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Uniting Mirinjani Weston ACTRACS ID: 2985

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

Home address: 15 Conder Street WESTON ACT 2611

Following an audit we decided that this home met 42 of the 44 expected outcomes of the Accreditation Standards. This home remains accredited until 26 June 2018.

We made our decision on 30 March 2017.

The audit was conducted on 28 February 2017 to 09 March 2017. The assessment team’s report is attached.

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

ACTIONS FOLLOWING DECISIONSince the review audit decision, we have undertaken assessment contacts to monitor the home’s progress and found the home has rectified the failure to meet the Accreditation Standards identified earlier. This is shown in the ‘Most recent decision concerning performance against the Accreditation Standards’ listed below.

Most recent decision concerning performance against the Accreditation StandardsSince the review audit decision we have conducted assessment contacts. Our latest decision on 06 June 2017 concerning the home’s performance against the Accreditation Standards is listed below.

Standard 1: Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal carePrinciples:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

Home name: Uniting Mirinjani Weston ACT Date/s of audit: 28 February 2017 to 09 March 2017RACS ID: 2985 2

2.16 Sensory loss Met

2.17 Sleep Met

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




3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

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




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit ReportName of home: Uniting Mirinjani Weston ACT

RACS ID: 2985

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

IntroductionThis is the report of a Review Audit from 28 February 2017 to 09 March 2017 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

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

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

42 expected outcomes

The information obtained through the audit of the home indicates the home does not meet the following expected outcomes:

2.8

2.11


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Review Audit from 28 February 2017 to 09 March 2017.

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

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

Details of homeTotal number of allocated places: 124

Number of care recipients during audit: 122

Number of care recipients receiving high care during audit: 119

Special needs catered for: 64 Bed secure unit for care recipients living with dementia


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

Interviews

Position title Number

Care recipients/representatives 29

Head of residential operations 1

Care services manager 1

Deputy services manager 1

Residential services head 1

Assistant to head of residential operations 1

Clinical nurse specialist 1

Registered nurses 4

Enrolled nurses 2

Care coordinators 4

Care staff 10

Continence link nurse 1

Pastoral carer 1

Leisure and lifestyle coordinator 1

Leisure and lifestyle staff 1

Quality improvement specialist 1

Physiotherapist 1

Occupational therapist 1

Administration assistant 1

Hospitality team leader 1

Catering staff 4

Laundry staff 2

Cleaning staff 2


Position title Number

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files (including progress notes, assessments, care and lifestyle plans and associated documentation)

17

Summary care plans 14

Medication charts 15

Personnel files 9

Other documents reviewedThe team also reviewed:

Accident and incident reports

Action plans

Annual safety measures report 2016

Audits and analysis of external benchmarking audits

Behaviour management: behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports

Care recipient satisfaction survey 2015

Care recipients' information handbook, information package and entry package

Clinical monitoring records: anticoagulant therapy, blood glucose levels, blood pressure, neurological observations and total care day records, clinical care assessment schedule and care plan review allocation and schedule

Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care and stoma care

Dietary documentation including allergies, preferences, menu

Education documentation: computerised system, including attendance sheets, compulsory training records, competency assessments, calendar

External contract and agreement

Feedback documentation

Food safety report

Human resource documentation including: performance appraisals, staff registrations, criminal history clearances, statutory declarations

Lifestyle management: lifestyle past history , leisure and spiritual assessments, activity calendars and promotional flyers, activity plans care plans, attendance records, activity evaluations, consent forms, memoriam book


Medication management: medication administration plans, signing sheets, PRN medication (whenever necessary) evaluations, clinical refrigerator temperature monitoring records, therapeutic monitoring guidelines and anti-coagulant therapy care plans, oxygen therapy care plans, medication incident reports, nurse initiated medication forms, Drugs of addiction registers, complex health care directives diabetic management, professional signatures register, medication advisory committee meeting minutes

