs, and supports them in their decision-making.

1.9 External servicesThis 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".


The home has mechanisms to identify external service needs to achieve its quality goals. The home's expectations in relation to service and quality is specified and communicated to the external providers. The home has agreements with external service providers which outline minimum performance, staffing and regulatory requirements. There are processes to review the quality of external services provided and, where appropriate, action is taken to ensure the needs of care recipients and the home are met. Staff are able to provide feedback on external service providers. Care recipients/representatives and staff interviewed stated they are satisfied with the quality of externally sourced services.


Standard 2 – Health and personal carePrinciple: 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.



Refer to Expected outcome 1.1 Continuous improvement for information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 2 Health and personal care are:

The introduction of Arcare aged care's Six 'senses' program and dedicated staffing assignment model guides care delivery. See expected outcome 1.1 Continuous improvement.

A review of the home’s admission or entry procedures was recently undertaken. As a result, new procedures were introduced that have improved the process and experience for care recipients and their families. This process ensures that the clinical needs of care recipients are comprehensively assessed pre entry. For example, two or three days prior to entry. This ensures that vital clinical information is available to staff but that the care recipient and their family feel welcome, at ease and are not overwhelmed on the day they actually enter the home.

The home's has reviewed its staff training in light of the electronic clinical software package used. All staff are trained during their orientation when they first join the home but recently a need for follow up training for existing staff was recognised and a package developed.

2.2 Regulatory complianceThis 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”.


Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to Standard 2 Health and personal care, management are aware of the regulatory responsibilities in relation to specified care and services, professional registrations and medication management. There are systems to ensure these responsibilities are met.




The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to health and personal care. Refer to Expected outcome 1.3 Education and staff development for more information. Examples of education and training provided in relation to Standard 2 Health and personal care include clinical care, medication management, pain management, nutrition, continence management, dementia awareness and behaviour management.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.

Team’s findingsThe home meets this expected outcome

There is a comprehensive system to assess, identify, monitor and evaluate care recipients individual care needs on entry and on an ongoing basis. Information obtained from care recipients and representatives when care recipients enter the home, together with a range of focussed assessments, are used to prepare individual care plans. The visiting medical officers regularly review care recipients and, when needed, care recipients are transferred to hospital for emergency treatment or to meet specific care needs. Staff training addresses issues relating to clinical care and, where appropriate, consultants are accessed to support staff and provide advice regarding specific care issues. The provision of care is monitored through audits, surveys, collection of clinical indicators and the comments and complaints mechanisms. Care recipients gave positive feedback regarding the clinical care they receive.

2.5 Specialised nursing care needsThis expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.


There is a system to identify and meet care recipients specialised nursing care needs. This includes initial and ongoing assessments and appropriate care delivery that is regularly reviewed and evaluated in consultation with care recipients and their representatives. Care recipients’ documentation identified a referral system to a range of allied health professionals and other specialists to assist the home manage care recipients complex and specialised needs. Staff training is provided to address specific care needs. Ongoing skills assessments ensure that staff skills and knowledge are up-to-date. Care recipients said their specialised nursing care needs are well managed.

2.6 Other health and related servicesThis expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.


There is a system to ensure referrals to appropriate health specialists occur in accordance with the care recipients needs and preferences. Referrals occur as the need requires with transport provided by the care recipient’s representatives or as arranged by the home. Management also organises health and related service visits to the home including, but not limited to, a dietician, speech therapist, physiotherapist and podiatrist. A review of care recipients’ care plans, progress notes, assessments and other documentation identified care recipients are referred to a range of health care specialists. Care recipients said staff members are proactive in making referrals to appropriate health specialists of their choice.


2.7 Medication managementThis expected outcome requires that “care recipients’ medication is managed safely and correctly”.


Systems are in place to manage the ordering, storage, administration, recording and review of medications. The registered nurses and medication competent staff members administer medications from sachets and use an electronic medication charting system. Registered nurses administer schedule eight drugs, insulin therapy, anticoagulants and cytotoxic medications. Medications are stored in locked clinical rooms or the locked medication trolleys. We observed safe and correct medication administration and staff demonstrated an understanding of the home’s medication management system. Management audits the medication system and collects and analyses monthly data as part of the home’s monthly clinical indicator reporting process. Care recipients said their medications are well managed and administered in a timely manner.

