Decision to Accredit Wingham Court Nursing Home · Decision to Accredit. Wingham Court Nursing Home...

Decision to Accredit

Wingham Court Nursing Home

The Aged Care Standards and Accreditation Agency Ltd has decided to Accredit Wingham Court Nursing Home in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Wingham Court Nursing Home is 3 years until 5 February 2012. The Agency has found the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. This is shown in the ‘Agency findings’ column appended to the following executive summary of the assessment team’s site audit report. The Agency is satisfied the home will undertake continuous improvement measured against the Accreditation Standards. The Agency will undertake support contacts to monitor compliance with the Accreditation Standards.

Information considered in making an accreditation decision The Agency has taken into account the following: • the desk audit report and site audit report received from the assessment team; and • information (if any) received from the Secretary of the Department of Health and Ageing;

and • other information (if any) received from the approved provider including actions taken

since the audit; and • whether the decision-maker is satisfied that the residential care home will undertake

continuous improvement measured against the Accreditation Standards, if it is accredited.

Home and Approved provider details Details of the home Home’s name: Wingham Court Nursing Home

RACS ID: 2632

Number of beds: 49 Number of high care residents: 43

Special needs group catered for: Nil

Street/PO Box: Primrose Road

City: WINGHAM State: NSW Postcode: 2429

Phone: 02 6553 4855 Facsimile: 02 6557 0336

Email address: [email protected]

Approved provider Approved provider: The Frank Whiddon Masonic Homes of NSW

Assessment team Team leader: Jennifer Woodman

Team member/s: Penelope Dobell-Brown

Date/s of audit: 10 November 2008 to 14 November 2008

Home name: Wingham Court Nursing Home Date/s of audit: 10 November 2008 to 14 November 2008 RACS ID: 2632 AS_RP_00851 v2.1

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Executive summary of assessment team’s report Accreditation decision

Standard 1: Management systems, staffing and organisational development

Expected outcome Assessment team recommendations

Agency findings

1.1 Continuous improvement Does comply Does comply 1.2 Regulatory compliance Does comply Does comply 1.3 Education and staff development Does comply Does comply 1.4 Comments and complaints Does comply Does comply 1.5 Planning and leadership Does comply Does comply 1.6 Human resource management Does comply Does comply 1.7 Inventory and equipment Does comply Does comply 1.8 Information systems Does comply Does comply 1.9 External services Does comply Does comply

Standard 2: Health and personal care


Agency findings

2.1 Continuous improvement Does comply Does comply 2.2 Regulatory compliance Does comply Does comply 2.3 Education and staff development Does comply Does comply 2.4 Clinical care Does comply Does comply 2.5 Specialised nursing care needs Does comply Does comply 2.6 Other health and related services Does comply Does comply 2.7 Medication management Does comply Does comply 2.8 Pain management Does comply Does comply 2.9 Palliative care Does comply Does comply 2.10 Nutrition and hydration Does comply Does comply 2.11 Skin care Does comply Does comply 2.12 Continence management Does comply Does comply 2.13 Behavioural management Does comply Does comply 2.14 Mobility, dexterity and rehabilitation Does comply Does comply 2.15 Oral and dental care Does comply Does comply 2.16 Sensory loss Does comply Does comply 2.17 Sleep Does comply Does comply


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Executive summary of assessment team’s report Accreditation decision

Standard 3: Resident lifestyle


Agency findings

3.1 Continuous improvement Does comply Does comply

3.2 Regulatory compliance Does comply Does comply

3.3 Education and staff development Does comply Does comply

3.4 Emotional support Does comply Does comply

3.5 Independence Does comply Does comply

3.6 Privacy and dignity Does comply Does comply

3.7 Leisure interests and activities Does comply Does comply

3.8 Cultural and spiritual life Does comply Does comply

3.9 Choice and decision-making Does comply Does comply

3.10 Resident security of tenure and responsibilities

Does comply Does comply

Standard 4: Physical environment and safe systems


Agency findings

4.1 Continuous improvement Does comply Does comply

4.2 Regulatory compliance Does comply Does comply

4.3 Education and staff development Does comply Does comply

4.4 Living environment Does comply Does comply

4.5 Occupational health and safety Does comply Does comply

4.6 Fire, security and other emergencies Does comply Does comply

4.7 Infection control Does comply Does comply

4.8 Catering, cleaning and laundry services

Does comply Does comply


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Assessment team’s reasons for recommendations to the Agency The assessment team’s recommendations about the home’s compliance with the Accreditation Standards are set out below. Please note the Agency may have findings different from these recommendations.

SITE AUDIT REPORT

Name of Home Wingham Court Nursing Home

RACS ID 2632 Executive summary This is the report of a site audit of Wingham Court Nursing Home 2632 Primrose Road WINGHAM NSW from 10 November 2008 to 14 November 2008 submitted to the Aged Care Standards and Accreditation Agency Ltd. on 20 November 2008. Assessment team’s recommendation regarding compliance The assessment team considers that the information obtained through audit of the home indicates that the home complies with • 44 expected outcomes Assessment team’s recommendation regarding accreditation The assessment team recommends that the Aged Care Standards and Accreditation Agency Ltd accredit Wingham Court Nursing Home. The assessment team recommends that the period of accreditation be 3 years. Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and believes the home complies with 44 of the 44 expected outcomes of the Accreditation Standards.

Name of home: Wingham Court Nursing Home RACS ID 2632 AS_RP_00857 v1.0 Dates of site audit: 10 November 2008 to 14 November 2008


Site Audit Report Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 10 November 2008 to 14 November 2008 The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of 2 registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team Team Leader: Jennifer Woodman

Team Member/s: Penelope Dobell-Brown

Approved provider details Approved provider: The Frank Whiddon Masonic Homes of NSW

Details of home Name of home: Wingham Court Nursing Home

RACS ID: 2632

Total number of allocated places:

49

Number of residents during site audit:

43

Number of high care residents during site audit:

43

Special need catered for:

Nil

Street/PO Box: Primrose Road State: NSW

City/Town: WINGHAM Postcode: 2429

Phone number: 02 6553 4855 Facsimile: 02 6557 0336 E-mail address: [email protected]


Assessment team’s recommendation regarding accreditation The assessment team recommends that the Aged Care Standards and Accreditation Agency Ltd accredit Wingham Court Nursing Home. The assessment team recommends the period of accreditation be 3 years. Assessment team’s recommendation regarding support contacts The assessment team recommends there should be 2 support contacts during the period of accreditation and the first should be within 12 months. Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and believes the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. Audit trail The assessment team spent 5 days on-site and gathered information from the following: Interviews Number Number