Meeting structure, meeting minutes including staff, clinical governance, work health and safety, care recipient

Mobility: mobility assessments, physiotherapy care plans, individual exercise programs, falls risk assessments

Nutrition and hydration: nutritional preferences assessments, weight monitoring records, dietitian reviews/management plans, speech pathologist reviews/reports, nutrition and hydration list and supplements list

Pain management and palliative care: revised pain management clinical pathway process, pain recognition flowchart, pain assessments, pain management plans, advanced care plan directives, palliative specialised nursing care plans, end of life clinical pathways, wellness and lifestyle pain management massage and heat pack therapy attendance records

Policies and procedures

Rosters and staff allocation and replacement sheets

Skin integrity: wound assessments and management plans, photographic wound monitoring records, pressure care directives, podiatry assessments and reports

Staff handbook, staff incidents, staff survey 2015

ObservationsThe team observed the following:

Activities in progress

Australian Aged Care Quality Agency notice on display.

Care recipients utilising pressure relieving, hip and limb protection equipment

Comments and complaints notices, feedback box, advocacy information displayed in the home

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

Equipment and supply storage areas: secure oxygen storage, supplies of linen, catering equipment, continence products, personal products, medical supplies, mobility and manual handling equipment

Fire safety system: sprinkler system, hose reels, fire blankets, extinguishers, correctly orientated emergency evacuation signage, clear fire egress, designated assembly areas

Infection control: personal protective equipment in use and in storage, hand sanitiser available, hand washing stations, staff practice, waste disposal systems, sharps containers, colour coded cleaning equipment in use, outbreak kits, instruction available to staff, yellow gerbera (infection ) prompts in care recipients' rooms, spill kits

Information notice boards

Interactions between staff ,care recipients and representatives

Living environment including, cottage/household living areas and care recipients and representatives utilising the café areas


Mobility equipment in use including mechanical lifters, walk belts, wheel chairs, shower chairs, low-low beds, hand rails in corridors and internal lift access

Policies and procedures available to staff online

Secure storage of care recipients' clinical files and confidential registered nurse handover

Secure storage of chemicals, safety data sheets adjacent to the chemicals to which they refer

Secure storage of medications; medication administration

Short group observation in craft room Carol Mailler wing

Sign in/out registers, internal key pad entry/exit systems, swipe card access and closed circuit televised security system

Staff notice board with wellness and safety information, education calendars and prompts

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

Vision and Mission statements, the Mirinjani pledge with staff signatures, diversity and inclusiveness information and Charter of Care Recipients' Rights and Responsibilities are displayed

Walk out guard of honour for deceased care recipient


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

Standard 1 – Management systems, staffing and organisational developmentPrinciple: Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The organisation has systems to pursue continuous improvement across the four Accreditation Standards. Recent examples of continuous improvement in relation to Accreditation Standard One include:

The organisation’s on-boarding or recruitment system has been improved. The e-recruitment process, installed about four months ago places barriers in the employment process until legislative obligations, such as police clearance, have been completed. The system monitors compulsory training of new recruits.

The organisation has undergone a re branding. Relationships have been developed and strengthened within the Uniting Church local area resulting in community participation in childrens’ activities and contribution in fundraising. All staff undertook code of conduct training to improve their understanding of the home’s mission and philosophy.

The home has piloted a household model of care for the previous two years and has commenced imbedding this model of care in Uniting Mirinjani. To support this improvement staff have undertaken training, improvements have been made to kitchen and dining areas. Staff positions, duties and titles are scheduled to change. Consultation with staff and unions has been undertaken. It is anticipated this improvement will be in place by June 2017.

An upgrade to the home’s computerised care documentation and planning system has been undertaken.

1.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.


