Annesley House - Aged Care Quality€¦ · Annesley House RACS ID 0100 15-19 Marion Street...

Annesley House RACS ID 0100

15-19 Marion Street LEICHHARDT NSW 2040

Approved provider: The Uniting Church in Australia Property Trust (NSW)

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 14 October 2015.

We made our decision on 28 August 2012.

The audit was conducted on 24 July 2012 to 26 July 2012. The assessment team’s report is attached.

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

Home name: Annesley House Date/s of audit: 24 July 2012 to 26 July 2012 RACS ID: 0100

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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 Accreditation Agency

decision

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.

Expected outcome Accreditation Agency decision




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.


decision




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.


decision




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

Annesley House 0100


Introduction This is the report of a re-accreditation audit from 24 July 2012 to 26 July 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents 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, resident 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 Accreditation 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 Accreditation Agency conducted the re-accreditation audit from 24 July 2012 to 26 July 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. 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 1997. Assessment team

Team leader: Greg Foley

Team member/s: Margaret Dawson

Approved provider details


Details of home

Name of home: Annesley House

RACS ID: 0100

Total number of allocated places:

86

Number of residents during audit:

74

Number of high care residents during audit:

28

Special needs catered for:

Mental health issues

Street/PO Box: 15-19 Marion Street State: NSW

City/Town: LEICHHARDT Postcode: 2040

Phone number: 02 9569 7175 Facsimile: 02 9564 5431

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

Facility manager 1 Residents/representatives 16

Deputy manager 1 Music therapist 1

Regional management 10 Art Therapist 1

Care staff 8 Chaplain 1

Administration officer 1 Pastoral carer 1

Visiting medical officer 1 Catering staff 1

Physiotherapist 1 Cleaning contractors 4

Leisure and lifestyle officers 2

Sampled documents

Number Number

Residents’ electronic clinical files including medical notes, progress notes, care plans, and other clinical documentation

6

Social, cultural, spiritual and lifestyle assessments/ attendance and evaluation records

4

Resident weight charts (electronic)

6 Pain management/evaluations/ management plans (electronic)

3

Wound management charts (hard copy)

6 Personnel files 5

Medication charts 6 Service/supplier agreements 4

Resident agreements 5

Other documents reviewed The team also reviewed:

Aged care resident information packages and handbook

Audits and surveys

Cleaning manual, records and inspection reports

Clinical indicator audits trends and evaluations, skin tears, falls, medication and infection control

Competency assessment program and records

Complaints register

Consolidated register of reportable and discretionary incidents

Continuous quality improvement plan

Contractor summary including a list of all service providers and suppliers


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Diabetic management plan and blood glucose monitoring charts, pain management, observations, specialised care needs forms, weigh and bowel charts

Fire and emergency manual and annual fire safety statement

Fire safety systems inspection and testing reports

Food safety manual and records

Hazard register and safety audit records

Infection control universal precaution folder, influenza and gastro information folders, hand washing and various infection control signs

Job descriptions and duty statements

Laundry procedures manual

Learning and development program and training records

Maintenance log, preventative maintenance manual and service reports

Manager’s tool kit – quick reference guide

Medical officer hard copy medical files

Medication administration documentation

Meeting minutes

Menu, dinner requests, dietary assessments and summary sheets

Newsletters

NSW Food Authority licence and audit report

Orientation program

Physiotherapy assessments, progress notes and nursing care plans

Policies and procedures

Record of professional registrations.

Register of criminal record checks

Residents’ social profile and leisure and lifestyle history assessments, consent for distribution of photos, activities calendar, my story and newsletters

Safeguarding your privacy consent forms and photography, video consent forms. Intimacy and privacy information

Staff communication flyers, diary/communication books, memorandums including, handover sheets, allied health and podiatry

Staff orientation pack including staff handbook

Staff roster

Thirty five day assessment schedule for new admissions/resident clinical review task list, aged care assessment team and aged care funding instrument assessments (ACFI)

Observations The team observed the following:

Activities in progress

Charter of residents’ rights and responsibilities on display

Complaints mechanisms including forms, brochures and suggestion box


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Day spa/sensory-wellness room

Dining rooms during lunchtimes, morning and afternoon tea, including resident seating, staff serving/supervising and assistive devices for meals