2.8 Pain managementThis expected outcome requires that “all care recipients are as free as possible from pain”.


There is a system to identify and manage care recipients’ pain and evaluate pain management strategies to ensure care recipients are as free as possible from pain. This includes initial and ongoing pain assessment using observation, discussion and pain assessment forms. Care staff members are knowledgeable regarding their role in pain management, including identification and reporting of pain. Care recipients have access to a physiotherapist five days a week who oversees the pain therapy programs. Staff said interventions for pain management include position change, exercise, massage, heat packs and pain relief medication. Care recipients gave positive feedback regarding their pain management.

2.9 Palliative careThis expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.


There is a system to ensure the comfort and dignity of terminally ill care recipients is maintained. Opportunities to discuss advanced care plans and end of life wishes are provided on a care recipient’s entry to the home and at regular case conferences. Staff said this is to ensure care recipients’ physical, emotional, cultural and spiritual needs and preferences are identified, documented and implemented. Management has access to the local palliative care outreach team if needed. Care recipients are supported to remain in the home in the event they require palliation. Staff members and documentation show pastoral care support is available to support and counsel terminally ill care recipients and their representatives.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.



Care recipients' nutrition and hydration requirements, preferences, allergies and special needs are identified and assessed on entry. Care recipients' ongoing needs and preferences are monitored, reassessed and care plans updated. There are processes to ensure catering and other staff have information about care recipient nutrition and hydration needs. Staff monitor care recipients' nutrition and hydration and identify those care recipients who are at risk. The home provides staff assistance, equipment, special diets and dietary supplements to support care recipients' nutrition and hydration. Staff have an understanding of care recipients' needs and preferences including the need for assistance, texture modified diet or specialised equipment. Staff practices are monitored to ensure nutrition and hydration needs are delivered in accordance with care recipients' needs and preferences. Care recipients and representatives interviewed are satisfied care recipients' nutrition and hydration requirements are met.

2.11 Skin careThis expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.


There is a system for maintaining care recipients’ skin integrity including initial and ongoing assessments, care planning and regular evaluation. The management team monitors accidents and incidents, including wound infections and skin tears, and acts appropriately on trends identified. Complex wound care is provided by the registered nurses, and the medication competent staff members complete simple dressings as documented. Wound charts were noted to be completed appropriately. A podiatrist regularly visits and treats care recipients. Care staff members are able to describe the process for identifying changes in care recipients’ skin integrity. Care recipients reported their skincare is well managed.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


There is a system to monitor and manage care recipients’ bladder and bowel continence and constipation effectively. This includes assessment on entry to the home and on an ongoing basis, involving evaluation of management strategies. These strategies include scheduled toileting, prompting, continence aids and increased fluids and fibre. Bowel management programs are in place and monitoring is via daily recording and reporting by care staff. Urinary tract infections are recorded monthly as part of the clinical indicators. Care recipients said they are satisfied with the support provided to ensure their bladder and bowel habits are well managed.

2.13 Behavioural managementThis expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.


The home has a system to assess and manage care recipients with challenging behaviours. The registered nurses complete initial and ongoing assessments of care recipient’s behaviours and this information is developed into a care plan. All episodes of challenging


behaviour are recorded, monitored closely and evaluated. Observations show staff interventions are successful in redirecting and diverting care recipients’ attention with effect and we noted the home was peaceful. The home has a memory support unit. Specialist advice is available from the visiting geriatrician and the external mental health team when needed. Care recipients and representatives said staff are responsive and provide support required to manage care recipients with behaviours which may disturb others.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.


The home has systems and processes in place to assist care recipients in achieving optimum levels of mobility and dexterity. There are mechanism used to identify, assess, evaluate and manage care recipients mobility and dexterity requirements. There is a team that monitors, ensures and implements strategies consisting of clinical care management, physiotherapist and aids, occupational therapists, registered nurses and care staff. There are physiotherapy assessments and care plans which inform staff on how they are to assist care recipients maintain and achieve optimum mobility, dexterity and rehabilitation needs. Regular education is provided for staff to follow current and new strategies in all aspects of manual handling including mandatory training. The physiotherapist will regularly assess, update and manage care plans and charts. Care recipients stated in the interviews their satisfaction with mobility and dexterity management and their overall personal improvements achieved since entry to the home.

2.15 Oral and dental careThis expected outcome requires that “care recipients’ oral and dental health is maintained”.


There is a system to ensure care recipients’ oral and dental health is maintained including initial and ongoing assessment of care recipients’ oral and dental needs. Assessments occur through staff observation and referrals to dentists and/or specialists are arranged as per care recipients’ needs and preferences. The day-to-day oral care is attended as per care recipients’ individual care plans with care recipients being encouraged to brush their own teeth or dentures to maintain their independence. Care recipients said staff members ensure the condition of their teeth, dentures and overall oral hygiene is well managed.

