Bupa Calwell - RACS ID 2948 - 43 Were Street

Bupa Calwell RACS ID 2948 43 Were Street CALWELL ACT 2905 Approved provider: Bupa Care Services Pty Limited Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 01 October 2019. We made our decision on 24 August 2016. The audit was conducted on 12 July 2016 to 14 July 2016. The assessment team’s report is attached. We will continue to monitor the performance of the home including through unannounced visits.

Home name: Bupa Calwell RACS ID: 2948 2 Dates of audit: 12 July 2016 to 14 July 2016 Most recent decision concerning performance against the Accreditation Standards Standard 1: Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision 1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met

Home name: Bupa Calwell RACS ID: 2948 3 Dates of audit: 12 July 2016 to 14 July 2016 Standard 2: Health and personal care Principle: Care recipients' physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. Expected outcome Quality Agency decision 2.1 Continuous improvement Met 2.2 Regulatory compliance Met 2.3 Education and staff development Met 2.4 Clinical care Met 2.5 Specialised nursing care needs Met 2.6 Other health and related services Met 2.7 Medication management Met 2.8 Pain management Met 2.9 Palliative care Met 2.10 Nutrition and hydration Met 2.11 Skin care Met 2.12 Continence management Met 2.13 Behavioural management Met 2.14 Mobility, dexterity and rehabilitation Met 2.15 Oral and dental care Met 2.16 Sensory loss Met 2.17 Sleep Met

Home name: Bupa Calwell RACS ID: 2948 4 Dates of audit: 12 July 2016 to 14 July 2016 Standard 3: Care recipient lifestyle Principle: 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 service and in the community. Expected outcome Quality Agency decision 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 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 systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

Expected outcome Quality Agency decision 4.1 Continuous improvement Met 4.2 Regulatory compliance Met 4.3 Education and staff development Met 4.4 Living environment Met 4.5 Occupational health and safety Met 4.6 Fire, security and other emergencies Met 4.7 Infection control Met 4.8 Catering, cleaning and laundry services Met

Home name: Bupa Calwell RACS ID: 2948 1 Dates of audit: 12 July 2016 to 14 July 2016 Audit Report Bupa Calwell 2948 Approved provider: Bupa Care Services Pty Limited Introduction This is the report of a re-accreditation audit from 12 July 2016 to 14 July 2016 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards. To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment. Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards.

The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home. Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets:  44 expected outcomes

Home name: Bupa Calwell RACS ID: 2948 2 Dates of audit: 12 July 2016 to 14 July 2016 Scope of audit An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 12 July 2016 to 14 July 2016. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team Team leader: Jennifer Morrow Team member/s: Carol Lowe Approved provider details Approved provider: Bupa Care Services Pty Limited Details of home Name of home: Bupa Calwell RACS ID: 2948 Total number of allocated places: 144 Number of care recipients during audit: 111 Number of care recipients receiving high care during audit: 107 Special needs catered for: 36 secure dementia care beds Street/PO Box: 43 Were Street City/Town: CALWELL State: ACT Postcode: 2905 Phone number: 02 6298 5400 Facsimile: Nil E-mail address: Nil

Home name: Bupa Calwell RACS ID: 2948 3 Dates of audit: 12 July 2016 to 14 July 2016 Audit trail The assessment team spent three days on site and gathered information from the following: Interviews Category Number General manager 1 Regional support manager 1 Business administration manager 1 Business administrator 1 Care managers 3 Registered nurses 5 Care staff 6 Recreational activities officer/work health and safety committee chairperson 1 General practitioner 1 Care recipients/representatives 16 Physiotherapy aide 1 Laundry staff 3 Cleaning staff 4 Maintenance staff 2 Chef 1 Catering staff 2 Recreational activities officers 3 Sampled documents Category Number Care recipients’ files 14 Education folders (2015 and 2016) 2 Personnel files 10 Medication charts 12 Audit folders (Accreditation Standards 1-4 and medication) 6 Cleaning folders 5