Manager education and quality (The Whiddon Group)

1 Clients (residents) 9

Director of care services 1 Relatives 4

Deputy director of care services

1 Volunteers 1

Registered nurses 2 Recreational activity officers 2

Endorsed enrolled nurses/ enrolled nurses

3 Laundry staff 1

Assistant-in-nursing 6 Cleaning staff 1

Administration assistant 1 Maintenance staff 1

Catering staff 2

Sampled documents Number Number

Clients’ (residents’) files 9 Medication charts 27

Summary/quick reference care plans 9

Comprehensive medical assessments

7

Nurse initiated medications forms 27

Medication Management Reports

8

high care agreements 2 Personnel files 6

Observation Charts 12 Wound Management Charts 9


Other documents reviewed The team also reviewed: • Accident and incident reporting system: database • Activities program: monthly schedule and participation reports; daily program and

attendance records • Admission documents: checklist for entry, medical information and care needs,

application for residency, admission form, financials, privacy, electoral enrolment, activity authority forms, authority and review of restraint, client agreement and specified care services

• Aged Care Certification Assessment results • Aromatherapy assessments and care plans • Audit program 2008 – schedule and results • Audit report and strategic plan for audit conducted Sept 2008 • Care plans – ‘Plan of Care’; plan of care review forms • Certificates, competency completion, and course preferences lists • Charts: special care charts, wound charts, observation charts, pain management flow

chart • Cleaning schedule, ‘sign off’ sheets and summaries • Client (resident) ‘welcome’ pack and corporate information handbook • Client satisfaction surveys (Feb 2008 and Oct 2008) • Clinical assessment forms: physical; end of life directive; medication and care needs;

dietary and nutrition care needs; continence; behaviour; falls risk; restraint; skincare ; pain; mobility; manual handling; physiotherapy; sleep pattern; weight loss; oral and dental; personal hygiene; communication and sensory; PAS cognitive scale; depression; aromatherapy; basic foot care assessment

• Comments and complaints folder; feedback forms: ‘I have an idea’, ‘Thank you’ • Communication book, diary of appointments • Complaint/ comment/ compliment reporting sheet • Contractors rule booklet, acknowledgement of receipt of contractors rule booklet, letters

of acceptance and contracts, professional insurances, certificates of currency • Dietary needs and preference sheets • Doctors’ communication book • Documentation requirements, audits and forms folder • Education needs and wants - appraisal 2008; training and development needs analysis

(2008 and 2009) • Education planner (2008), education records, education system review documentation • Effective workplace relationships (training program) • Equipment maintenance service records • External audit results and benchmarking (Sept 2008) • Fire safety orientation and induction guide • Fire safety system and equipment maintenance service reports, fire safety inspection

reports (monthly); emergency lighting records, fire egress and equipment layout • First aid certificate register • Food safety plan; kitchen pre-operational checklist; kitchen cleaning records ‘sign off’;

fresh produce sanitisation records, goods received records • General pest inspection reports • Gentle exercise and walking program • Handover sheets • Infection incident and prevalence and antimicrobial utilisation – monthly chart • Intranet communication and information systems


• Inventory folder: lists and logs showing condition of items, stores lists, chemical log, equipment replacement plan, painting plan, forms list, schedule for policy review.

• Job descriptions and duty statements • Laundry procedure ‘sign off’ sheets for functions such as washing curtains, lifter belts,

bath mats, bedspreads, delicates • Letter: site is approved for clinical experience for student enrolled nurses • Manuals: human resource; infection control; food safety plan; support services manual

(2008); safe work practices: maintenance; recreation; administration; maintenance; kitchen; personal care; laundry.

• Medication incidents file, medication error reports • Medication management review reports • Meeting Minutes 2008: quality committee, occupational health and safety, nurses

(RN/EEN), care staff, clients (residents), support staff, medication advisory committee (MAC), care service employees (CSE) staff, supervisory committee, recreational activity officers (RAO)

• Meeting schedule 2008 • Memo folder for staff; memoranda 2008 • Mission, Values and commitment to quality statements • Monthly education attendance register • Monthly infections report, monthly skin tear reports • New client and 12 month assessments list • New client assessments: pain management; skin care; continence care; mobility,

dexterity and rehabilitation; oral and dental; sensory loss; sleep care; nutrition & hydration; palliative care; specialised nursing care; medication administration care; emotional care; leisure interests and activities; cultural and spiritual care; activities of daily living; hair and nail care; safety; behaviour management care.

• NSW Food Authority audit report (May 2008) and completed action plan • NSW Food Authority License (11 Sept 2009) • NSW Public Health notification and line listing • Nurse initiated medication list (NIM) • Occupational health and safety folder • Orientation: checklist; power point presentation; schedule for existing staff (Sept to Dec

2008) • Pain treatment records • Pharmacy notification form • Physio exercises folder • Physiotherapy aide education record • Podiatry chart and book • Police check folder: volunteers, contractors and students • Policies and procedures - The Whiddon Group Wingham • Preventative maintenance program and ‘sign off’ records • Priority action plan – resident and relative survey Jan – Oct 2008 • Privacy agreements (staff) • Quality folder (2008) • RAO assessments: leisure assessment, social and human needs • RAO monthly report to director of care services • Registration folder: registered nurses, enrolled nurses, medical officers, physiotherapist,

aromatherapist, bus driver license • Resident movement book • Resident satisfaction survey results (combined survey)


• Risk management system: risk management folder, hazard reporting logs, action plans, workplace inspection checklists, water testing for legionella documents, thermo mixing valve temperature checks

• Staff appraisals: annual performance plans; training and development plans; competency assessments

• Staff handbook • Staff satisfaction survey; staff survey results and priority action plan (Sept 2008) • Shower book • Strategic plan 2006-2008 • Temperature records – medication fridge; main kitchen; daily food production; fridges,

freezers and cool room; hostel servery; Bain Marie temperature records servery; laundry • The Whiddon Group News – Wingham (Sept 2008) • The Whiddon Group Wingham – quality improvement log summary (2007-2008) • Therapy tracking sheets • Visitors and contractors ‘sign-in’ books • Wingham Court staff newsletter (Oct 2008) • Workers compensation notification 2008 (folder) • Workplace inspections Observations The team observed the following: • Activities in progress including craft, music concert, dancing and church • Annual fire safety statement (30 Sept 2008) • Antiseptic bio hand cleanser at entrances and strategic points • Automatic chemical dispensers for cleaning and laundry • Carer support education re dementia (flyers) • Catering: dietary and nutrition assessments available • Chemical and oxygen storage • Cleaning room and trolley • Comments, complaints and suggestion box • Dining room during meal service • Electrical equipment tagged for safety • Emergency flip charts • Equipment and supply storage areas and supply levels • Fire safety equipment tagging • Flyer displayed for visitors re food brought into the home • Food store and random expiry dates • Gardens and courtyards • General stores: cleaning and catering • Hand washing sinks and gel hand sanitiser • Interactions between staff and clients • Living environment – residential accommodation and communal areas • Material safety data sheets strategically located throughout the home • Medication management process including ordering, storage and administration.