The organisation has systems to identify changes to legislation, regulatory requirements. These are provided through access to a peak body, various websites and information updates from industry bodies and government departments. The organisation also has access to a commercial legislation updating service which routinely sends information as legislative changes occur. Information on legislative changes is discussed at management meetings such as the quality meeting and work, health and safety. Staff advised changes are discussed at staff meetings, education sessions or via memos. Recent legislative updates relating to Standard one, Management systems, staffing and organisational development includes:


Criminal history record checks are carried out for all staff, volunteers and contractors as required.

Contracts with external service providers confirm their responsibilities under relevant legislation, regulatory requirements and professional standards.

Notices were in place informing care recipients and representatives of the review audit.

There is a system for the secure storage, archiving and destruction of personal information in accordance with privacy legislation and regulations relating to care recipients’ records.

Comments and complaints and advocacy brochures are available in the home.

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


The organisation has a learning and development program which provides on-line on-boarding (orientation) program for new staff and a range of mandatory annual training modules. The learning and development officer provides an annual training a calendar for the home, to which onsite management add further training to suit the needs of the home. The system assists management and staff members in gaining appropriate knowledge and skills to perform their roles effectively. There are minimum requirements for employment in the home. Records of staff attendance at training sessions are maintained. Staff say there is opportunity for professional development to support their role in the home. Recent education sessions attended by various individual staff members include:

Staff have attended code of conduct training

Management and staff undertake bullying and harassment training

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


There is a policy and procedures for complaints management. Care recipients and representatives are informed of internal and external complaints mechanisms on entry to the home. Complaints mechanisms are documented in the care recipient handbook and in the residential service agreement. Feedback forms for suggestions, comments and complaints and a locked suggestion box for confidential feedback are readily accessible to stakeholders. Care recipients and representatives express satisfaction and appreciation for the care and service provision. Review of feedback documentation identified numerous compliments and minimal complaints.

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



The organisation provides a faith based, inclusive service and has documented their mission, values and philosophy and commitment to quality. The vision, values and philosophy statements and commitment to continuous improvement are documented in the care recipient handbook, in the staff handbook, in corporate information and are on display in the home.

1.6 Human resource managementThis expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".


The home has appropriately qualified and sufficient staff to ensure services are delivered in accordance with the needs of the care recipients. Human resource policies and procedures direct the recruitment and performance management of staff. Criminal history and visa certification is obtained prior to employment and is monitored for renewal. Position descriptions, staff handbooks, policies and procedures provide staff guidelines. Personnel files are maintained and stored securely. Part time staff or agency staff provides replacement staff for annual or unscheduled leave. Staff said they are able to complete their duties in the allocated time. Care recipients and representatives said staff are caring.

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


The home demonstrates appropriate stocks of goods and equipment for quality service delivery are available. This includes health and personal care supplies and equipment, food, furniture and linen. There is a system for monitoring and management of inventory and equipment. Appropriate levels of stock and equipment are achieved through the implementation of procedures for budgeting, purchasing, inventory control, assets management and are maintained through a corrective and annual planned preventative maintenance program.

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


There are systems for the creation, usage, storage, archiving and destruction of records, including electronic records. Policy and procedures guide staff in their practices and are reviewed to ensure they meet regulatory and industry standards. The home’s internal communication processes include meetings, meeting minutes, memos, newsletters, communication books, verbal consultation and feedback. Care recipients are provided with information prior to entry, in the care recipient handbook and the residential agreement, by notices, newsletters and at meetings. Information is managed in accordance with the organisation’s privacy policy.

1.9 External servicesThis expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".



There are effective systems and processes to ensure external services are provided to meet the care service needs of care recipients and the home’s service quality goals. The organisation has preferred suppliers and contractors. Service agreements and contracts are developed, monitored and reviewed. The home monitors the quality and effectiveness of services provided including through consultation with appropriate staff, care recipients and representatives. There is a process to address, and if required change, external service providers when services received do not meet the needs of care recipients or the home.


Standard 2 – Health and personal carePrinciple: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement. The home demonstrates it is actively pursuing continuous improvement in relation to Accreditation Standard Two and examples include: A registered nurse development program was provided over a six month period in 2016.