Equipment available and in use for manual handling include hand rails, ramps, walk belts, mobile walkers and walking sticks

Equipment in use, supplies and storage areas

Fire safety equipment and warning system and evacuation kit

Infection control resources including an outbreak kit

Interactions between clinical/care staff and medical and other health and related services personnel

Interactions between staff, residents, relatives/representatives and visitors

Living environment

Medications being correctly and safely administered and securely stored and medication refrigerator temperatures

Notices of impending Accreditation Site Audit on display throughout the home

Resident and staff noticeboards

Staff work areas


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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 residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The home has a quality management system and is actively pursuing continuous improvement. It is operated by UnitingCare Ageing and uses the organisation’s quality framework for the pursuit of continuous improvement. Areas for improvement are identified through input from all stakeholders using mechanisms that include: improvement logs, regular meetings, feedback mechanisms, a program of audits and surveys and analysis of monitoring data. All opportunities for improvement that are identified are recorded on a continuous improvement plan that enables the planning, implementation and evaluation of the improvements. This process is coordinated by management at the home with the support and oversight of management at a regional level. Residents/representatives and staff are encouraged to actively contribute to this process and those interviewed report they are aware of the ways they can make suggestions for improvement. The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard One and recent examples of this are listed below.

A new online learning and development package was introduced in 2012 by the organisation. It has training modules for all essential training as well as optional modules. It provides a more flexible option for training that can be accessed by all staff. Staff are given time to complete the modules and can access them at their own convenience and work at their own pace. Their participation can be monitored more easily and linked to the staff appraisal system. The feedback from staff and management is positive.

A managers’ toolkit has been introduced by the organisation. It is a quick reference guide to procedures and contacts which provides simple and easy access to essential information for the manager at the home.

Following an audit of equipment the need for new mattresses was identified. In May 2012 all mattresses at the home were replaced. This has resulted in greater comfort for residents, improved infection control and better maintenance of skin integrity.

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 identifies all relevant legislation, regulatory requirements, professional standards and guidelines through information forwarded by government departments, peak industry


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bodies and other aged care and health industry organisations. This information is disseminated to staff through updated policies and procedures, regular meetings, memos and ongoing training. Relevant information is disseminated to residents/representatives through residents’ meetings, notices on display in the home and personal correspondence. Adherence to these requirements is monitored through the home’s continuous quality improvement system, which includes audits conducted internally and by external bodies. Staff practices are monitored regularly to ensure compliance with regulatory requirements. The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard One.

Criminal history record checks have been carried out for all staff and volunteers.

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

Residents/representatives were informed of the reaccreditation site audit in accordance with the Accreditation Grant Principles 2011.

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 There is a system to ensure that management and staff have appropriate knowledge and skills to perform their roles effectively. It includes an education program which is provided by the regional learning and development department and is developed with reference to training needs analysis, performance appraisals, staff input and management assessments. The program includes in-service training by senior staff, training by visiting trainers and suppliers, on-line training modules, subscription to an aged care education service, one to one training on duty, and access to external training and courses. There is also a comprehensive orientation program for all new staff and a buddy system is used to support the new staff during their first days of employment. Records of attendance at training are maintained, the training is evaluated and the effectiveness of the training is monitored through performance appraisals and competency assessments. Management and staff interviewed report they are supported to attend relevant internal and external education and training. Residents/representatives interviewed are of the view staff have the skills and knowledge to perform their roles effectively. Examples of education and training that management and staff attend relating to Accreditation Standard One include:

The orientation program covering such topics as: the organisation’s vision, mission and values and systems and structure of the organisation.

The in-service program covering such topics as: the use of the organisation’s systems for on-line training, appraisals, nurse call and documentation.