Electronic medication data available through corporate license via the website. • Menu (displayed) • Noticeboards: catering, clients (residents) and relatives; staff; continuous improvement,

safety, education, dietary preferences • Personal clothes labeller – laundry • Security of documents


• Staff work areas – care stations, utility room, offices, staff room • Staff work practices • Staff: ‘above and beyond’ awards • Video surveillance camera and screen display


Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The Whiddon Group Wingham utilises a quality framework that has been developed by the organisation in consultation with staff which is based on a systems approach to continuous improvement. The key elements of the quality framework are: system and process review; service partner relationships; evidence based practice; values driven competent staff; strategic and annual planning; and evaluation. The system focuses on achievements and improvements for clients (residents), the home and the organisation as a whole. The home has a quality committee with representatives from across the site which monitors the quality system, audit results and action plans; and facilitates continuous improvement. Clients, their representatives, management and staff are involved in the quality system through identification of opportunities for improvement which are captured through a variety of ways including: ideas, suggestions, comments and complaints; improvement logs; accident/ incident data; audits; infection surveillance; staff appraisals; surveys; meetings and observations. Action plans are utilised throughout the home in all departments to monitor the implementation of improvements. Forward planning by the home and the organisation is through annual and strategic planning. The home subscribes to an external auditing organisation which includes provision of analysed data and benchmarking results across similar sized aged care homes. Results of internal and external audits are followed up through the homes continuous improvement system. Actions are monitored, reviewed and evaluated as appropriate to ensure improvements are achieved for clients and the home as a whole. The home has implemented improvements in relation to Standard One - Management systems, staffing and organisational development including: • The organisation has developed a quality framework in consultation with

management and staff which clearly shows each and every part of the group and how its operation is connected. Staff members are an essential part of the group operations and help achieve the overall outcome of client focussed quality care. The framework is depicted as a tree with branches representing the systems which underpin the continuous improvement process resulting in quality care and service provision for clients.

• The organisation orientation training system has been updated to a comprehensive package which includes a trainers manual, power point presentation and staff workbook. The package covers provision of care and services across the home, is relevant to all staff and includes areas such as health and hygiene, infection control, safe food handling, hand washing, policies, privacy, employee benefits, awards, occupational health and safety, appraisals, the quality framework, and mandatory reporting and elder abuse. The home ensures existing staff are provided with


current up-to-date information by providing time to complete the orientation program. Staff state this is very beneficial.

• The client management information system is been continually modified and upgraded to include changes such as new regulatory requirements. For example the Aged Care Funding Instrument (ACFI) information is now sent directly through the system to the appropriate government department thus facilitating efficient payment of funding entitlements.

• Information noticeboards for clients (residents) and their representatives have been installed in the main living area enabling easy access to information on past, current and future happenings around the home.

1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s recommendation Does comply The Whiddon Group policy and procedure manuals have been developed or sourced to ensure a consistent approach to compliance with regulations, legislation and professional standards and guidelines across the organisation. In addition site specific policy and procedures are in place for Wingham to complement those provided by the organisation. The home is provided with information related to changes in regulations, legislation and professional standards and guidelines through the organisation head office which employs experts in regulatory compliance across the standards. In addition subscriptions to appropriate bodies ensure a wide variety of sources on industry changes; and professional participation on relevant committees, attendance at conferences and access to the internet provides further information. Management of the home communicate changes to staff through regular meetings, education sessions, memos, flyers and during conversation. A resource library of legislation, regulations, staff awards and other relevant information is available for staff in the staff room. Management monitor staff practice to ensure regulatory compliance in various ways including staff appraisals, through the auditing system, accident and incident reports, education attendance, observation of work practice and competency assessments. In relation to Standard One – Regulatory compliance management of the home ensure all staff award information is available, current and adhered to; resident private information is stored securely and only accessible by authorised persons, and all computers are password protected with staff access at appropriate levels of the system.

1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The Whiddon Group is proactive in promoting and providing learning opportunities for management and staff. A learning culture is fostered by the organisation and the home which is evidenced through budget allocation for training and development; provision of scholarships and resources; work experience is provided for training organisations on


site at Wingham; and staff are supported and encouraged to achieve ‘above and beyond’ what they thought possible. The home has a comprehensive staff education program covering topics across the four Accreditation Standards which is developed through the specific requirements of clients (residents), the education needs of staff; information obtained from staff annual appraisals and changes in industry information. The home implements a comprehensive corporate orientation and induction program which includes competency assessment to ensure staff have learned and retained the knowledge and skills necessary to provide quality care and services for clients. In addition annual mandatory training on core topics such as fire safety and manual handling are completed by all management and staff. Education modalities available for staff include the aged care channel, external academic resources, and training opportunities through the local community and technical colleges. The education program is continually evaluated through feedback from management and staff, and modified as needed. Management maintain a database register of staff education attendance which facilitates easy access to information for annual staff appraisals. Examples of education and staff development achievements in relation to Standard One - Management systems implemented at the home include: • Successful completion of a leadership development program by management • All full time and part time registered nurses have commenced a course in front line

management • All staff are completing the updated orientation and induction program to ensure

currency of information • Administration staff completed a course in medical terminology • Management and other relevant staff completed training in the application of the

aged care funding instrument • All care staff have completed certificate 111 and three have completed certificate

1V in aged care; an assistant-in-nursing is completing a registered nurse qualification; and enrolled nurses have completed a medication administration course.

1.4 Comments and complaints

This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s recommendation Does comply The home has a comprehensive feedback system which enables clients and their representatives to make suggestions, comments and complaints; and to thank individual staff. The home welcomes and encourages feedback from clients and their representatives. A display of brochures and forms such as ‘I have an idea’ and ‘thank you’, and information on how to make a complaint are freely available near the main foyer. A suggestion box is located with the display which enables confidential feedback. Clients and their representatives satisfaction is surveyed and benchmarked with results, and identified opportunities for improvement, reviewed and followed up by management. The complaint system is communicated through client agreements, newsletters, the client (resident) handbook, displayed flowcharts, external complaints pamphlets, and is discussed at client and representative meetings. Complaints received are logged onto a register, kept confidential and followed up by management to resolution. Clients and their representatives express ‘satisfaction’ with the care and


services provided by the home and confirm they have no hesitation approaching management or staff with any issues of concern.