2.16 Sensory lossThis expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.


There is a system to ensure care recipients’ sensory losses are identified and managed effectively. The identification of any impairment includes sight, vision, touch, taste and smell. A care plan is developed incorporating these needs and other specialists are involved as required, including audiology and optometry. We observed examples of interventions used by the home to manage care recipients’ specific sensory loss. Care recipients said staff members ensure their sensory needs are identified, and well managed. The leisure and lifestyle program incorporates sensory stimulation such as massage, music, large print books, gardening and cooking.


2.17 SleepThis expected outcome requires that “care recipients are able to achieve natural sleep patterns”.


There is a system to ensure care recipients are able to achieve natural sleep patterns through initial and ongoing identification of night care requirements and sleep assessments. Strategies used to help care recipients to sleep include offering food or a warm drink or snacks, massage or position change, relaxing music, pain management and appropriate continence management. Other interventions include night sedation if ordered by a medical officer. Care recipients have a choice of when they retire and their preferred waking times are documented. Care recipients said the home’s environment is quiet at night and they are given individual care to help settle.


Standard 3 – Care recipient lifestylePrinciple: 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.



Refer to Expected outcome 1.1 Continuous improvement for information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 3 Care recipient lifestyle are:

The Arcare's Relationship App can be downloaded to a smart phone and/or tablet and is available to all care recipients. It is designed to assist them to keep up-to-date with family news, encourage and support visits and assist them to keep track of important appointments and social engagements.

The home recently introduced a tablet based computer system for care recipients. The tablets are supplied by an external provider who personalises each device to the needs of individual care recipients. Two staff provide care recipients with onsite “help desk” support. Currently 62% of care recipients have taken up the offer of the personalised tablet and are enjoying the benefits. Care recipients are emailing, accessing social media sites such as Facebook and accessing relevant information about the home through the 'My Arcare" App. They have access to details re key personnel and onsite services including the activities program, the Café - opening times and menu, hairdressing salon and the home's main menu. Care recipients are finding this a very informative, effective communication tool and entertainment device. They can easily access their preferred sites, games, favourite music lists and family contacts. Many like the games and some play these with their grandchildren. Care recipients with special cultural and linguistic needs are able to access programs in their own language. This is a clever idea that is enabling a generation of people who are not computer literate to combat isolation and boredom through the benefits of technology. Its use is promoting independence and choice, and is enabling care recipients to maintain links with the community. Having easy access to their favourite games and music is stimulating the mind.

The home opened in September 2017 so programs such as the activities program were recently reviewed to ensure that they remain fit for purpose. As a result additional staff hours have been allocated to this program. The allocation and/or employment of new activities staff member will enable the provision of additional activities.

3.2 Regulatory complianceThis 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”.


Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to


Standard 3 Care recipient lifestyle, management are aware of the regulatory responsibilities in relation to compulsory reporting, user rights, security of tenure and care recipient agreements. There are systems to ensure these responsibilities are met.



The home has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to care recipient lifestyle. Refer to Expected outcome 1.3 Education and staff development for more information. Examples of education and training provided in relation to Standard 3 Care recipient lifestyle include elder abuse, compulsory reporting, the Arcare Six 'Senses' program - the Relationship-First Approach, emotional support, person-centred activities, cultural diversity, privacy and dignity, choice and decision making.

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the lifestyle officer, care recipient//representative meetings and involvement of family in the activity program. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors including pets are encouraged. Care recipients and representatives are satisfied with the way they are assisted to adjust to life at home and the ongoing support they receive. However, one care recipient out of the 21 interviewed disagree with the statements that if they were feeling a bit sad or worried there were staff they could talk to, that they were encouraged to do as much as possible for themselves and that staff know what they are doing.

3.5 IndependenceThis 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".


The home ensures care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Community visitors, volunteers and entertainers are encouraged and arranged. The environment encourages care recipients, their representatives and their friends to participate in activities. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain independence.


3.6 Privacy and dignityThis expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".


There are systems to ensure privacy and dignity is respected in accordance with care recipients individual needs The assessment process identifies each care recipients’ personal, cultural and spiritual needs, including the care recipients preferred name. Permission is sought from care recipients to display their photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Care recipients’ rooms are managed so that privacy is not compromised; lockable storage is available to all care recipients. Staff handovers and confidential information is discussed in private and care recipients’ files are securely stored. Staff practices observed respected care recipients privacy and dignity. Care recipients and representatives interviewed said staff treat everyone with respect and feel that their privacy is respected and that their information is secure. However, one care recipient out of 21 interviewed felt that staff followed up when they raised things with them, explained things to them and treated them with respect only some of the time.