Seven of the twelve registered nurses attended this program. The program included sessions on clinical assessment and decision making, pharmacology, clinical tools, dementia and behaviour management, palliative care and person first.

Currently the clinical nurse specialist works four days per week. Management have planned to increase the allocated position and offer an additional day, in this role to an existing registered nurse staff member.

The clinical governance meeting have commenced monthly.

A relaxed dining program has been introduced to support care recipient choice and appetite. Care recipients are able to wake and have meals as they prefer. Meals are fortified with cream and butter to support weight increase in those who require it.

Following identification of gaps in the home’s wound management improvements have been made. Improvements include the clinical nurse specialist to meet weekly with the endorsed nurses who generally attend to wound dressings. Management will meet fortnightly with the clinical nurse specialist to review clinical and wound management. Training in the C11 document (wound assessment chart) is scheduled and staff will attend to improve their documentation skills. Two digital cameras have been ordered to support wound management processes.

2.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about health and personal care”.


Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of regulatory compliance with Accreditation Standard Two includes:

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


The home has a policy and procedures for the notification of unexplained absences of care recipients and maintains a register for recording these absences in accordance with The Accountability Principles 2014.

A coroner’s matter involving a fall from a wheel chair was discussed at a recent staff meeting.

Mental health awareness training was provided in November 2016.



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 attended by management and staff in relation to Accreditation Standard Two include:

Recent training in management of cytotoxic medication and management occurred.

A case study of unwitnessed falls, use of anticoagulant therapy and potential head injury.

Continence charting and urine analysis training has been held. Two continence facilitators were trained in November 2016.

Dementia training has been held. Understanding delirium in the elderly training was provided in November 2016.

Medication competency assessment is a requirement of the new household model of care. 60% of eligible care staff have been trained with the remaining 40% to be trained shortly.

On 22 February 2017 an external wound consultant provided a six hour training session on wound process, management and staging to 10 staff in the home. Management said the feedback following this session was most positive.

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


There are systems and processes to ensure care recipients receive appropriate clinical care and policies and procedures to guide staff practice. Twenty four hour registered nursing care is provided and a comprehensive program of assessments is completed on entry. Individualised care plans are formulated, regularly reviewed and monitored by registered nurses. Care is planned in consultation with the care recipient and/or their representative, the care recipient’s medical practitioner and allied health professionals. Staff have a sound understanding of the clinical care process. The home has appropriate supplies of equipment and resources maintained in good working order to meet the ongoing and changing needs of care recipients. Care recipients and representatives state they are satisfied with the clinical care provided and representatives say they are informed of changes in the care recipient’s condition and care needs.

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



There are systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified staff. Documentation and discussions with staff show care recipients’ specialised nursing care needs are identified when they move into the home and addressed in the care planning process. Registered nurses coordinate assessments on the care recipients’ specialised care needs. The home liaises with external health professionals including the local area health service to ensure care recipients’ specialised nursing care needs are met. Staff access internal and external education programs and there are appropriate resources and well maintained equipment to provide specialised nursing care. Care recipients and representatives are satisfied with the specialised nursing care provided.

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


Documentation shows the home refers care recipients to external health professionals and any changes to care following specialist visits are implemented in a timely manner. A physiotherapist is on site three days and the wellness and lifestyle occupational therapist five days each week. Several allied health professionals visit the home on a regular basis including pathology services and the Area Health Service Mental Health Team. Representatives report management and staff ensure they have access to current information to assist in decision-making regarding appropriate referrals to specialist services. Care recipients and representatives are satisfied with the way referrals are made and the way changes to care are implemented.