1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s recommendation Does comply The Whiddon Group Mission, Values and Philosophy of Care, developed in consultation with staff, are documented in key documents and displayed on the wall of the home. The provision of choices and opportunities of life enrichment for clients (residents) through innovative care services forms the basis of care and service provision. The values of growth, integrity and excellence articulate to the staff the behaviours by which they are measured. A leadership development program for management is in place; and forward planning through annual and strategic plans provides a guide for continuous improvement and ultimately the provision of quality care and services throughout the home.

1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s recommendation Does comply Management of the home ensures there are sufficient appropriately skilled and qualified staff to provide quality care and services for clients (residents) through monitoring of clients’ condition and care requirements, feedback from staff, audit results and survey responses, observation, and industry standards. Policies and procedures are in place to guide management in areas relating to recruitment and selection, performance management, terms and conditions of employment, managing employee issues and workplace conduct. Recruitment of staff is usually undertaken on a local basis either from applications received at the home, internal advertising of positions or if required external advertising through local newspapers. The home utilises a formal application process, interviews, and police and reference checks prior to appointment. All staff complete a comprehensive orientation and induction program which includes health and hygiene, infection control, safe food handling, hand washing, policies, privacy, employee benefits, awards, occupational health and safety, appraisals, the quality framework, and mandatory reporting and elder abuse. New staff complete ‘buddy shifts’ where they receive supervised orientation to their routine duties prior to commencing employment. Competency assessments, provision of education, supervision as required, a professional registration register and regular staff appraisals assist in the monitoring process to ensure staff are appropriately skilled and qualified. A staff replacement program is in place; and existing staff and their families have access to an employee assistance program. The home experiences a low staff turnover and as a consequence employs a significant number of staff across all departments who have been employed at the home for many years. The home celebrates staff commitment and achievement through years of service and annual employee awards. Staff state they are happy and enjoy working at the home


1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply The home has systems in place to ensure adequate stocks of appropriate goods and equipment are available to provide quality care and services. A comprehensive preventative and corrective maintenance program is undertaken by a maintenance officer supported by external service providers. A review of maintenance records and interview with clients and staff indicate a timely response to maintenance issues. Annual inventory lists are completed to identify furniture or equipment which requires replacing. This information is used for forward planning through budgets for replacement as needed. Major equipment purchases are undertaken in consultation with the occupational health and safety committee (OH&S), executive management and the Board. The OH&S committee and staff participate in trials of goods and equipment prior to purchase. General stock is ordered according to usage and inventory lists are in place to prevent overstocking. Linen is laundered by an external contractor with stocks monitored by a designated staff member to ensure appropriate levels of fresh linen are maintained. The team noted there are stocks of goods required to provide clinical services. A chemical company oversees stock levels to ensure adequate supply. Staff state there are adequate supplies of goods and equipment to provide quality care and services for clients.

1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply The home has an effective information management system which ensures current, accurate information is available for management and staff which facilitates delivery of quality care and services for clients (residents). A comprehensive meeting structure enables communication between all levels of staff and management, and clients. Minutes of meetings are recorded and made available for the perusal of appropriate stakeholders. The privacy and confidentiality of clients records, personnel files and other documents is ensured through secure locked areas of the home which are accessible only to appropriate staff. Computer systems are networked; a secure password system is in place; there is access to email, intranet and internet; corporate information such as manuals for clinical care are available electronically; and a Whiddon Group website provides organisational information. Other modes of communication include newsletters, facsimile transmission, memos, noticeboards, phone, internal mail, post and direct communication. Clients, their representatives, management and staff state satisfaction with the internal and external flow of information at the home.


1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s recommendation Does comply The home has a system in place to ensure external goods and service providers meet the needs and quality requirements of the home. Management and staff of the home monitor the goods and services provided by external services and contractors through direct observation, audits, feedback from clients (residents), and the homes’ maintenance and food safety system. External contractor agreements are regularly reviewed and suppliers changed when required. The Whiddon Group head office monitors major contracts such as building. Information on local service providers such as the physiotherapist, the pharmaceutical provider, and electrical contractors are maintained by the home. All contractors working on the premises are provided with a contractors rule booklet, register they are on the premises by ‘signing in and out’ and wear identification tags. All contractors are required to have a current police record check prior to working unaccompanied on the premises. Clients, their representatives, management and staff state satisfaction with the goods delivered including food stocks, the work undertaken by external services contracted to the home and external service providers including allied health and related professionals.


Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has an effective system to manage continuous improvement. Please refer to expected outcome 1.1 Continuous improvement for additional information relating to the homes’ quality management system. In relation to continuous improvement in Standard Two – Health and personal care the home has implemented improvements including: • The home developed and implemented a system for ensuring updates to clients

(residents) care documentation is completed regularly and updated as clients needs and preferences change. The system includes documentation in client’s progress notes and updating of care plans which ensures information pertinent to individual clients needs and preferences are captured and followed up by nursing staff.

• The home has introduced a medication audit folder. A variety of medication system audits are now completed which has resulted in improved medication management. For example the home identified through audits that medication documentation errors in schedule 8 drug registers required improvement. The issue was discussed at registered nurse meetings, legislation and memos distributed and additional audits commenced. This initiative has resulted in a marked improvement in staff adherence to legislation and accountability; and ensures safes and correct management of the home’s medication system.

• The home has improved the management of clients with diabetes through implementation of a pilot program through Hunter New England Health which included staff training and provision of new equipment. In addition coloured diabetic stickers are used in client progress notes to denote initial blood glucose readings and episodes of high or low blood sugar. The improvements have increased staff knowledge and skills resulting in improved diabetic management.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s recommendation Does comply The home has an effective system to manage regulatory compliance related to health and personal care. For comments regarding the system please refer to expected outcome 1.2 Regulatory compliance. In relation to Standard Two – Health and personal care residents’ medications are stored and administered according to the Poisons Act, and management of the home


maintains a register of staff professional registrations ensuring staff are appropriately skilled and qualified, and their registration remains current.