Home name: Bupa Calwell RACS ID: 2948 4 Dates of audit: 12 July 2016 to 14 July 2016 Other documents reviewed The team also reviewed:  Bupa Calwell – resident handbook and pamphlet  Bupa Care Services resident handbook  Care plan schedule, handover, communication diary’s,  Care plans, assessments allied health specialist referral, care folders and charts including pain management, wound treatments, food and nutrition documents, continence care, behaviour logs, physiotherapy and rehabilitation instructions  Care recipients’ information handbook  Catering information including: dietary information, temperature records for thedelivery, storage, preparation and serving of meals, cleaning records, menu  Commissioning education program powerpoint presentation  Complaints on computer system and confidential improvement log folder  Consent to use personal information, display name, consent for treatment and procedures  Daily staffing sheets, staffing availability forms and roster  E-learning education program on computer system  Emergency procedure flipchart  Employee handbook  Guide to incident reporting flipchart  Induction guide – new employee and induction checklist  Infection control: manual, outbreak information/records, vaccination records, infection data, and fridge temperature records  Job description and duty statement folder  Legislative information including: ACT Government – Health Food Business Registration (20 October 2015 to 22 October 2016), mandatory reporting register – computer printout, volunteers police check information and registered nurses and allied health professional registrations folder , staff police check information on computer system and visa information, log books for the sprinkler system, emergency warning system, emergency intercom system, fire detection and alarm systems, passive fire and smoke systems and fire hydrant systems  Leisure and lifestyle: weekly program and calendar, attendance records, lifestyle assessments, photographs

Home name: Bupa Calwell RACS ID: 2948 5 Dates of audit: 12 July 2016 to 14 July 2016  Maintenance program including: reactive maintenance folders in the care offices, preventative maintenance program, sign off sheets, schedule for the preventative maintenance program with external companies, work instructions for the maintenance system, microbial sampling (warm water system), preferred contractors and suppliers telephone listing, service reports on equipment, chemical register, product safety data sheets  Medication management: policy, pharmacy folder, medication charts, medication sign charts, doctor’s orders, incident reports, controlled drugs register  Meeting minutes folder  Resident and accommodation agreement Observations The team observed the following:  Activities in progress  Certificate of completion of a structure - 23 October 2015  Charter of residents’ (care recipients’) rights and responsibilities on display at front entrance  Continuous improvement log folder, cleaning log folder, complaints and advocacy information pamphlets on display at front entrance  Dining rooms during meal service, staff assisting care recipients as needed  Displayed notices including re-accreditation audit notices, advocacy brochures, education and activities calendars meeting minutes and menus  Emergency evacuation plans and emergency kits  Equipment and supply storage areas  Infection control spill kits, sharps containers, outbreak management kits, personal protective equipment, colour coded cleaning equipment, hand sanitiser throughout the home, waste disposal facilities  Interactions between staff, care recipients and representatives  Living environment  Short group observation in Hilly Oaks lounge/dining/activities room  Storage of medications  Value statement on display at front entrance and various locations around the home  Visitors registers and security measures

Home name: Bupa Calwell RACS ID: 2948 6 Dates of audit: 12 July 2016 to 14 July 2016 Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings The home meets this expected outcome Bupa Calwell (the home) opened in late 2015 and participates in a program of organisational audits to review and monitor the quality of service delivery. An audit schedule guides the management team with the program of audits to be conducted across a range of clinical, environmental and administrative areas. The audits results are entered onto the home’s continuous improvement plan as well as a computerised system which enables senior management at the organisation’s head office to monitor any audit trends as well as ensuring audits are being completed.

Additional audits can be undertaken if issues are identified and external audit teams from within the organisation can be called in to conduct audits on specific topics if required. Improvements are also sourced via continuous improvement logs, confidential continuous improvement logs and verbal complaints. Feedback is also sought through the staff, care recipient and representative meetings. A sample of improvements relating to Standard One includes the following:  The general manager advised that some staff files had come to the home when these staff members had been transferred from other homes within the group.

A review of the personnel files identified information was not always filed in a consistent manner and some key information was missing from files. Follow-up has been undertaken with the human resource recruitment centre to track down missing documents. Administration staff have been progressively working through staff files to ensure information is filed appropriately to enable management to track information when needed. The general manager advised the administration staff now have a work instruction to guide them with filing requirements.