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


Management demonstrates care recipients’ medication is managed safely and correctly. Registered nurses and medication endorsed care staff administer medications via a blister packaging system. A current pharmacy contract and locked storage of medication promotes safe and correct management of medication to care recipients. The electronic medication system includes photographic identification of each care recipient with their date of birth and clearly defined allergies. Pharmacy and medical practitioner protocols have been established in the home and staff practices are consistent with policy and procedures. The medical advisory committee review legislation changes, medication and pharmacy issues. Regular medication reviews are completed by a consultant pharmacist Medication incident data is collated as part of the quality clinical indicators and is reviewed and actioned by the clinical nurse specialist. Care recipients and representatives are satisfied care recipients’ medications are managed in a safe and correct manner.

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

Team’s findingsThe home does not meet this expected outcome


The home does not have an effective system to ensure all care recipients are as free as possible from pain. Pain is not regularly monitored; regular pain assessments are not attended. Pain management plans are generic and not specific to individual identified needs; they are not regularly reviewed, evaluated or updated. Regular analgesia and whenever necessary (PRN) medications are not evaluated after administration for effectiveness. Alternate pain management strategies are not utilised.

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


There are systems to ensure the comfort and dignity of terminally ill care recipients and support for their families and those involved in their care. Documentation and staff discussions show the spiritual, cultural, psychological and emotional needs of care recipients are considered in care planning and ongoing pastoral care and emotional support is provided. Representatives are informed of the palliation process and the home is in regular communication with representatives, medical practitioners and specialists throughout the palliative care process.

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


Documentation demonstrates care recipients’ nutrition and hydration status is assessed on entry to the home and individual needs including swallowing difficulties, sensory loss, special diets and individual preferences are identified and included in care planning. Appropriate referrals to the speech pathologist, dietitian and dentist are made in consultation with the care recipient/representative and others involved in their care. The organisational seasonal menu is reviewed by a dietitian and provides care recipients with an alternative for the midday and evening meal. Care recipients are weighed monthly or more often if indicated and weight loss/gain monitored with referral to medical practitioners or allied health for investigation and treatment as necessary. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements including thickened fluids, pureed and soft food. Care recipients and representatives are satisfied with the frequency and variety of food and drinks supplied.

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

Team’s findingsThe home does not meet this expected outcome

Management cannot demonstrate care recipients’ skin integrity is consistent with their general health. While staff monitor care recipients’ skin as part of daily care, changes in skin integrity are not always reported to the registered nurse and/or referred to their medical practitioner. Registered nurses, enrolled nurses and care coordinators attend wound dressings however wound management plans are not always updated or effectively evaluated. The home does not have an effective reporting system for monitoring accidents and incidents including skin integrity, skin tears are not included in the clinical indicators.


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


There are systems to ensure care recipients’ continence is managed effectively. A continence link nurse oversees continence management at the home and reports to the deputy director of care or registered nurse. Clinical documentation and discussions with staff show continence management strategies are developed for each care recipient following initial assessment. Care staff report they assist care recipients with their continence programs regularly and monitor care recipients’ skin integrity. Staff are trained in continence management including scheduled toileting, the use of continence aids, and the assessment and management of urinary tract infections. Bowel management strategies include daily monitoring. Staff ensure care recipients have access to regular fluids, appropriate diet and medications as ordered to assist continence. There are appropriate supplies of continence aids to meet the individual care recipient’s needs. Care recipients and representatives state they are satisfied with the continence care provided to the care recipients.

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


There are systems to effectively manage care recipients with challenging behaviours. Documentation and discussions with staff show care recipients’ behavioural management needs are identified by initial assessments and behaviour care plans formulated. Behaviour management strategies include one-on-one and group activities which are regularly reviewed in consultation with the care recipient and/or representatives and other specialist services. Staff confirm they have received education in managing challenging behaviours and work as a team to provide care. The home has access to other health professionals including the area health service mental health team. Staff were observed to use a variety of management strategies and resources to effectively manage care recipients with challenging behaviours and to ensure the care recipients’ dignity and individual needs were respected at all times. Care recipients and representatives are satisfied with how challenging behaviours are managed at the home.