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has a comprehensive education and staff development system which ensures management and staff have appropriate knowledge and skills to perform their roles effectively. For comments regarding the system please refer to expected outcome 1.3 Education and staff development. Examples of education and staff development achievements in relation to Standard Two – Health and personal care implemented at the home include: • Staff attendance at education on wound care, pain identification and management,

palliative care, oral hygiene assessment and management, cardio pulmonary resuscitation, and first aid

• Two registered nurses completed an accredited course on ear irrigation • Clinical staff attended several sessions on diabetes management; diabetes and low

GI food; and the use of blood glucose monitors • The physiotherapy aide completed a recognised course

2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply The home has a system in place to ensure that clients receive appropriate clinical care that is specific to their individual needs. Plans of care (care plans) are now being computer formulated based on assessments conducted at entry and during the assessment period, as well as when care needs change. All care plans are prepared by an endorsed enrolled nurse (EEN) and are reviewed by a registered nurse (RN) at least three monthly to reflect the care needs of the clients at all times. The care plan reviews are conducted in line with the medical officers three monthly medication and restraint reviews. Clients are referred to allied health and medical professionals to promote optimal clinical outcomes. The team observed staff providing care consistent with the clients’ care plans and recording routine observations in their progress notes. Clients’ files show that medical officers and other relevant health care specialists regularly visit and review the clients’ condition. Clients and their representatives interviewed confirm they are kept informed about any therapy needs and are very satisfied with the care provided.


2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s recommendation Does comply The need for specialised nursing care is identified on entry to the home and on an ongoing basis with details documented in clients care plans. The home currently cares for clients with specialised nursing care needs such as complex wound management, diabetes management, continuous oxygen and supra pubic catheters. Special care charts are utilised to document the implementation of special requirements/activities. Clinical records reviewed describe care required for individual clients and files contain referrals to health specialists and follow up of treatment prescribed. Staff are provided with education and appropriate equipment for specialised nursing care; and the home utilises the services of clinical specialists from the local hospital as necessary. Interviews conducted with clients and their representatives and staff confirm clients specialised nursing care needs are appropriately met.

2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s recommendation Does comply The clients are able to access appropriate health specialists through referrals from their medical officer. A number of health care specialists visit the home on a regular basis and as required including a physiotherapist, podiatrist, aromatherapist, optometrist, dietician, psycho-geriatrician and palliative care clinical nurse specialist. Other specialist health services can be accessed through the local area health service. Records of visits to specialists are kept in client files and relevant advice from these specialists is included in clients’ care plans. Staff advised, and clients and their representatives confirm the home assists in the arrangement of appointments to health specialists and transportation to appointments as necessary.

2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply The home has clear policies and procedures for the safe and correct management of medications and a medication advisory committee considers and advises on policy. A medication audit protocol folder is in place which includes regular audits on medication charts, schedule 8 (S8) medicines and stock. A corporate licence has been acquired for an electronic medication information site on the internet. Shortcut access to this was seen on the corporate website. The medication needs of each client are assessed when they first move into the home in consultation with their representative and medical officer. All staff responsible for administering medications are appropriately trained and participate in annual competency assessments. A single-dose blister medication pack system is used; and all packs are checked against medical officers’ orders upon delivery from the pharmacist. The team observed that staff are using safe


and correct procedures in the administration of medication and that they are stored securely. Medical officers review resident medication needs every three months. A pharmacist is contracted to conduct routine audits and all files reviewed included a comprehensive medication review. Medications no longer required, those out-of-date, or damaged medications are disposed of appropriately. Clients and their representatives interviewed report they are assisted with their medication requirements and express satisfaction with the administration of clients medications.

2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply An individual pain management plan is prepared for all clients identified as experiencing pain. The plan is developed in consultation with the client, their representative, and the client’s medical officer. The home has clear policies and procedures regarding pain management. Strategies to manage pain experienced by clients are determined according to the abilities, needs and preferences of the individual. The team noted that staff administered pain medication as prescribed and recorded any change in the behaviour of clients that may be due to pain. Stickers which denote when ‘as required’ pain medication has been administered are used in progress notes to record periodic pain relief. Feedback is sought from clients and their representatives as to the effectiveness of pain management strategies. A non verbal pain scale is used to assess clients with communication and/or cognitive deficits. The home provides a range of alternatives to medication such as aromatherapy, heat packs, massage, music and one-to-one reassurance and diversion. Clients and their representatives interviewed confirm clients are maintained as free from pain as possible and that pain relief can be accessed as required.

2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply The home has clear policies and procedures for provision of palliative care. Staff have received training to help them understand the needs of terminally ill clients and their families. The palliative care team from the local area health service are consulted as necessary to provide input into care planning, including pain management strategies, for terminally ill clients. A palliative care resource box has been set up to assist staff in providing support. A dining room in one wing, that is rarely used, can be converted into a palliative care room during the end stages of palliation if required to ensure privacy and dignity for the resident and their family. Family members are consulted in all aspects of a clients care. The local ministers of religion regularly visit the home and are contacted on the request of clients and/or their families to provide spiritual support. Feedback from relatives of deceased clients commended the staff for the care they provided and confirm that the comfort and dignity of terminally ill clients is maintained.


2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply Clients are assessed on entering the home for their dietary needs and preferences using oral, dental, and dietary and nutrition assessments. Strategies are developed to address any issues identified and these are documented in a care plan that is reviewed at least every three months. Clients are weighed three monthly as part of routine observations and a weight loss assessment is conducted if required. Clients are offered a varied, healthy and well balanced diet, which was developed in consultation with a dietician. The home has access to a speech therapist to assess the swallowing ability of a client as required; and special diets and dietary supplements are available as needed. Staff assist clients with their meals when needed and are able to monitor the intake of foods and fluids through special care charts when required. Clients and their representatives interviewed confirm that clients are served food that meets their likes and dislikes and dietary requirements.

2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply Clinical documentation reviewed confirms that clients have a skin assessment completed on entry to the home and a care plan, which includes individual needs, is developed to assist in maintaining/improving the clients’ skin integrity. A recognised skin assessment tool is used to identify if the client is at risk of pressure areas so that prevention strategies can be implemented. Staff monitor clients’ skin integrity daily, provide moisturiser for each client after showering and encourage clients to keep up their fluid intake. Incidents of skin tears are monitored and appropriate action taken. Wound care is carried out by qualified staff and treatment/progress is documented in wound care charts. Nurses provide routine nail care for clients with specialist foot and skin care for diabetic clients provided through a podiatrist that visits every six weeks. Clients and their representatives interviewed confirm they are happy with the care provided.