The general manager advised that the home undertook a review of the work instruction for the education program and identified that the instructions were not being followed. A training needs analysis was issued to staff to enable them to record their training and education requests. This information was then entered into a matrix to identify the most popular requests for education topics as well as their preferred form of education delivery. This information is now being used to further develop the education program. Pre and post education evaluation forms are being reviewed to glean any information which can be used to develop and improve the education sessions.

Home name: Bupa Calwell RACS ID: 2948 7 Dates of audit: 12 July 2016 to 14 July 2016 1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The organisation has a legislative review committee which monitors legislative changes through access to various websites and information updates from industry bodies and government departments. This information is reviewed and work instructions are then reviewed and updated as needed.

These are accessible to staff across the home and organisation via the intranet. A hard copy is also maintained at the reception area. Information on legislative changes is disseminated to the homes within the group when required. At an operational level a regulatory compliance sub-committee monitors compliance with relevant legislation on an ongoing basis. Staff advised any changes are discussed at staff meetings, education sessions or via memos.

1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home has a system to ensure staff members have appropriate knowledge and skills to perform their roles effectively. The home has recently utilised a training needs analysis to identify education requests from staff (refer to comments above under expected outcome Continuous improvement 1.1). Additional education topics are also identified through audit results, clinical discussions as well as face to face discussion with staff.

The organisation has an e-learning program which includes a series of compulsory education topics. Completion of the mandatory education is monitored by the organisation. External companies are also contracted by the organisation to provide education programs. Education sessions relevant to Standard One include: Compliance and Bupa Management System (BMS), Aged Care Funding Instrument (ACFI), person first coach training and ADACAS – education to leadership team (9 March 2016).

Home name: Bupa Calwell RACS ID: 2948 8 Dates of audit: 12 July 2016 to 14 July 2016 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome The home has a system to ensure care recipients and their representatives have access to internal and external complaints processes. This includes displaying information about the external complaints system and advocacy services at the main entrance to the home.

Information on raising complaints is contained within the residential agreement and handbook which is provided to care recipients and their representatives as part of the entry process to the home. Care recipients’ meetings are held in each area of the home to provide a forum in which care recipients and/or their representatives are able to discuss concerns. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings The home meets this expected outcome The organisation’s commitment to quality as well as their values statements is on public display at the entrance to the home. Information is presented to staff through key documentation such as the staff handbook which is given to all staff on commencement of employment. The organisation’s values are also discussed with new staff members as part of the corporate orientation process. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".

Team’s findings The home meets this expected outcome The home has a system to make sure there are sufficient appropriately skilled and qualified staff members. The general manager and regional support manager advised that since the home opened in late 2015 the staffing requirements are based on the acuity and care needs of the care recipients. The home’s existing pool of staff members provides coverage for sick and annual leave arrangements. Systems are in place to employ new staff. This includes advertising nationally within the organisation as well as advertising locally when required. The organisation’s human resource section ensures all relevant police and visa checks are undertaken for all new staff as well as on an ongoing basis.

New staff members are partnered with experienced staff as part of the orientation process. Staff said that absences through sick or holiday leave are replaced. Care recipients expressed their general satisfaction with the care provided by the staff.

Home name: Bupa Calwell RACS ID: 2948 9 Dates of audit: 12 July 2016 to 14 July 2016 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The home has systems to ensure there are adequate supplies of goods and equipment. The regional support manager and general manager advised as part of the commissioning process for the new home there was a standard order for equipment and stock to ensure all relevant items are in place. There are systems in place to manage the regular ordering of supplies and equipment to ensure adequate supplies are available.

Staff in key areas are responsible for the ordering of stores on a routine basis. The organisation has a designated range of suppliers for services and equipment. Staff members said there are sufficient supplies of equipment and goods to provide care and services.

1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome Information is disseminated to staff through shift handovers, staff meetings and information on noticeboards. Information is relayed to care recipients and their representatives through information on display at the front entrance, various noticeboards and meetings. Documentation no longer required is archived initially on-site. The general manager advised that arrangements are in place with a secure external storage site to store documentation prior to secure destruction.