3.7 Leisure interests and activitiesThis expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".


The lifestyle program offers an extensive range of activities five days a week. There are individual programs for both the mainstream and dementia unit with many activities integrated. There is a daily second exercise class offered on the upper level to cater to all care recipients, especially those individuals that find the morning exercise class too early to attend. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. Lifestyle programs include concerts, bus outings, entertainers, bingo, bocce, happy hour, word games, quizzes, twice-daily exercise classes, knitting, craft, and cooking. Care recipients are given the choice of whether or not to take part in activities. The results of the interviews, document review confirm care recipients and representatives are satisfied with the activities provided to the care recipients. During the three days of the re-accreditation site audit we observed meaningful engagement and obvious enjoyment of the lifestyle program.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients/representatives are asked about end of life wishes and


this information is documented in their file. Religious services are held onsite. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met.

3.9 Choice and decision-makingThis 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".


Management demonstrates each care recipient participates in decisions about the services the home provides and is able to exercise choice and control over their lifestyle through consultation around their individual needs and preferences. Management has an open door policy and this promotes continuous and timely interactions between the management team, care recipients and/or representatives. Observation of staff practices and interviews show care recipients have choices available to them including waking and sleeping times, shower times, meals and activities. Care recipients/representative meetings occur regularly to enable care recipients/representatives to discuss and provide feedback about the services provided. Care recipients and representatives state they are satisfied with the support of the home relative to their choice and decision making processes.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


The home was able to demonstrate care recipients and their representatives have been provided with information about security of tenure and understand care recipients rights and responsibilities. The care recipient handbook and care recipient agreement outlines security of tenure and potential care recipients are supported to consider the contents of the agreement before signing and becoming a resident in the home. Any change of room is only done in consultation with the care recipient and/or their designated representative and seeking their agreement to the change. The Charter of Care Recipients’ Rights and Responsibilities was seen to be on display around the home. Care recipients said they feel secure in the home and understand their rights and responsibilities in living at Arcare Glenhaven.


Standard 4 – Physical environment and safe systemsPrinciple: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Refer to Expected outcome 1.1 Continuous improvement for information about the home's systems to identify and implement improvements. Recent examples of improvements in Standard 4 Physical environment and safe systems are:

The new 5-week rotating menu recently introduced at the home provides care recipients with excellent choice and variety. The catering division invited care recipients to comment and or provide feedback on the menu via a new survey form designed for this purpose. Care recipients are using this to provide feedback and make suggestions regarding their meal preferences. For example, the inclusion of Lambs Fry and Bacon was suggested and trialled. This is providing care recipients with the opportunity to suggest favourite dishes for inclusion on the menu. In addition, the home plans to introduce a care recipients ‘choice dish’ and will ask care recipients to share their favourite recipes.

A food safety program operates in the home's main kitchen and kitchenettes. The home has received an 'A' rating for its food safety program when last audited by NSW Food Authority on 3 March 2018.

A number of initiatives are contributing to the safety and comfort of the environment. For example, the newly introduced colour coded flat mop system is assisting the home to minimise manual handling risk to staff and the risk of spreading infection. In addition, the home has introduced both staff and care recipients vaccination clinics with good result.

The home's has extensive gardens that are easily accessible to care recipients. A recent review of these areas has resulted in a recommendation that a pergola be erected in the garden in Tweed.

The home has reviewed its laundry procedures in relation to the management of lost clothing and has introduced a register, a labelling system and a lost clothes bin to counteract this. The effectiveness of this system is being monitored.

4.2 Regulatory complianceThis 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”.


Refer to Expected outcome 1.2 Regulatory compliance for information about the home's systems to identify and ensure compliance with relevant regulatory requirements. Relevant to Standard 4 Physical environment and safe systems, management are aware of the


regulatory responsibilities in relation to work, health and safety, fire systems and food safety. There are systems to ensure these responsibilities are met.



The home has a system to monitor the knowledge and skills of staff members and enable them to effectively perform their role in relation to physical environment and safe systems. Refer to Expected outcome 1.3 Education and staff development for more information. Examples of education and training provided in relation to Standard 4 Physical environment and safe systems includes incident reporting, fire safety, chemical awareness, infection control, use of equipment, manual handling and food safety.