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


There are systems to ensure optimum levels of mobility and dexterity are achieved for each care recipient. These include comprehensive assessments, the development of mobility and dexterity plans and mobility programs. There is a physiotherapist on site weekly four days each week. Individual programs are designed by the physiotherapist and are designed to promote optimum levels of mobility and dexterity for all care recipients. Falls incidents are analysed and are monitored in the quality clinical indicators. Care recipients and representatives report appropriate referrals to the physiotherapist are made in a timely manner. Staff are trained in falls prevention, manual handling and the use of specialist equipment. Assistive devices such as mobile frames, walk belts, mechanical lifters and wheelchairs are available.


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


There are systems to ensure care recipients’ oral and dental health is maintained. Oral and dental health is assessed on entry to the home and documented on care plans. Staff state they receive education in oral and dental care and assist care recipients to maintain daily dental and oral health. Swallowing difficulties and pain are referred to the medical practitioner or allied health services for assessment and review. Care recipients and representatives state care recipients are provided with appropriate diets, fluids, referral and equipment to ensure their oral and dental health is maintained.

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


Sensory loss is assessed on entry to the home and appropriate referrals are made to ensure care recipients’ care needs are managed effectively. Specialist equipment is maintained in good working order and staff are trained in sensory loss. Staff have implemented programs to assist care recipients with sensory stimulation including of taste, touch and smell. Care recipients and representatives report staff are supportive of care recipients with sensory loss and promote independence and choice as part of daily care.

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


Care recipients’ sleep patterns including a history of night sedation are assessed on entry and sleep care plans are formulated. Lighting and noise is subdued at night. Care recipients’ ongoing sleep patterns are reviewed and sleep disturbances monitored and appropriate interventions put in place to assist care recipients to achieve natural sleep. Staff report care recipients who experience sleep disturbances are assisted with toileting, repositioning, snacks and fluids as requested and assessed as needed. Care recipients and representatives are satisfied with the way care recipients’ sleep is managed.


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



Refer to expected outcome 1.1 Continuous improvement for information about the home’s system for actively pursuing continuous improvement. The home demonstrates it is actively pursuing continuous improvement in relation to Accreditation Standard Three and recent examples include:

Several television rooms in the Carol Mailler units have been developed into activity rooms for the interest of care recipients. A pool room, a nursery, a themes music room and a games room have been included into the activities of care recipients. We were told school students visit the home and will utilise the pool and games rooms to assist interactions with the care recipients. Care recipients assisted in painting outdoor furniture to make it attractive and feel involved in the design of their outdoor areas.

An ANZAC Day dawn service has commenced in the home with participation of staff, family and care recipients. Management said this initiative has proven successful and well attended.

Coffee and tea making products stored in containers and attractive cups and plates have been purchased and placed in areas to support care recipients and representative access and independence. Blackboards have been purchased and installed in the kitchen areas to promote meal choices. The print is in large clear letters and staff said the boards help prompt meal choices.

Following the death of a beloved pet dog, a new dog has been acquired and is undergoing training to be a companion dog for the home. Gypsy a brown Labrador, has commenced short visits to the home to the delight of care recipients.

3.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”.


The organisation has systems in place to identify regulatory and legislative changes. Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of regulatory compliance with Accreditation Standard Three include:

Care recipients are offered a residential care agreement that includes security of tenure and the care and services that are to be provided and meet the requirements of The Aged Care Act 1997 and The User Right Principles 2014.The agreement has been updated to include changes to legislation on 1 July 2014 in relation to rates and accommodation bonds.


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

The Charter of Care Recipients’ Rights and Responsibilities is displayed in the home.

The organisation has an inclusiveness policy; staff have had training on the home’s diversity policy and the organisation has received a rainbow tick.



Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of regulatory compliance with Accreditation Standard Three include:

“Person first” training to support the household model of care has been provided to 50% of staff and the other staff are scheduled to complete this training soon. This training will support staff understanding of choice, preferences and individualising care.