Files are able to be retrieved as needed. Information retained on the computer system is routinely backed-up on external servers which are maintained by specialist staff at the organisation’s head office. Access to the home’s computers and data within the system is secured via password. Documents and forms used by the organisation are maintained on the intranet with only authorised staff able to make changes. Refer to comments in expected outcome 2.4 Clinical care regarding the management of clinical information.

1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome The organisation has systems to ensure any externally provided services and goods meet specific requirements. Contracts or service agreements are managed at the head office. As part of this process information regarding relevant trade licences, registrations and insurance documentation is obtained. This includes ensuring tradespeople have the appropriate police checks in place.

Local companies and tradespeople are sourced wherever possible. The performance of companies, suppliers and tradespersons is monitored and poor service

Home name: Bupa Calwell RACS ID: 2948 10 Dates of audit: 12 July 2016 to 14 July 2016 delivery is discussed with the company or tradesperson concerned. Staff members advised equipment or goods supplied are good quality.

Home name: Bupa Calwell RACS ID: 2948 11 Dates of audit: 12 July 2016 to 14 July 2016 Standard 2 – Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement regarding the continuous improvement system which exists in the home. Examples of recent improvements in relation to Standard Two include:  As a result of discussions at the medication advisory committee meeting in December 2015 the home has introduced special containers to hold medications (not schedule 8 medications) which require disposal. The containers are provided by the pharmacy and one is located in each of the communities’ treatment rooms. The contents are periodically transferred into one container for collection by the pharmacy.

As a result of customer feedback across the organisation the home is participating in a pilot called “NOURISH” (Needs, Own, Unambiguous, Research, Interaction, Structure and Housekeeping) in May 2016. This pilot is covering a range of services provided by the home. Seven homes within the group are in the pilot program and each home is responsible for a particular component of the pilot. At Bupa Calwell the home is covering Housekeeping which is looking at the dining experience. As a result of care recipient feedback the home has increased hot breakfasts from one to two days per week. Work is currently underway with staff training on the dining experience through table service and the appropriate setting of tables for meals.

For example the place mats used in the dementia specific units (Lake Haven and Hilly Oaks) have been replaced with a different style of table covering to improve the appearance of the dining tables.  A review in April 2016 of clinical documentation identified not all assessments had been signed by the registered nurses; care plans did not always match-up with the clinical assessments; wound photographs did not always have the ruler in the photograph to enable the viewer to see the actual size of the wound and; safety risk assessments had not been fully completed. Action is being taken to rectify these matters.

A spreadsheet is being used to track what is required to update the care recipients care file. The care documentation the team reviewed was consistently completed in line with the home’s guidelines.

Home name: Bupa Calwell RACS ID: 2948 12 Dates of audit: 12 July 2016 to 14 July 2016 2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information regarding the system to ensure the home complies with legislation and regulations relevant to care recipients’ health and personal care.

The organisation manages the process to ensure the registrations of the registered nurses and endorsed enrolled nurses are current. The organisation and general manager has access to the Australian Health Practitioner Regulatory Agency (AHPRA) website to verify current registrations if required. The home’s staff maintain the register of dangerous drugs in line with legislative guidelines.

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Education sessions include: understanding dementia, wound management, peg feed pumps, dysphagia, medication training, syringe driver and Parkinson’s disease.

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

Team’s findings The home meets this expected outcome Care recipients receive clinical care that is appropriate to their individual needs and preferences. On entry to the home an interim care plan is completed by the registered nurse. Assessments are then completed and the information is used to develop individual care plans, which include interventions and strategies enabling care staff to deliver care. The care managers, registered nurses and care staff monitor care through observation and review, case conferences, incident and exception reporting processes. Results show that care recipients’ needs are identified, documented and reviewed regularly, and care is provided consistent with their care plans.

Care workers’ practices are monitored for compliance with the home’s processes and procedures. Care recipients and representatives said they are satisfied with the level of consultation and with the personal care provided to care recipients.

Home name: Bupa Calwell RACS ID: 2948 13 Dates of audit: 12 July 2016 to 14 July 2016 2.5 Specialised nursing care needs This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Care recipients’ specialised nursing care is identified and met by appropriately qualified nursing care workers. Specialised care needs are assessed on entry and in an ongoing process as new care needs occur. The care managers and registered nurses monitor the care each care recipient receives to ensure specialised care needs, for example specialised feeding by tubes, diabetes management, urinary catheterisations and complex wound care is delivered.