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1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Residents/representatives are informed of internal and external complaint mechanisms through the resident handbook, discussion during orientation to the home, notices and at residents’ meetings. Forms for comments and complaints are available in the home and brochures about an external complaint mechanism and an aged care advocacy service are also available. Management maintains a log of all comments and complaints and we noted that issues raised are addressed in a timely manner to the satisfaction of complainants. Residents/representatives can also raise concerns and identify opportunities for improvement through resident meetings, satisfaction surveys and informally. The home has an open door policy and we observed residents taking advantage of this to speak directly with management and staff. Residents also have regular access to individual consultations with medical professionals and the chaplain where concerns can be raised privately. Residents/representatives interviewed say they are aware of how to make a comment or complaint and feel confident concerns are addressed appropriately. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The vision, values, philosophy and commitment to quality are well documented and on display in the home. They are also available to all residents/representatives, staff and other stakeholders in a variety of documents used in the home. Vision, mission and values are an integral part of the orientation program and all staff are required to abide by a code of ethical behaviour that is aimed at upholding the rights of residents and the home’s vision, values and commitment to quality. Feedback from residents/representatives and staff and observations of staff interaction with residents demonstrated the vision and values of the home underpin the care provided to the residents. 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 Management has systems to ensure there are appropriately skilled and qualified staff to meet the needs of the residents. New staff are screened through the recruitment process to ensure they have the required skills, experience, knowledge and qualifications for their roles. The orientation and education program, outlined in expected outcome 1.3 Education and staff development, provide the staff with further opportunities to enhance their knowledge and skills. There are job descriptions for all positions and policies and procedures provide guidelines for all staff. The staffing mix and levels are determined with reference to residents’ needs, a range of clinical monitoring data and feedback from staff and


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residents/representatives. Relief staff are drawn from existing permanent and casual staff to ensure any vacancies that arise in the roster are filled. The performance of staff is monitored through annual appraisals, competencies, meetings, audits, the feedback mechanisms of the home and ongoing observations by management. Staff interviewed said they have sufficient time to complete their designated tasks and meet residents’ needs. Residents/representatives interviewed report their satisfaction with the care provided by the staff. 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 demonstrated it has a system to ensure the availability of stocks of appropriate goods and equipment for quality service delivery. There are processes to identify the need to re-order goods, address concerns about poor quality goods, maintain equipment in safe working order and replace equipment. Supplier agreements are established and monitored by the organisation with authority for ordering delegated to management at the home. The acquisition of new equipment is managed by the regional office and management say the home is well supplied. Maintenance records show equipment is serviced in accordance with a regular schedule and reactive work is completed in a timely manner. The system is monitored through regular evaluations, audits, surveys, meetings and the feedback mechanisms of the home. Staff confirm they have sufficient stocks of appropriate goods and equipment to care for residents and are aware of procedures to obtain additional supplies when needed. 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 There are information management systems to provide management and staff with information to perform their roles effectively and keep residents/representatives well informed. Assessments and clinical care notes, which are regularly reviewed, provide the necessary information for effective care. A password protected computer system facilitates electronic administration, clinical documentation and access to the internet, the organisation’s intranet and e-mail communication. Policy and procedure manuals and job descriptions clearly outline correct work practices and responsibilities for staff. Residents/representatives receive information when they come to the home and through meetings, notices and newsletters. Mechanisms used to facilitate communication between and amongst management and staff are meetings, memos, communication books, handover sheets, feedback and reporting forms and notices. All personal information is collected and stored securely and there are procedures for archiving documents in accordance with regulatory requirements. Staff and residents/representatives interviewed report they are kept well informed and consulted about matters that impact on them.


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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 There is a system to ensure all externally sourced services are provided in a way that meets the home’s needs and service quality goals. The home accesses externally sourced services to meet needs across the four Accreditation Standards from a list of service providers who have been approved by the organisation. Service agreements are entered into with contractors for the provision of services and all external service providers are required to have current licences, insurance and comply with relevant legislation and regulatory requirements. There are schedules for all routine maintenance work to be undertaken by contractors and there is a list of pre-selected contractors who are used on a needs basis. Residents are able to access external services such as hairdressing, podiatry and other allied health professionals. The services provided are monitored by management at a local and organisational level through regular evaluations, audits and the feedback mechanisms of the home and there is a system for managing non-conformance of service providers. Residents/representatives, staff and management interviewed say they are satisfied with the external services provided.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement. The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Two and recent examples of this are listed below.

Management identified a gap in the availability of specialist psychiatric services for residents under the age of 65. Arrangements have been made for a psychiatrist to visit the home on a weekly basis to provide this service. This has filled the gap and reduces the need for hospitalisation. Residents can be reviewed more frequently and the presence of the psychiatrist on site allows for a more consultative approach to care between the doctor and the registered nurse at the home.

