WIXLIB

Assessment informationThis section covers information about the home’s performance against each of the expectedoutcomes of the Accreditation Standards.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 residents, their representatives, staff andstakeholders, and the changing environment in which the service operates.1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuousimprovement”.Team’s findingsThe home meets this expected outcomeThe home has systems and processes to capture information from residents, staff and otherstakeholders to identify areas for improvement. Management identify opportunities forimprovement through various mechanisms including quality activities, projects, adverseevents, suggestions, complaints, maintenance requests, meetings, informal interaction and thechanging needs of residents. Management and staff respond to these opportunities at the timeand/or may record these on improvement forms or directly onto the continuous improvementplan. The plan includes action taken, progress, time frames, completion and outcomes.Management and key staff monitor the system in an ongoing manner with scheduled reviewsof the program. Regular reporting of results are made to all parties and incorporate aconsultative approach through regular meetings, newsletters, memoranda and satisfactionsurveys. Staff said they are encouraged and actively participate in the home’s continuousimprovement processes. Residents and representatives confirm ongoing improvements occurat the home.Examples of continuous improvement related to Standard 1 include: In response to resident and staff comments regarding lifting slings, managementreviewed the types and numbers of slings in the home. Although sufficient types andnumbers were available, management identified the inconsistent distribution of cleanslings once returned from the laundry. This resulted in staff labelling the slings with acode applicable to the units or resident rooms within the home and all staff informed ofthe system. Team leaders now routinely monitor the correct use of slings as to residenttransfer needs which so far, have not resulted in any changes. Management saidcomplaints regarding slings have ceased and believe the improved system has resultedin a reduction in the number of resident bruises and skin tears of previously unknownorigin. Residents confirmed staff now utilise the correct sling and are more comfortableand confident with staff. Residents’ ongoing comments regarding the podiatry services resulted in key staffobserving the service provided to residents. Staff identified the service provided by onepodiatrist was rushed with minimal resident interaction. Management referred this tocorporate management and another podiatrist now attends to residents at the home.Management said resident feedback has been positive regarding the service by the newpodiatrist. Residents have commented they find the new professional more friendly andHome name: Noble Manor Residential Aged CareRACS ID: 37836Dates of audit: 01 April 2014 to 02 April 2014

gentle when handling them and they spend time prior to treatment talking through theirconcerns or preferences.1.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place toidentify and ensure compliance with all relevant legislation, regulatory requirements,professional standards and guidelines”.Team’s findingsThe home meets this expected outcomeThe home has systems to identify and ensure compliance with all relevant legislation,regulatory requirements, professional standards and guidelines. The organisation receivesrelevant information from Government, peak bodies and professional associations.Associated departments or committee groups review changes, update policies if required, andinform management at the home. Management in turn inform staff and in general, relevantstakeholders of regulatory changes and where necessary, may provide further education forstaff. Orientation and information handbooks identify specific regulatory compliance issuesrelevant to stakeholders with regulatory compliance a standing agenda item at all meetinggroups. Corporate management oversee governance and through regular reporting processesand quality activities. Observation of staff practice ensures staff knowledge and practices areconsistent and compliant with regulatory requirements. Staff said they receive informationregarding regulatory changes and reiterated their responsibilities related to Standard 1 in theirwork roles.Examples of regulatory compliance in relation to Standard 1 include: The home has a continuous improvement system. The organisation and the home’s management have effective systems to manage andmonitor police certificates and statutory declarations, as appropriate. The organisation has a system to monitor the currency of professional registrations forstaff and contracted health professionals. There are appropriate and secure information storage and destruction systems in thehome.1.3 Education and staff development:This expected outcome requires that “management and staff have appropriate knowledge andskills to perform their roles effectively”.Team’s findingsThe home meets this expected outcomeManagement identify educational needs for staff through staff suggestions, training needsanalysis, audit results, incident reviews and changing resident needs. Management ensurestaff have appropriate skills and knowledge through competency testing, audits andobservation. Management uses a variety of mechanisms to deliver education including toolboxtraining, online education resources, external courses and organisational education sessions.Management develops an annual education calendar to meet identified staff developmentHome name: Noble Manor Residential Aged CareRACS ID: 37837Dates of audit: 01 April 2014 to 02 April 2014