Results show that care recipients receive specialised nursing care consistent with preferences and identified needs. The registered nurses and care staff qualifications are maintained or upgraded through education and competency programs. Practices are monitored through the home’s internal procedures. Care recipients and representatives said they are satisfied with the specialised nursing care the care recipients receive. 2.6 Other health and related services This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.

Team’s findings The home meets this expected outcome Care recipients are referred to appropriate health specialists in accordance with their needs and preferences. The need for referral to health specialists is identified on entry, through the ongoing assessment process, and when care needs change. Diaries and change of shift handover reports inform care staff of appointments to health specialists. Care recipient’s families provide transport or the home organises it and an escort can be arranged. Documentation review confirmed referrals are made to an array of health specialists including behaviour specialists, psycho-geriatricians, speech pathologists, eye specialists, dieticians, physiotherapists, podiatrists and dentists.

Care staff are knowledgeable about the referral procedure. Care recipients and representatives said they are satisfied with the arrangements for referral to health specialists.

2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Care recipients’ medication is managed safely and correctly. Medication is delivered using a medication package system stored in individual secure medication cupboards in each care recipients room. Monitoring of the medication system is the role of care managers, registered nurses and pharmacist, it includes checking expiry dates, sign sheets, storage, as required usage (PRN), poly-pharmacy, side effects and medication errors.

All medications are administered by registered nurses or competency assessed care staff and we observed

Home name: Bupa Calwell RACS ID: 2948 14 Dates of audit: 12 July 2016 to 14 July 2016 medication being administered to care recipients safely and correctly. Results show care staff have access to a medication incident reporting system that is monitored for improvement opportunities and ongoing education is provided to maintain skills. Care recipients and representatives said they are satisfied with the manner in which care recipients’ medication is managed. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome Care recipients are assisted to be as free as possible from pain.

The general practitioner, physiotherapist, physiotherapy aide, registered nurses and carers assess care recipients when they enter the home and when their needs change. Pain management treatments such as heat therapy, massage, exercise programs, and medication or a combination of these treatments are implemented. The registered nurses, allied health professionals and carers monitor the effectiveness of pain management treatments through their assessment and documentation processes. Results show that pain management is tailored to each care recipient’s needs and care recipients are as free from pain as possible.

Care staff are knowledgeable about each care recipient’s pain management plan. Care recipients and representatives said they are satisfied with the pain treatments used to ease the care recipient’s pain.

2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome Care recipients’ comfort and dignity during palliation is maintained. Care needs are assessed on a regular basis and decisions are made in consultation with the care recipient and/or their representative when palliation is required. Gentle massage, pain relieving medication, pressure relieving mattresses and regular repositioning are examples of the comfort offered. Local clergy are available to provide spiritual support as required.

Advance care directives are completed on an individual basis in consultation with the care recipient and/or their representative to ensure their wishes are met and dignity is maintained. Representatives gave us positive and appreciative feedback about the manner in which palliative care services are provided.

2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Care recipients are assisted to receive adequate nourishment and hydration. Each care recipient’s dietary and hydration needs are assessed on entry to the home and on an ongoing

Home name: Bupa Calwell RACS ID: 2948 15 Dates of audit: 12 July 2016 to 14 July 2016 basis. The home has access to a dietician and a speech pathologist and treatments suggested are incorporated into the care recipient’s plan.

The registered nurses and carers monitor nutrition, hydration and weight loss. Where indicated specific instructions are provided to staff which include meal supplements, thickened fluids, soft diets and increased monitoring. Results show that care recipients receive adequate nourishment and hydration. Care staff are knowledgeable about the dietary and hydration processes used at the home. Care recipients and representatives said they are satisfied with the choice of meals and beverages offered. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.

Team’s findings The home meets this expected outcome Care recipients’ skin integrity is consistent with their general health. Skin integrity is assessed during the entry assessment period and when care needs change. Incidents, accidents, wound infections, and skin tears are monitored and trends identified and actioned. Documentation including care plans and wound charts show that skin care is managed effectively. Care recipients have access to a podiatrist and a hairdresser. The home has a range of wound care products to use for different types of wounds and a system to track healing processes.