Due to the increased needs of residents a falls prevention program has been established. A physiotherapist visits the home each week to assess the mobility needs of residents and provide individual treatment as required. Group exercises are run by care staff. This provides more regular physiotherapy service and improved outcomes for residents.

In response to a need for a more systematic approach to the management of continence aids the system was reviewed in consultation with the supplier. A new bag system for continence aids was introduced for each resident who requires the aids. The daily allocation of continence aids is stored in the bags assuring the correct size and number of pads is set out for the right time. This has resulted in more efficient and accurate management of the continence aids and improved comfort and care for residents.

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. The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Two.

A record is kept of the current registration of registered nurses and other health care professionals.

Medications are administered safely and correctly in accordance with current regulations and guidelines.


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The home has a policy and procedures for the notification of unexplained absences of residents and maintains a register for recording these incidents.

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 details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of education and training that management and staff attend relating to Accreditation Standard Two include:

The in-service program and one to one training provided by the clinical nurse educator covering such topics as: clinical care, medication administration, oral and dental care, and personal care.

An external course on mental health first aid.

Annual clinical assessment of competency for medication administration for all staff who administer medication.

The deputy manager is currently enrolled in studies to become a registered nurse. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home has a system to assess, implement, evaluate and communicate the residents’ clinical care needs and preferences. The review of residents’ files demonstrated the home regularly assesses the residents’ clinical care needs and updates care plans in collaboration with the residents, representatives and the relevant health professionals. The home uses validated assessment tools and evidence based interventions to meet the ongoing needs of the residents. Interviews with staff indicated they have the knowledge and skills to deliver clinical care in line with residents’ care plans and the home’s policies. The home regularly evaluates and improves assessment tools, care planning, care delivery and staff practices. Residents/representatives expressed satisfaction with the care provided to residents. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Interviews with staff and documentation demonstrated residents’ specialised nursing care needs are identified and managed by appropriately qualified staff as required. The home has processes for staff to consult on best practice care with external specialists (psychiatrist, psychiatric mental health team, wound care and diabetic management) if required. Interviews


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with staff demonstrated they have the knowledge and skills to assess, manage and evaluate specialised nursing care. Documentation showed the staff use evidence based assessment tools and interventions to deliver specialised care. The home monitors staff practices and provides education which includes specialised nursing care. Interviews with residents/representatives indicated they are satisfied with the specialised nursing care provided to residents. 2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome The home has an effective system to refer residents to health services such as allied health to meet the residents’ needs and preferences. Documentation demonstrated residents’ needs are assessed on entry and at regular intervals and referrals are planned, documented, communicated and followed up by staff. Staff interviews demonstrated they have a good understanding of the referral process and the procedure to assist residents to access appointments with external health and related services. Residents/representatives communicated the home informs and supports residents to access health specialists and they are satisfied with the home’s referral process for residents to other health and related services. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome The home has an effective system to manage residents’ medications safely and correctly. It has policies and procedures and medication audits are carried out and reviewed through the home’s quality improvement process. Medications are reviewed regularly and adjusted accordingly in consultation with residents/representatives. Observations showed the home has an effective medication dispensing process, safe storage of medications and appropriate qualified staff to manage medications. Regular education and competency assessments are undertaken for staff on medication management. Interviews with staff confirmed practices are consistent with policies and procedures and incidents are reported, followed up and linked into the home’s continuous improvement system. The resident/representative interviews verified they are satisfied with the way the home manages residents’ medications. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome The home has processes to assess and monitor pain and develop care plans to ensure residents are as free as possible from pain. Documentation demonstrated interventions are reported in the residents’ care plans and depending on the residents’ needs and preferences pharmacological and/or non-pharmacological interventions are implemented and reviewed regularly. Interviews with staff demonstrated they have an understanding of individual resident’s pain requirements and the home’s pain management policies and procedures. The