4.4 Living environmentThis 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".


The home's environment reflects the safety and comfort needs of care recipients, including comfortable temperatures, noise and light levels, sufficient and appropriate furniture and safe, easy access to internal and external areas. All care recipients are accommodated in large private suites with ensuite shower and courtyard and/or balcony access. Care recipients also have access to manicured courtyards and courtyards and to an onsite Café, hairdressing salon, movie theatre/worship room and intimate dining and lounge rooms. A private dining room is available and can be booked for special functions. All areas are accessible via lifts. The safety and comfort of the living environment is assessed and monitored through feedback from meetings, surveys, incident and hazard reporting, audits and inspections. There are appropriate preventative and routine maintenance programs for buildings, furniture, equipment and fittings. Staff support a safe and comfortable environment through hazard, incident and maintenance reporting processes. Care recipients and representatives interviewed are satisfied the living environment is safe and comfortable.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


There are processes to support the provision of a safe working environment, including policies and procedures, staff training, routine and preventative maintenance and incident and hazard reporting mechanisms. Opportunities for improvement in the occupational health and safety program are identified through audits, inspections, supervision of staff practice, and analysis of incident and hazard data. Sufficient goods and equipment are available to support staff in their work and minimise health and safety risks. Staff have an understanding of safe work practices and are provided with opportunities to have input to the home's workplace health and safety program. Staff were observed to carry out their work safely and are satisfied management is actively working to provide a safe working environment.


4.6 Fire, security and other emergenciesThis 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".


Policies and procedures relating to fire, security and other emergencies are documented and accessible to staff; this includes an emergency evacuation plan. Staff are provided with education and training about fire, security and other emergencies when they commence work at the home and on an ongoing basis. Emergency equipment is inspected and maintained and the environment is monitored to minimise risks. There are security procedures and systems to ensure the buildings and grounds are secure. Fire safety risks are minimised through an alarm and detection system, sprinkler system, emergency lighting, fire doors and firefighting equipment. Staff have an understanding of their roles and responsibilities in the event of a fire, security breach or other emergency and there are routine security measures.

Care recipients/representatives interviewed feel safe and secure in the home; they are also satisfied that staff are capable of assisting the care recipient in emergencies.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


The home has processes to support an effective infection control program. The infection control program includes regular assessment of care recipients' clinical care needs in relation to current infections, susceptibility to infections and prevention of infections. Staff and management follow required guidelines for reporting and management of notifiable diseases. Care plans describe specific prevention and management strategies. The home's monitoring processes identify opportunities for improvement in relation to infection control; this includes observation of staff practices, analysis of clinical and infection data and evaluation of results. Preventative measures used to minimise infection include staff training, a food safety program, cleaning regimes, vaccination programs, a pest control program, waste management and laundry processes. Staff are provided with information about infections at the home and have access to policies and procedures and specific equipment to assist in the prevention and management of an infection or outbreak. Care recipients/representatives and staff interviewed are satisfied with the prevention and management of infections.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


The home identifies care recipients' needs and preferences relating to hospitality services on entry to the home through assessment processes and consultation with the care recipient and their representatives. There are processes available that support care recipients to have input into the services provided and the manner of their provision. The home's monitoring processes identify opportunities for improvement in relation to the hospitality services provided; this includes feedback from care recipients and representatives and monitoring of staff practice. Hospitality staff interviewed said they readily have access to information about care recipient preferences and receive feedback about services provided.


Meals are freshly cooked in the main kitchen under the direction of a chef who is responsive to suggestions regarding the meals and to the changing dietary needs of care recipients. The 5-week cyclic menu has been reviewed by a dietitian and provides excellent variety and choice.

Cleaning is carried out by the home's staff according to a schedule with daily cleaning of care recipients' rooms and regular detail cleaning.

Care recipients' personal clothing and linen is laundered in the onsite laundry. Clothes are labelled and recently processes used to manage lost/misplaced clothing were reviewed and strengthened

Care recipients/representatives interviewed are satisfied the hospitality services meet the care recipient's needs and preferences. However, three out of the 21care recipient/representatives interviewed said they liked the food some of the time stating that it was not always to their taste, that there was not enough old fashioned food and that there was not enough soup. Two out of the 21 care recipients/representatives interviewed stated that they hoped the recent changes to the laundry services were effective, as they had previously had problems with missing laundry.


Published_decision_(SA_and_RA) · Web viewMeals are freshly cooked in the main kitchen under the direction of a chef who is responsive to suggestions regarding the meals and to

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