Wound care is delivered by the registered nurses. Dietary supplements are available to promote skin integrity. Assistance is provided with personal hygiene and repositioning as often as needed. Results show that skin integrity is consistent with each care recipient’s general health. Care recipients and representatives said they are satisfied with the way the care recipient’s skin integrity is managed.

2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome Care recipients’ continence is managed effectively. Continence requirements are assessed during the entry assessment period and when care needs change. The continence program includes assessing care recipients for toileting needs and preferences. The registered nurses recommend and monitor individual toileting programs including, fluids, fibre, aperients, and exercise. Bowel care is monitored each shift and care workers are able to advise and provide treatments that promote regularity.

Data on infections that affect continence is collected, analysed and actioned. Continence products were observed to be plentiful and varied. Results show that continence is managed effectively. Care recipients and representatives said they are satisfied with the way the home manages the care recipient’s continence.

Home name: Bupa Calwell RACS ID: 2948 16 Dates of audit: 12 July 2016 to 14 July 2016 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome Care recipients with challenging behaviours are managed effectively. Behaviour assessment occurs during the entry assessment period, and reassessment occurs whenever the care recipient’s identified behaviours change. Care recipients are monitored to ensure factors that can produce a change in behaviour such as pain, urinary tract infections and reduced oral intake are identified and actioned quickly.

The home has access to specialist services who provide advice and strategies for managing challenging behaviours. We observed all staff interacting with care recipients with ease and respect. Care staff demonstrated knowledge of each care recipient’s individual requirements. Results show that challenging behaviours are monitored, triggers are identified and strategies are developed to promote effective management. Care recipients and representatives said they are satisfied with the way the home’s care staff minimise the impact of challenging behaviours. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings The home meets this expected outcome Care recipients are assisted and encouraged to achieve optimum levels of mobility and dexterity. The physiotherapist assesses all care recipients on entry to the home, when care needs change and on an ongoing basis. Plans are developed for care recipients to receive the most effective treatments to achieve and maintain their mobility and dexterity. The physiotherapist, registered nurses, and physiotherapy aide monitor the effectiveness of falls prevention strategies and reassessment occurs whenever care recipients fall. Results show that care recipients are assisted to mobilise, they are encouraged with rehabilitation and they have access to aids to promote dexterity.

Care staff are knowledgeable about the programs. Care recipients said they are satisfied with the assistance they receive with mobility and dexterity.

2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Care recipients’ oral and dental care is maintained. An oral and dental assessment is completed during the period following entry and when care needs change. Care staff encourage care recipients to brush their own teeth and maintain denture care. The registered nurses and care staff manage and monitor oral and dental care. Referrals to dental specialist services and speech pathologists are made after consultation with the care recipient or their representative.

Results show that oral and dental care is maintained. Care staff are

Home name: Bupa Calwell RACS ID: 2948 17 Dates of audit: 12 July 2016 to 14 July 2016 knowledgeable about the dental programs. Care recipients and representatives said they are satisfied with the dental care received by care recipients. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Care recipients’ sensory losses are identified and managed effectively. Assessment occurs on entry and care plans provide information so that care staff may ensure glasses and hearing aids are properly fitted and maintained.

The registered nurses monitor sensory loss and refer to specialist services when indicated. The physiotherapist tests skin sensitivity prior to prescribing treatments for pain management. Results show that sensory losses are identified and managed effectively. Care recipients and representatives said they are satisfied with the support provided to assist care recipients to manage sensory loss. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”.

Team’s findings The home meets this expected outcome Care recipients are able to achieve natural sleep patterns. Sleep patterns are assessed on entry to the home and when care needs change. Some of the strategies used to ensure natural sleep patterns include a warm milk drink, night light, massage, pain management, pressure reducing mattresses and continence management. Sleep monitoring is documented to assist and staff are available to assist care recipients who cannot use the bell. Results show that care recipients are able to achieve natural sleep patterns. Care recipients and representatives said they are satisfied with the strategies in place that enable care recipients to achieve natural sleep patterns.

Home name: Bupa Calwell RACS ID: 2948 18 Dates of audit: 12 July 2016 to 14 July 2016 Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement regarding the continuous improvement system which exists in the home.