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home seeks best practice pain management advice and education from external health services to meet the needs of residents with complex pain. Interviews with residents/representatives indicated they are satisfied with residents’ pain management programs. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome The home has policies and procedures to guide staff in the provision of palliative care and implements individual end of life wishes to meet residents’ care needs with dignity and comfort. Interviews with staff demonstrated they have the knowledge and skills to care for palliative care residents who require it. The home seeks palliative care advice and education from external specialty services to ensure best practice and residents who require high levels of palliative care are transferred to hospital. Interviews with residents/representatives verified they are satisfied with the care and the emotional and spiritual support given to residents’ end of life issues. They are also content with the home’s approach to maintaining residents’ comfort and dignity. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome The home has a system to ensure regular assessment, communication, monitoring and updating of residents’ nutritional and hydration status, and specific needs and preferences (including awareness of cultural, religious, allergies and medical requirements). Interviews with staff and residents/representatives revealed nutrition and hydration care plans are developed with a multidisciplinary approach and linked to the general care process. Documentation showed special diets, dietary supplements, extra fluids, and appropriate referrals are provided for residents. Observations showed that staff assist residents at meal times as required. The home has a process for residents/representatives to provide feedback and make suggestions about the meals provided at the home. Residents/representatives stated residents’ preferences are documented and delivered and they are satisfied with the meals and drinks provided to residents. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The home has policies and procedures to maintain skin integrity consistent with the residents’ health. Documentation and staff interviews showed the residents’ skin care needs are assessed on entry and at regular intervals. This information is documented and communicated in the residents’ care plans and these are regularly evaluated and updated. The assessment and care plan process is completed in consultation with the


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residents/representatives and medical practitioners. Interviews with staff demonstrated they know how to assist residents to care for their skin and they record skin irregularities and report incidents. The home has procedures to identify and monitor residents at risk of impairment to skin integrity and interventions and aids to protect skin integrity. Interviews with residents/representatives indicated they are satisfied with the skin care provided to residents. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome The home has a system to ensure that residents’ continence needs are effectively managed. Documentation and staff interviews confirmed that continence is managed through initial and ongoing assessments and individualised care plans with input from the residents/representatives and other appropriate health professionals. The residents’ continence interventions are regularly monitored and evaluated for effectiveness and changes communicated to staff. Observation confirmed the home has appropriate continence aids to meet the residents’ needs and preferences. Interviews with staff demonstrated they understand the residents’ continence needs and preferences. Residents/representatives expressed satisfaction with the residents’ continence management programs. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The home has appropriate behaviour management policies, procedures and interventions to care for residents with challenging behaviours. Documentation showed the home uses validated assessment tools to assess residents’ behavioural needs on admission and at regular intervals in consultation with residents/representatives and appropriate health professionals. Care plans are developed and regularly updated and the home consults with psychiatrists and external mental health services to ensure interventions meet the needs of individual residents. Interviews with staff demonstrated they have the knowledge and skills to effectively implement individualised behaviour management strategies for the residents. Interviews with residents/representatives indicated they are satisfied with the way the home manages residents with challenging behaviours. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome The home has policies and practices to support residents to maintain optimum mobility and dexterity. Interviews with staff and documentation demonstrated the physiotherapist does mobility and dexterity assessments and interventions are communicated in the residents’ care plans. The care plans are developed and reviewed regularly in collaboration with


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residents/representatives and appropriate health professionals. Documentation and staff interviews verified the activity program, which includes gentle exercise and art and craft activities, is designed to maintain residents’ mobility and dexterity. Observations showed residents participating in activities to optimise their mobility and dexterity. Staff interviews verified there are adequate mobility and independent living aids available to meet the residents’ needs and preferences. The effectiveness of the program is assessed through audits, monitoring of staff practices, regular review of residents’ care plans and falls incident/accident reports. Residents/representatives stated they are satisfied with the care provided to maintain and enhance the residents’ mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome The oral and dental health of residents is assessed on admission in consultation with residents/representatives and other appropriate health professionals and a care plan is developed to meet each resident’s needs and preferences. The home has policies and processes to regularly monitor and review residents’ ongoing oral and dental heath needs, Referrals are also facilitated to appropriate heath professionals (such as dentists and dental technicians). Interviews with staff demonstrated they have the knowledge and skills to deliver care consistent with the residents’ oral and dental needs and preferences. Residents/representatives indicated they are satisfied with the oral and dental care provided to residents. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome The home has a system to ensure that residents’ sensory losses are identified and managed effectively in consultation with residents/representatives and external health professionals and services. Documentation identified senses are assessed on entry to the home, reviewed regularly and care plans are developed to communicate the residents’ needs and preferences. Interviews with staff showed they have the knowledge and skills and the home has links to the relevant support services (such as vision and hearing impaired services) to ensure optimal support for residents’ with sensory losses. Observations verified the home has a sensory program for residents and this includes a sensory-wellness room, massage therapy and a variety of activities facilitated by the lifestyle team. Documentation and staff interviews verified these therapies and activities are monitored and evaluated to ensure they meet the individual needs and preferences of the residents. Residents/representatives stated they are very satisfied with the home’s management of the residents’ sensory needs.