2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply All clients have a continence assessment on entry to the home. A continence care plan and toileting program is developed if required which is regularly reviewed and evaluated. Clients have ample access to toilets throughout the home and access to a call bell system when physical assistance is required. Staff monitor and document the continence of clients in daily charts and progress notes as required. Natural and dietary strategies are used as the first preference to manage continence issues. The team observed there are adequate supplies of disposable continence aids of varying sizes available for clients; and staff are trained in the use of these products. Clients and their


representatives interviewed confirm they are happy with the care provided and that clients continence is managed effectively.

2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply The home demonstrates that the needs of clients with challenging behaviours are managed effectively. Review of clinical documentation shows that specific behavioural assessments are conducted on moving into the home, annually and when necessary. Challenging behaviours, triggers and management strategies are documented in care plans and challenging behaviours are monitored through the use of ‘behaviour stickers’ placed in progress notes to highlight occurrence. Clients are referred to specialist medical officers as necessary and reports from referrals were noted in clients’ clinical records. The home has access to a psycho-geriatrician, clinical pharmacologist and a behavioural consultant. The use of psychotropic medication is monitored and alternate strategies are identified and implemented as appropriate. Staff interviewed were able to confirm various strategies used to assist in modifying clients’ behaviours; and also stated they are provided with education in behavioural management. Clients and their representatives interviewed by the team state they are satisfied with the way the needs of clients with challenging behaviour are managed.

2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply The mobility and dexterity of clients is assessed on entry to the home and on an ongoing basis by a consultant physiotherapist who provides a care plan and individual exercise programs for clients. A therapy nurse assists clients with these individual exercises, balance and strengthening programs and the team noted details of this in the clients’ files reviewed. The recreational activity officer also holds a weekly exercise class for clients. Equipment and assistive devices are available and a comprehensive falls program is in place. Clients and their representatives interviewed state they are happy with the assistance provided to clients to achieve optimum levels of mobility and dexterity.

2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply The home demonstrates that clients’ oral and dental health is maintained. Clients’ oral and denture care needs and preferences are identified on entry to the home through a variety of assessments. Care plans are developed and a monitoring program implemented to update the plans for any changes in an ongoing manner. Staff assist clients with oral hygiene daily as outlined in the care plan, and any needs or problems are noted in the progress notes and communication book. There is a local dentist who


is available for routine appointments and emergency care is organised through the public hospital in Taree. Clients interviewed advised the team they are assisted with oral hygiene when necessary and are satisfied with the care provided.

2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Assessments of clients’ sensory loss are undertaken on entry to the home and strategies to cater for sensory needs are documented in clients’ care plans. Staff assist clients with cleaning glasses and hearing aids as required as part of the clients’ daily hygiene routine and the team observed the patience and sensitivity of staff interacting with clients with sensory loss. An optometrist visits the home regularly. A hearing specialist form Australian Hearing Services also visits several times a year. Other hearing specialists are also available in the wider community. The activities program includes a sensory stimulation program that engages all the senses and has proved very popular with clients. A ‘tactile touch trolley’ has been set up as part of this program and contains interesting items for clients to touch which provides a stimulating and varied touch experience. A sensory garden has been established in a secured garden area for all clients and visitors to enjoy. The home provides a safe hazard free environment and aids to assist those with sensory loss such as large print books and magnifiers are available. Clients and their representatives interviewed by the team indicate they are satisfied with the management of clients sensory loss.

2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Clients’ sleep needs and preferences are assessed on entry to the home and strategies to ensure clients are able to achieve natural sleep patterns are documented in the clients’ care plans. Night staff conduct regular rounds during the night to ensure clients are not unnecessarily disturbed during their sleeping hours. Strategies to assist clients achieve a natural sleep pattern include pain and continence management, heat packs, aromatherapy, warm drinks and medication where prescribed. Clients and their representatives interviewed confirm that the environment is quiet at night and that staff use a range of strategies to assist them if they have difficulty in sleeping.


Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has an effective system to manage continuous improvement. Please refer to expected outcome 1.1 Continuous improvement for additional information relating to the homes’ quality management system. In relation to continuous improvement in Standard Three - Resident lifestyle the home has implemented improvements including: • Exercises from the ‘brain gym’ program are incorporated into regular exercise

sessions which are enjoyed by clients (residents) and have the added benefit of reconnecting brain function to activity.

• The home has implemented ‘recognition for long term service’ by voluntary community advisory committee members and ladies auxiliary members who provide ongoing support for the clients of the home. These volunteers are now presented with life member badges and certificates of appreciation.

• A ‘Welcome’ book with updated handbook has been developed for new clients moving into the home. The book includes helpful information including safety issues, what to do of the fire alarm sounds, amenities for visitors, TV channels, phone numbers, and meals and reception times. To ensure all clients have access to current information management have distributed the ‘Welcome’ and handbook to all existing clients.

• In consultation with clients a variety of new activities are being trialled at the home including flower arranging sessions run by a client who is a florist by trade; beauty therapy by a volunteer who provides hand massages and manicures; cooking from around the world with a guest presenter; quoits; old time dancing demonstrations; and magnetic darts for men. Clients state they certainly enjoy the activities they choose to attend.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s recommendation Does comply The home has an effective system to manage regulatory compliance related to resident lifestyle. For comments regarding the system please refer to expected outcome 1.2 Regulatory compliance.


In relation to Standard Three – Resident lifestyle clients are informed of their rights and responsibilities which are documented in client agreements, and are displayed on the wall of the home. Staff sign privacy agreements prior to commencement of duties.

3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has a comprehensive education and staff development system which ensures management and staff have appropriate knowledge and skills to perform their roles effectively. For comments regarding the system please refer to expected outcome 1.3 Education and staff development. Examples of education and staff development achievements in relation to Standard Three – Resident lifestyle implemented at the home includes: • A recreational activity officer attended a course on ‘brain gym’ which is a program

designed to improve clients (residents) cognitive functioning and helps maintain their mental health. In addition the program plays a significant role in the prevention or management of confusion, depression, lethargy and low self esteem. Exercises from the ‘brain gym’ program are being enjoyed by residents.

• New employees and current employees are provided with information on residents’ rights and responsibilities and the importance of maintaining privacy and dignity during orientation and reorientation training sessions.

• Recreational activity officers and the physiotherapy aide attended a course on head and shoulder massage which is enjoyed by clients of the home as part of the activity program

• Recreational activity staff attend local networking meetings which provides contacts and information on new activity ideas for the home.