Examples of recent improvements in relation to Standard Three include the following:  The home has undertaken improvements to the activities program as a result of a visit by the Australian Aged Care Quality Agency. During this visit it was identified that the monthly activities program was not always on display and not all the programs were being evaluated. The monthly activities program is now on public display to enable care recipients to plan what activities they would like to attend. Work is underway on creating “maps of life” for each care recipient which identify care recipients social history and interests.

Evaluation of the activities program is underway. The general manager advised the home is still endeavouring to employ more activities staff to provide improved activities to the care recipients.

It was identified as part of a review of the quality program that focus group discussions had not been undertaken with care recipients and their representatives. This program will be undertaken by the activities staff. This focus group discussion will cover the 44 Accreditation expected outcomes and provide an opportunity for care recipients and their representatives to be consulted and provide feedback on the quality of service provision.  As a result of feedback from care recipients and their representatives the home has developed a site specific handbook. The general manager advised that a working party of one care recipient and two representatives had looked at the types of information needed by new care recipients which were not included in the corporate handbook.

A new handbook was printed and issued to care recipients in April 2016. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s system to ensure compliance with legislation and regulations relevant to care recipients’

Home name: Bupa Calwell RACS ID: 2948 19 Dates of audit: 12 July 2016 to 14 July 2016 lifestyle. The home maintains relevant registers such as a mandatory reporting register. The organisation manages the residential care agreement to ensure new care recipients or their representatives are provided with the most up to date version. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for details of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively.

Education sessions provided at the home include customer feedback, mandatory reporting as part of the compulsory education program for all staff and privacy and dignity as part of the orientation program for all new staff. 3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".

Team’s findings The home meets this expected outcome Care recipients receive support in adjusting to life in the new environment and on an ongoing basis. On arrival each care recipient is orientated to the home and introduced to other care recipients and care workers. A social profile is completed and the information is used to assist in providing ongoing emotional support. Care recipients are encouraged to bring personal items to the home to personalise their room. Care staff and the recreational activities’ officers spend time with each care recipient when they arrive at the home to assist with the settling in process.

All staff are knowledgeable about how to provide emotional support to care recipients and their representatives. Care recipients and representatives said they are satisfied with the emotional support given to care recipients.

3.5 Independence This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service. Interests and activities outside the home are encouraged. Voting in federal and local elections is facilitated. We observed care staff assisting care recipients with a range of activities that encourage and support them to maintain their independence.

Care recipients and representatives said they are satisfied with the encouragement and support given to care recipients to maintain independence

Home name: Bupa Calwell RACS ID: 2948 20 Dates of audit: 12 July 2016 to 14 July 2016 3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Care recipients have the option to consent or refuse the use of their photographs or personal details being on display or in print. Care information is kept in locked cupboards and on password protected computers.

Care staff are able to describe their work practices in relation to privacy and dignity. Care staff were observed interacting with care recipients and representatives with dignity and respect while maintaining confidentiality. Results show that privacy, dignity and confidentiality is recognised and respected. Care recipients and representatives said they are satisfied with the level of privacy and dignity given to care recipients 3.7 Leisure interests and activities This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".

Team’s findings The home meets this expected outcome Care recipients are encouraged and supported to participate in a range of activities of interest to them. The home runs an activities program which is based on care recipient input. Group activities include entertainers, bingo, men’s group, movies and crafts. Verbal feedback, activity evaluations and regular meetings with care recipients ensures their input into the activity program. Activities staff record care recipient’s participation at activities. Alternative activities such as access to fiddle boards, library books, hand massages and one to one activities are available to those who choose not to join the group activities or are unable to do so.

Results show that care recipients are encouraged and supported to participate in activities. Care recipients and representatives said they are satisfied with the activities offered to care recipients.

3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome Care recipients’ interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. Important national, cultural and religious days for example Christmas, Easter, St Patrick’s and ANZAC Day are celebrated. Church services and are held at the home, and care recipients are assisted to attend services in the local community. The local clergy are called upon on as required and visit regularly to provide support to all care recipients who wish to be visited.

Communication boards are available in languages for care recipients who do not use

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