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2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome The home has a system to assist residents to achieve natural sleep patterns. Documentation showed the home assesses sleep patterns in consultation with medical practitioners, residents/representatives and with consideration for related pain and behaviour management issues. Care plans are developed to communicate the residents’ care needs and preferences in relation to sleep patterns. Staff demonstrated they are aware of residents’ sleep patterns and strategies to assist residents who have difficulty sleeping. There is usually minimal noise at night providing an environment which is conducive of sleep. Residents/representatives stated they are satisfied with the home’s approach to achieving natural sleep patterns for residents


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement. The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Three and recent examples of this are listed below.

At the suggestion of the recreational activities officer a sensory room was established. It is called the ‘day spa’ and has been fitted with lounge chairs, a sound system, special lighting and curtains for privacy. The residents were consulted and assisted in setting it up. Activities such as manicures, pedicures and aromatherapy are programmed to take place with the activities officer and the residents can use it themselves as a quiet room. The day spa is an extra resource that can enhance residents’ lifestyle and residents say they appreciate the new space.

Management recognised the lack of privacy when visiting doctors used the treatment room for consultations. In response a separate consultation room was established for visiting medical professionals. The new consultation room and the treatment room were both renovated to create more effective work spaces. It has resulted in greater privacy for residents and doctors who are no longer being interrupted by nurses accessing the treatment room. It has also meant there is improved access to the treatment room for other residents who no longer have to wait while consultations take place.

At the suggestion of residents a number of new group activities have been introduced. There are now weekly visits to a local gymnasium, to a local café and to the local cinema. To cater for residents who do not join in the outing to the cinema an in-house cinema experience has been introduced to the activities program. Residents enjoy the added variety of these activities.

3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s 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. The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Three.


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Information is provided to residents/representatives in the resident handbook and the resident agreement regarding residents’ rights and responsibilities including security of tenure and the care and services to be provided to them.

The Charter of residents’ rights and responsibilities is included in the resident handbook and displayed in the home.

Staff are trained in residents’ rights and responsibilities in their orientation program and sign a code of ethical behaviour to ensure residents’ rights are respected.

The home has a policy and procedures for the mandatory reporting of alleged and suspected assaults and maintains a register of these incidents.

Training has been provided for staff on the mandatory reporting of elder abuse. 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 details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of education and training that management and staff attend relating to Accreditation Standard Three include:

The orientation program covering such topics as the code of ethical behaviour.

Compulsory training on the mandatory reporting of elder abuse.

The in-service program covering such topics as: resident lifestyle and guardianship and consent.

The quarterly regional recreational activities officer meetings which include training, guest speakers and opportunities for networking.

3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home has a system to support residents while they adjust to life in the new environment and during their stay. Review of residents’ files showed social, cultural and spiritual history and support needs are recorded on entry. This information is used to develop a care plan with strategies to support the individual emotional needs of each resident and this is regularly reviewed and evaluated. The leisure and activity staff spend time with new residents and pastoral care is available to support residents and their families. Residents/representatives stated residents have adequate support to adjust to their new life. They are also satisfied with the ongoing emotional, pastoral and spiritual support that residents and their representatives receive.