3.4 Emotional support

This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s recommendation Does comply The home has a system in place to ensure clients receive support in adjusting to life in the home and on an ongoing basis. Clients and their representatives are interviewed prior to moving into the home, given a tour of the home and are provided with information about the home through a ‘welcome pack’ that explains the services provided and lists helpful information about operational activities. The client’s emotional needs are assessed, documented and regularly reviewed. The education program enables the staff to better understand the needs of clients; and observations of staff interactions with clients showed warmth, respect, empathy and understanding. The staff and especially the recreational activity officer provide one to one attention to the clients on a regular basis and at times of special need. Family and friends are encouraged to visit and community groups provide further emotional support for the clients. Clients and their representatives interviewed express satisfaction with the emotional support offered by management and staff.


3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s recommendation Does comply Clients’ individual care needs including sensory needs and mobility are identified and assessed; and strategies are implemented to maintain maximum independence. Regular exercises and the strength and balance program assist clients to maintain optimal mobility and independence. Clients are encouraged to participate in the recreational activities of the home and are given the opportunity to go on regular outings including a weekly bus trip. The effectiveness of the assistance provided to clients in relation to their independence is monitored through regular review of care plans and client satisfaction surveys, the comments and complaints mechanism and clients and their representatives meetings. Observations by the team, and clients and their representatives interviews confirm that clients are encouraged to maintain their independence and participate in the life of the community within and outside the home.

3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s recommendation Does comply Staff are provided with training on privacy and clients’ rights during their orientation, and are required to sign confidentiality agreements on appointment to their positions. The team observed interactions between staff and clients that demonstrates how staff respect the privacy and dignity of clients by knocking and waiting for permission before entering clients’ rooms, through the appropriate use of curtains to screen residents in shared rooms and referring to clients in a dignified manner and by their preferred name. All personal information is collected and stored securely with access by authorised staff only and there are procedures for archiving and disposing of documents in accordance with privacy legislation. Written consent is obtained from clients to place photographs on display and publish their names in newsletters. The system to maintain the privacy and dignity of clients is monitored by regular audits, the comments and complaints mechanism, and clients and their representatives meetings. Staff interviewed provided examples of the ways they show respect for clients’ privacy and maintain their dignity and confidentiality; and clients and their representatives interviewed are satisfied that staff respect their privacy and maintain their 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 recommendation Does comply The interests and capabilities of the clients are recorded when they move into the home. The recreational activity officer prepares a monthly program to cater for these interests and capabilities and includes a wide range of activities over seven days a


week. One to one attention for the clients is an integral part of the program and caters for those clients who are less capable of active participation in the program or choose not to take part in group activities. Weekly bus trips provide an opportunity for clients who like to get out and about; and volunteers, community and church groups visit the home regularly to help the clients stay in touch with the wider community. The effectiveness of the activities program in meeting clients’ interests and needs is monitored through attendance records, activities evaluations, clients and their representatives’ meetings, client surveys and informal feedback given to the staff. The clients and their representatives interviewed indicate they are encouraged and supported to participate in a wide range of interests and activities.

3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s recommendation Does comply The home has a system for ensuring that clients’ individual interests, customs, beliefs and cultural and spiritual values are fostered. The social history of each client is assessed and documented when they move to the home. The information is then communicated to relevant staff members who discuss individual preferences with clients and their representatives. Clergy and representatives from Roman Catholic, Presbyterian, Uniting and Anglican Churches conduct regular religious services at the home, and are available to provide pastoral care for clients at times of special emotional and spiritual need. Provision is made for the celebration of special cultural and religious days, for example Christmas, Easter, Anzac Day and Australia Day. Many of the clients are from the local region and subscriptions to, and readings from, the local newspaper and bus trips to the local area help to maintain the cultural link with the local community. The clients and their representatives interviewed are satisfied with the care the home provides for the support of clients cultural and spiritual lives.

3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s recommendation Does comply The home has processes in place to ensure clients participate in decisions about the services provided and are enabled to exercise choice and control in relation to their lifestyle. Clients and their representatives are provided with information to assist them in making informed choices. Clients indicate their likes and preferences when they move to the home and these are documented in client notes and care plans. The team observed staff consult with clients about their wishes and preferences; and the choices of clients are respected in all care activities, leisure interests, lifestyle and beliefs. The effectiveness of the system in place to ensure clients are able to exercise choice and control over their lives is monitored through client surveys, meetings and the comments and complaints mechanism. Staff interviewed are able to describe a number of ways they encourage and support clients to make choices and decisions, and clients and their representatives interviewed confirm this to be the case.


3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s recommendation Does comply The home provides a ‘welcome pack’ and corporate client information hand book to clients and their representatives which include a copy of residents’ rights and responsibilities and how to make a comment or complaint. In addition the charter of residents’ rights and responsibilities is displayed on the wall of the home. Client agreements include information on security of tenure, and interviews are held with clients and their families during which detailed explanations are provided regarding security of tenure. A record of client’s power of attorney is maintained if available and clients are referred to the Guardianship Board where appropriate. Interpreters are provided for clients and their representatives who come from culturally and linguistically diverse backgrounds. Clients and their representatives are surveyed with information obtained used for the home’s continuous improvement process. Interviews with clients confirm they feel secure and happy living at the home.


Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home has an effective system to manage continuous improvement. Please refer to expected outcome 1.1 Continuous improvement for additional information relating to the homes’ quality management system. In relation to continuous improvement in Standard Four – Physical environment and safe systems the home has implemented improvements including: • Extensive renovations have been completed at the home which incorporates a new

entrance foyer, management offices, amenities and renovated bathrooms. This has resulted in an improved living and working environment for clients (residents), their representatives, management and staff.

• The home has developed and implemented an emergency and disaster management manual which is site specific and compliments the organisation emergency management manual. Staff have been provided with training in the use of the new manual which covers a wide variety of situations. In addition the homes emergency flip chart has been rewritten to ensure it reflects pertinent information for the local Wingham area.

• The home has created emergency evacuation packs which include caps with built in torches, identification bracelets for clients, a safety officer’s vest, pen and paper, and the key to the community hall. The packs are located with the homes evacuation folders which document current client information which may be required in the case of an emergency evacuation of the home.

• Infection control signage has been improved through the home by making signs brighter, and placing extra signs at entrances to the home and near ‘sign in and out’ books for client representatives, visitors and contractors. This has improved the awareness of visitors entering the home and helps ensure the clients of the home are protected from illnesses prevalent in the community.

• In response to a food safety audit the home has formalised procedures for fruit and vegetable preparation; implemented monitoring records for cooking and cold food service; implemented a calibration program; and updated the food safety manual to include staff training requirements and orientation attendance.