In September 2016 inclusiveness and sexuality in the ageing training was provided.

3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the Chaplain, pastoral care workers and lifestyle staff; care recipient/representatives meetings and involvement of family in the activity program. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors including pets are encouraged. Care recipients and representatives interviewed are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive.

3.5 IndependenceThis expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".


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


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


There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs, including the care recipient’s preferred name. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and staff sign to acknowledge confidentiality of care recipients’ information. Care recipients’ rooms are managed so that privacy is not compromised; lockable storage is available to all care recipients. Staff handovers and confidential information is discussed in private and care recipients’ files securely stored. Staff practices respect privacy and dignity and care recipients and representatives are satisfied with how privacy and dignity is managed at the home.

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


Mirinjani’s lifestyle program offers an extensive range of activities six days a week. Care recipients’ past recreational interests and preferences are assessed on entry and monitored on an ongoing basis. The home demonstrates care recipients are encouraged and supported to participate in a wide range of activities of interest to them. The lifestyle coordinator oversees the program and lifestyle staff and guides the volunteers. Lifestyle programs include shopping trips, regular bus outings, entertainers, karaoke, bingo, colouring in, word games, craft and an intergenerational program in conjunction with the local pre-school. Care recipients are given the choice of whether or not to take part in activities. The results of interviews, document review and observations confirm care recipients and representatives are highly satisfied with the activities provided to the care recipients.

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


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days consistent with the care recipients residing in the home. Culturally significant days and anniversaries of importance to the care recipients are celebrated with appropriate festivities. Care recipients and/or representatives are asked about end of life wishes and this information is documented in their file. The home has a full time Chaplain and pastoral staff; pastoral visitors of various other denominations also regularly visit and religious services are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met.


3.9 Choice and decision-makingThis expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".


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

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


Information is provided to explain care and services for new care recipients and/or their representative prior to entry to the home. The UnitingCare Ageing accommodation agreement is offered to each care recipient and/or representative to formalise occupancy arrangements. The agreement and the care recipient handbook include information about their rights and responsibilities, care and services provided, fees and charges, complaints handling, their security of tenure and the process for the termination of the agreement. Care recipients and/or representatives are advised to obtain independent financial and legal advice prior to signing the agreement. The Charter of Care Recipients’ Rights and Responsibilities and other relevant information is documented in the handbook. Care recipients and representatives are satisfied with the information provided by the home regarding security of tenure and their rights and responsibilities.


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



Refer to expected outcome 1.1 Continuous improvements for information about the home’s system for actively pursuing continuous improvement. The home demonstrates it is actively pursuing continuous improvement in relation to Accreditation Standard Four and recent examples include:

Numerous environmental improvements have been completed, with further planned to support the household model of care. Vinyl timber look flooring has been installed to improve the appearance and cleaning of common areas in the “nursing home” section of the home. The home’s food service delivery has improvements completed and some planned to support the household model. It is planned to have the kitchen areas accessible to care recipients and representatives. Refrigerators will be placed outside the kitchen/servery areas so care recipients and representatives are able to self-serve drinks, ice-creams and snacks. The servery benches in some areas will be lowered to increase interaction with care recipients. Care recipients will be encouraged to participate in daily life activities.

Floor to ceiling photo collages of Canberra and the local environment have been installed at the entry to the four wings of the Carol Mailler unit. The attractive pictures support reminiscence and conversation about the familiar landmarks and areas.

The organisation identified an opportunity to improve safety systems. A revamped work health and safety team has been developed. An action plan for the establishment of this committee directed set agenda items, a focus on reduction of staff injuries, improved hazard identification and regular monitoring. A staff WHS board now provides current information and promotions to support and encourage staff in their safety systems awareness.

Solar panels have been installed on the home’s roof to support management of resources.

4.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”.


Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

Examples of regulatory compliance with Accreditation Standard Four include:

The home has a food safety program including a food safety licence.