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3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome There is an effective system to assist residents to maintain their independence and links with their friends and the community outside of the home. On entry to and at regular intervals residents are assessed for what independence means to them and how this can be achieved in relation to physical, emotional, cultural, social, and financial aspects of their lives. This information and the agreed strategies to promote independence are communicated in an individualised care plan and this is regularly evaluated and revised as needed. Observation confirms the home provides equipment, aids, qualified staff and programs (leisure, physical and spiritual therapy) to assist residents’ with mobility, dexterity, communication and cognitive needs. The leisure program supports residents to undertake regular community outings. Interviews with residents/representatives verified residents are encouraged and supported to be independent with care and lifestyle needs, mobility and decision-making. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome There are policies and procedures and a mechanism to log and address concerns/complaints in relation to privacy, dignity and confidentiality. Interviews with staff showed they understand each resident has a right to privacy, dignity and confidentiality. Observations demonstrated that residents’ information is securely stored and staff attend to residents’ care needs in a respectful and courteous manner. Information on residents’ rights and responsibilities is given to new residents and displayed. There are also attractive common areas that are used by residents and visitors. Residents/representatives verified staff understand and respect residents’ rights to privacy, dignity and confidentiality. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome There is a comprehensive individualised lifestyle program offered to all residents. Staff interviews and documentation confirmed the program is developed from information obtained from residents/representatives about their interests, hobbies, life stories and special life events. There is an activities coordinator and activity staff who plan and implement the home’s lifestyle program. The residents have the choice of attending a variety of activities held within and outside the home. One to one activities are provided for residents who are unable to benefit from group sessions or choose not to participate. Interviews with residents/representatives showed they are very satisfied with the residents’ leisure activities program.


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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 The home has a system to promote residents’ individual interests and to ensure their customs, beliefs and cultural and ethnic backgrounds are fostered and respected. Documentation on entry showed each resident’s cultural and spiritual needs are identified and communicated in a care plan. This care plan is regularly reviewed and updated in collaboration with the resident/representative. The home facilitates religious services and chaplain and pastoral care visits meet the needs and preferences of the residents. Cultural days and personal significant days are celebrated at the home. Interviews with staff demonstrated they know and understand the needs of residents from other cultures. Interviews with residents/representatives indicated they are satisfied with the way the home values and supports residents’ cultural and spiritual needs. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home has systems to ensure each resident is able to exercise choice and control over their care and lifestyle. Documentation showed each resident’s specific needs and preferences are documented and communicated to staff and external health service providers. The residents’ care plans are evaluated and reviewed regularly in collaboration with residents/representatives. Documentation showed residents’ meetings are held and residents are encouraged to express their views about care and service provision. Resident and staff interviews verified residents make choices about their meals, personal and health care, health professionals, environment and activities as long as they don’t infringe on the rights of other residents. Residents/representatives report satisfaction with their level of participation in decision-making and residents’ ability to make choices while living at the home. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome The home has systems to ensure residents have secure tenure within the residential care service and understand their rights and responsibilities. New residents and their representatives are offered comprehensive information regarding their rights and responsibilities and are offered a resident agreement to formalise occupancy arrangements. Residents are provided with the opportunity to have the contents of the agreement with fees and charges fully discussed before entry. Residents/representatives are consulted regarding room changes or alternative accommodation should the need arise and state they are satisfied with the information the home provides regarding their security of tenure and rights and responsibilities.


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement. The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Four and recent examples of this are listed below.

In 2011 the nurse call system was updated. In addition to bedside call bells buttons were placed strategically on the walls as an extra option to call nurses. Nurse call pendants were introduced for all residents so they can call for assistance anywhere in the building or in the grounds. New displays were installed at the nurses’ station and around the building to more readily identify any calls and the pagers worn by staff are now linked to the system as well. This has resulted in better access to staff and improved safety for residents.

A building audit in 2012 identified a number of areas as needing refurbishment. In response: 16 rooms were repainted, blinds and curtains in 20 rooms were replaced, the flooring in three rooms was replaced and a number of cupboards were repaired. This has resulted in an improvement to the living environment of residents.

Following a review of the fire safety system the manager and another staff member completed fire safety officer training. The staff member has been delegated the responsibility of monitoring the fire safety program at the home so there can be a more coordinated approach to fire safety at the home.

As a result of an emergency in June 2012 management identified the need for better communication between staff. Digital cordless phones were introduced for all care staff so that they are able to have instant contact with all other staff on site. This provides an improved communication system and better preparedness for emergencies.

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. The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Four.


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The team was shown records indicating and observed that thermostatic valves and electrical equipment is being inspected, tested and maintained in accordance with work health and safety regulations.