needs and mandatory training requirements. Management and staff said the type, frequencyand availability of education meets their needs. Residents and representatives are satisfiedstaff have the appropriate knowledge and skills to deliver quality care.Examples of recent education relevant to Standard 1 Management systems, staffing andorganisational development include: customer service improving documentation time target – payroll (finger scan) understanding accreditation.1.4 Comments and complaintsThis expected outcome requires that "each resident (or his or her representative) and otherinterested parties have access to internal and external complaints mechanisms".Team’s findingsThe home meets this expected outcomeThe home has comment and complaint mechanisms that are accessible to all stakeholders.The comments and complaints system includes feedback forms, stakeholder meetings,satisfaction surveys, informal interactions with staff and an ‘open door’ policy of access tomanagement. Stakeholders have access to information about the internal and externalcomplaint services and advocacy services which are available in languages other thanEnglish. Comments and complaints are actioned and documentation indicates stakeholdersraising concerns, receive feedback in a timely manner. Regular audit and data analysisprocesses assist management evaluate the effectiveness of actions taken and identify anyassociated trends for further response. Staff stated they are comfortable to raise matters thatconcern them and expressed their responsibility in assisting residents with concerns orcomplaints. Residents and representatives said they are comfortable in approaching staff andmanagement with any issues and expressed satisfaction in relation to actions taken.1.5 Planning and leadershipThis expected outcome requires that "the organisation has documented the residential careservice’s vision, values, philosophy, objectives and commitment to quality throughout theservice".Team’s findingsThe home meets this expected outcomeManagement documents the home’s philosophy and vision and values statement whichcaptures their commitment to quality care. Management have displayed their philosophy andvision and values statement in the front foyer of the home.Home name: Noble Manor Residential Aged CareRACS ID: 37838Dates of audit: 01 April 2014 to 02 April 2014

1.6 Human resource managementThis expected outcome requires that "there are appropriately skilled and qualified staffsufficient to ensure that services are delivered in accordance with these standards and theresidential care service’s philosophy and objectives".Team’s findingsThe home meets this expected outcomeManagement employs appropriately skilled and qualified staff to meet resident care needs.The management team facilitates recruitment following policies and procedures and employs arange of staff with a skill mix to achieve their objectives. Casual and part time staff replacestaff on annual or sick leave and rosters are driven by the care needs of residents. Positiondescriptions and duty lists inform and guide staff and new staff participate in an orientation andinduction program and complete ‘buddy’ shifts. Staff complete mandatory education includingmanual handling and fire and emergency and appropriate staff complete medicationcompetencies. Management and staff confirmed staff have appropriate skills to meet residents’needs. Staff said management provide them with an orientation of work practices, enjoy theirwork and express a commitment to the residents and to the management team. Residents andrepresentatives express confidence in the abilities of staff and say they are very satisfied withthe services staff provide to them.1.7 Inventory and equipmentThis expected outcome requires that "stocks of appropriate goods and equipment for qualityservice delivery are available".Team’s findingsThe home meets this expected outcomeManagement has systems to ensure appropriate goods and equipment are available for thedelivery of quality service and care. The organisation supports the maintenance, replacementand supplementation of inventory and equipment through budget allocations, ordering systemsand the provision of corporate resources. Management authorises the purchase of capitalequipment following trial and evaluation and provides staff training where required.Key staff regularly order and ensure adequate supplies of clinical and non-clinical stockincluding back up supplies as required, through the organisation’s preferred suppliers. Staffrotate stock where required, maintain adequate stock levels with goods stored in clean, tidyand secure storage areas. Preventative and reactive maintenance programs ensureequipment is maintained and in good working order. Staff, residents and representativesexpressed satisfaction with the quality, quantity and availability of goods and equipment asrequired.1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".Team’s findingsThe home meets this expected outcomeManagement and staff gather information through the assessment and care planning process,financial and contractual information, staff employment, continuous improvement activities,Home name: Noble Manor Residential Aged CareRACS ID: 37839Dates of audit: 01 April 2014 to 02 April 2014