A current fire safety statement is displayed and equipment is being inspected, tested and maintained in accordance with fire safety regulations.

Safety data sheets are displayed adjacent to the chemicals to which they refer.

The kitchen and catering service has been audited as required.



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 attended by staff relating to Accreditation Standard Four include:

Annual compulsory training includes work health and safety fundamentals, hand hygiene, infection control, food hygiene, manual handling and fire training. 79% of staff have completed the 2017 safe handling training.

Nine manual handling champions have been trained to support competency training of staff.

Registered nurses have undertaken fire warden training.

4.4 Living environmentThis expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".


The home has three levels, a basement service and parking area, ground floor (with a courtyard garden) and upper care recipient rooms. Care recipients have single rooms with private ensuite bathrooms in the Carol Mailler wing and single rooms with shared bathrooms in the nursing home section. Lounge and sitting areas offer opportunities for visitors and care recipients to have private space if desired. The home is comfortable with attractive furnishings. There is a comprehensive program for maintenance which includes corrective and preventative maintenance schedules to ensure the grounds, building and equipment are maintained. Care recipients and representatives express satisfaction with the home’s living environment and maintenance systems.

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


There is a system to provide a safe working environment consistent with workplace, health and safety policy and regulatory requirements. Staff are trained in manual handling and fire awareness and evacuation procedures during their orientation and on an on-going basis. Preventative and corrective maintenance programs ensure equipment is in good working order and the environment is safe. Work health and safety is monitored. Staff are supported by return to work and employee assistance programs. Interviews with staff confirm they have


an understanding of work health and safety systems and are satisfied management is active in providing a safe work environment.

4.6 Fire, security and other emergenciesThis expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".


The home has systems to minimise fire, security and emergency risks. As part of the home’s safety system there are external contractual arrangements for the routine maintenance of the fire-fighting equipment and internal fire alarm system. A random check on various pieces of fire-fighting equipment around the site, confirmed they are inspected on a regular basis. Staff advised fire safety is included as part of the orientation sessions for new staff members as well as part of the mandatory education program. Staff members were able to provide a consistent response on the procedures to be followed in the event of a fire. Key information on a range of other emergency situations such as bomb threats or intruders is located in colour coded flip charts which are located near the telephones. Key contact information for a range of services and emergency personal are also included in the disaster management plan.

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


The home has an effective infection control program. The program includes surveillance and reporting processes, waste management and a food safety program. Preventative measures include orientation and ongoing training, audits and competencies for staff and the provision of protective personal equipment. Cleaning, food safety and vaccination programs are in place. Outbreak kits are available and monitored, emergency supplies are available on-site and sharps and other contaminated waste are disposed of appropriately. Documentation review, observations and staff interviews confirm the home has an effective infection control program.

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


There are processes to ensure hospitality services enhance care recipients’ quality of life and the staffs’ working environment. Hospitality services are monitored through feedback, audits, surveys and meetings. Care recipients and representatives interviewed indicate they are satisfied with the catering, cleaning and laundry services provided.

CateringFood is provided by a main kitchen, located in a sister home close by and prepared and supplemented with fresh options on site. The rotating seasonal menu has been reviewed by a dietitian and caters for the individual needs and preferences of care recipients. The home has a food safety program and has been reviewed by the ACT Food Authority.


CleaningThe living environment was observed to be clean and generally without odour. The cleaners follow a set daily schedule which ensures care recipient rooms and common areas are cleaned. Cleaning staff demonstrate knowledge of the home’s cleaning schedules, practices and safe chemical use. Chemicals used in the home are safely stored and safety data sheets are available, accessible and current.

LaundryThe on-site laundry is in operation seven days a week for all laundry. The laundry also launders all clothing and linen for Eabrai Lodge and Mirinjani Hostel. Chemicals used are auto dosed and include sanitisation. Staff ensure care recipient clothes are labelled.


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