A review of records and observations showed fire safety equipment is being inspected, tested and maintained in accordance with fire safety regulations and the annual fire safety statement is on display in the home.

A review of staff training records and interviews with staff indicates that staff have fulfilled the mandatory fire awareness and evacuation training.

The home has a NSW Food Authority licence as required by the Vulnerable Persons Food Safety Scheme and the home has a food safety program.

Safety data sheets (SDS) are displayed adjacent to the chemicals to which they refer. 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 details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of education and training that management and staff attend relating to Accreditation Standard Four include:

Mandatory training for all staff at orientation and annually in; infection control, fire awareness and evacuation, work health and safety, manual handling and food safety.

The in-service program which included training in fine dining and service of residents.

Extra food safety training for all catering staff.

An external fire safety officer course for the manager and one personal care assistant. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s findings The home meets this expected outcome Management is actively working to provide a safe and comfortable environment consistent with residents’ care needs. All residents are accommodated in individual rooms and residents have personalised their own rooms. The living environment is clean, well furnished, well lit and free of clutter. The buildings and grounds are well maintained with a program of preventative and routine maintenance. The safety and comfort of the living environment is monitored through environmental inspections, resident/representative feedback, incident and hazard reports, audits and observation by staff. Residents/representatives interviewed express their satisfaction with the living environment.


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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 Management has a system to provide a safe working environment that meets regulatory requirements. There is a regional health, safety and wellbeing committee, which includes a representative from the home, to oversee work health and safety across the organisation and at the home. All staff are trained in manual handling, work health and safety and fire awareness and evacuation procedures during their orientation and on an on-going basis. There is a maintenance program to ensure the working environment and all equipment is safe. The home monitors the working environment and the work health and safety of staff through regular audits, risk and hazard assessments, incident and accident reporting and daily observations by management and staff. The staff interviewed show they have a knowledge and understanding of safe work practices and were observed carrying them out. 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 There is a system to provide an environment and safe systems of work that minimise fire, security and emergency risks. A trained fire safety officer oversees fire safety at the home and all staff take part in mandatory training in fire awareness and evacuation procedures. The home is fitted with appropriate fire fighting equipment and warning systems and inspection of the external contractor records and equipment tagging confirms the fire fighting equipment is regularly maintained. The current annual fire safety statement is on display and emergency flipcharts and evacuation plans are located throughout the home. The fire and emergencies manual outlines the correct procedures to be followed in the case of an emergency and there is an evacuation folder and kit which includes a current list of residents and other essential information. Security is maintained by keyed entry at all times and a lock-up procedure at night. The systems to minimise fire, security and emergency risks are monitored through internal audits, external inspections, at staff team meetings and through regional review. Staff interviewed indicate they know what to do in the event of an emergency and residents interviewed say they feel safe in the 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 ensures its infection control program is effective through clear policies and procedures, education and an infection surveillance program. Management coordinates the program with the support and supervision of the organisation. The home has mandatory training in infection control and hand washing competencies are assessed. Hand washing facilities, personal protective equipment and other equipment is available to enable staff to carry out infection control procedures. The infection control program also includes an outbreak management policy and kits, a food safety program used in the kitchen, a vaccination program for residents and staff, pest control and waste management. The staff


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interviewed show they have a knowledge and understanding of infection control and were observed implementing the program. The program is monitored through reporting of all infections, trend analysis, audits, benchmarking and organisational review. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome The hospitality services provided are meeting the needs of the residents and are enhancing their quality of life. There is a rotating menu that provides choice and variety of meals and all meals are cooked fresh on site. The menu has been reviewed by a nutritionist and caters for special diets and for the individual needs and preferences of residents. The chef is responsive to suggestions regarding the meals and to the changing dietary needs of residents. The home is cleaned by full time contract cleaners and is carried out according to a schedule. The quality of the cleaning is monitored by the management and staff of the home and the contractor supervisor and we observed the home to be clean. Personal clothing is laundered at the home by care staff and the linen is laundered off site by a contractor. Residents also have the choice of washing their own clothes if they wish. The hospitality services are monitored through audits, surveys, meetings and the feedback mechanisms of the home. Residents/representatives interviewed say they are satisfied with the hospitality services provided.

Annesley House - Aged Care Quality€¦ · Annesley House RACS ID 0100 15-19 Marion Street...

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