4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s recommendation Does comply The home has an effective system to manage regulatory compliance related to physical environment and safe systems. For comments regarding the system please refer to expected outcome 1.2 Regulatory compliance. In relation to Standard Four - Physical environment and safe systems the home meets regulatory requirements for fire and safety, and occupational health and safety. The home has applied for and been granted a NSW Food Authority license. The home has implemented infection control procedures to manage gastroenteritis and influenza outbreaks.

4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home has a comprehensive education and staff development system which ensures management and staff have appropriate knowledge and skills to perform their roles effectively. For comments regarding the system please refer to expected outcome 1.3 Education and staff development. Examples of education and staff development achievements in relation to Standard Four - Physical environment and safe systems implemented at the home include: • A registered nurse has completed a recognised immunisation course with

assistance from The Whiddon Group which facilitates the administration of the client and staff immunisation programs at the home.

• Training in occupational health and safety and manual handling was attended by staff.

• Infection control sessions included: pandemic management, and infection control specifically for cleaning and laundry staff

• Fire safety training, evacuation and the use of fire safety equipment.


4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s recommendation Does comply The Whiddon Group Wingham high care home provides accommodation for 49 clients (residents). The home has a limited number of single rooms with the majority of rooms being shared. The team observed screens around each bed which are in good order and of a length to provide privacy; and clients state staff draw the screens prior to providing care. Some clients prefer the multi-bed rooms for company and the feeling of added security. Clients are encouraged to decorate their personal space with photographs and mementoes from their lives. Communal living areas of the home are tastefully decorated in modern colours. Clients and their visitors enjoy sitting and socialising in the central courtyard which has well maintained gardens and lawn. Many of the clients, their representatives, management and staff have lived in the area for a long time which adds to the community feel of the home. The Wingham community supports the home through volunteers on a local advisory committee and the ladies auxiliary who tirelessly work to provide funds for extra comforts for clients. The home has a comprehensive program to ensure the safety of clients, their visitors, management and staff which includes regular environmental audits, evening lock-up procedures, an external security service, key pad coded door locks and video surveillance of the front entrance. A comprehensive preventative and corrective maintenance program is in place. Clients and their representatives state satisfaction with the care and services provided, and compliment management and staff on the wonderful care provided for clients living at the home.

4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply Management of the home is actively working to provide a safe working environment which meets regulatory requirements. The homes occupational health and safety (OH&S) system is demonstrated through regular OH&S meetings; compliance audits such as food safety; staff training and competency assessment; environmental and work place audits; accident/ incident reporting; safety signage throughout the home; and personal protective equipment available for staff. A preventative maintenance program for plant and equipment is in place. The home’s hazard management system includes caution signs, hazard alert indicators and a hazard register. The OH&S committee proactively manages risk through hazard identification and trend analysis of accidents and incidents. Identified hazards or risks are immediately addressed or controlled, documentation is completed, a review by management occurs and action plans are developed and implemented. Accident/incident data is analysed with results reported during committee meetings, and follow up action identified and implemented through action plans. There is an effective return to work program for staff and an external rehabilitation provider is used for complex cases. Staff state they understand the OH&S system of the home, and are conversant with their representatives and mechanisms for reporting issues.


4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s recommendation Does comply Management of the home are actively working to provide a safe and secure environment for clients, management, staff and visitors. The fire, security and emergency systems implemented at the home includes policies and procedures, management and staff training, emergency equipment, lockup procedures, an external security service, video surveillance, environmental audits, clear evacuation plans, and an evacuation pack and folder of client information in the case of an emergency. The home has a designated, accredited fire safety officer, fire safety program and the required annual fire safety statement. All fire equipment is inspected according to Australian Standards by an external provider and remedial action is taken immediately if required. A fire safety audit is conducted monthly, followed up by management and reported to the corporate office. All staff are required to have a current first aid certificate and first aid kits are available. Emergency and disaster plans are in place. Staff attendance at compulsory fire training is monitored and enforced by management.

4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply The home has an effective infection control program which includes staff education, hand washing competencies for all staff, client and staff immunisation programs, management and disposal of contaminated and ordinary waste, implementation of safe food practices, use of colour coded cleaning and catering equipment, and an infection surveillance program. Infection control is a component of education, orientation and induction. Competencies are undertaken to assess staff knowledge and skills and are benchmarked against other aged care homes. Clinical client infections are identified, treated, documented, trended and followed up with reports provided to management and discussed at meetings. Catering staff are trained in accordance with NSW Food Authority requirements and a food safety plan is in place. Safe food practices include: monitoring of food storage conditions; monitoring of the temperatures of food production, stock rotation, and regular servicing of equipment such as the dishwasher. Food safety audits are undertaken. A comprehensive infection control manual is in place. Biological testing of the hot water system is undertaken with results monitored by management and followed up as required. The home has an outbreak management program which includes detailed information on what to do, who to notify and documentation which may be required. Personal protective equipment and hand sanitising gel is available throughout the home. The laundry has designated clean and dirty areas, the temperature of machines is monitored and a chemical sanitiser is used in all wash loads. Cleaning procedures include regular schedules, an automatic chemical feed system and colour coded equipment.


4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s recommendation Does comply The catering service of the home is based on the premise of safe food handling, client preference and sound nutrition. Menus are based on clients’ likes and dislikes, including cultural and lifestyle choices and client survey results. There are feedback mechanisms in place for clients and their representatives to comment on menu choice, presentation and quality. Changes to the menu are made in response to feedback and special requests. A comprehensive nutrition and hydration assessment is undertaken when clients first move into the home and their needs and preferences change. A comprehensive safe food handling system is in place which includes audits by the NSW Food Authority. All meals are snacks are prepared fresh on site with the majority of fresh supplies obtained from the local area, which in turn supports the local community. Barbecues, cultural days and theme days are added to the monthly menu. Clients and their representatives state ‘satisfaction’ with meals provided at the home including the variety, size, temperature and quality of meals. The cleaning and laundry service is based on the premise of sound infection control and management of clients living environment. The cleaning and laundry systems are actively supported by a comprehensive education program which includes infection control hand washing, the use of colour coded equipment and chemical handling. The cleaning and laundry programs are monitored by internal and external audits, and the corporate auditor to ensure compliance with relevant standards with remedial action taken as required. Laundry services are provided on site for residents’ personal laundry. An external laundry provides a linen service. Clients clothes are laundered, ironed if required and returned to their rightful owner. Dirty and clean items do not cross over during the washing process. Clients and their representatives commented on the cleanliness of the home and how beautifully client’s clothes are laundered and returned.

Decision to Accredit Wingham Court Nursing Home · Decision to Accredit. Wingham Court Nursing Home...

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