meetings and correspondence. Management and staff have access to policies and proceduresand clinical and resource information to guide care and work practices. Resident andpersonnel files are stored securely in restricted access areas and management archivesresident and staff documentation. Management and staff disseminate other informationthrough quality reports, care consultations, handovers, electronic mail and texts. There aresystems for document review and control and secure off site back up of electronic systems.Checklists and information between care and support services are generally completed.Residents and representatives said management and staff ensure they are aware ofinformation relevant to them through care consultations, noticeboards, in meetings and bymail.1.9 External servicesThis expected outcome requires that "all externally sourced services are provided in a way thatmeets the residential care service’s needs and service quality goals".Team’s findingsThe home meets this expected outcomeThe organisation sources external services to meet residents’ requirements and service goalswith procedures for establishing contracted services, selection criteria and negotiation. Productsuppliers and service contractors sign service agreements which include standards of service,regulatory and license requirements, qualifications and insurance. Management monitors andevaluates performance of delivery services through observation, stakeholder feedback andformally through cyclic review processes. External service personnel sign in and out when onsite and wear specific identification tags. The corporate office liaises with external providers,suppliers and tradespeople to address any dissatisfaction with services or supplies. Staff haveaccess to preferred supplier and service contact lists. Staff, residents and representatives saidthey are satisfied with the services provided by the current external contractors and suppliersat the home.Home name: Noble Manor Residential Aged CareRACS ID: 378310Dates of audit: 01 April 2014 to 02 April 2014

Standard 2 – Health and personal carePrinciple: Residents’ physical and mental health will be promoted and achieved at theoptimum level, in partnership between each resident (or his or her representative) and thehealth care team.2.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuousimprovement”.Team’s findingsThe home meets this expected outcomeThe home has an established continuous improvement system that shows ongoingimprovement in resident health and personal care. For a description of the home’s system ofcontinuous improvement refer to expected outcome 1.1 Continuous improvement. Staff andmanagement document incidents such as falls, skin tears, behaviours and medicationadministration or supply issues. Management regularly collates incident data that is thenanalysed for trends, discussed with appropriate staff and actioned. Staff, residents andrepresentatives are satisfied the home is actively working to improve residents’ health andpersonal care.Examples of continuous improvement related to Standard 2 include: Management initiated a palliative care project which resulted in five registered nursesand the general manager attending an external education session delivered by apalliative care support organisation with resource material available for the home.Nursing staff in turn provide education to other staff with one of the five staff now takingon the role of portfolio manager. Documented staff feedback regarding the educationattended highlighted the increased knowledge and focus in identifying resident pain,delirium or dehydration and interventions sooner than later. Changes introduced includescheduled consultation with families and residents regarding end of life wishes, palliativecare brochures in resident information packs, the introduction of a palliative care kit andculturally appropriate as required. Management said another five staff are booked toattend palliative care education and to ensure coverage of staff skills across all shiftsand arrange information sessions for residents and their families. Documented feedbackshows families’ appreciation in the respect, care and comfort provided by staff duringtheir resident’s end of life and the support and patience shown to family members duringthis time. Management said the project continues and evaluation is ongoing. A change in pharmacist and the packing of medications from multi-dose to single-doseresulted in a reduced number of medication incidents related to packing errors. The newpharmacist now continues to provide annual medication reviews as preferred by thehome, regardless of regulatory changes from annual to bi-annual reviews. Managementidentified previously, where medications were incorrectly packaged, the service providerwas untimely in rectifying the medication required and staff were spending too much timetrying to follow up on medication urgently needed for residents. Since the change,management demonstrated packing errors have significantly reduced and medicationsconsistently delivered. Residents expressed satisfaction with the change and arereceiving their required medication on time.Home name: Noble Manor Residential Aged CareRACS ID: 378311Dates of audit: 01 April 2014 to 02 April 2014

2.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place toidentify and ensure compliance with all relevant legislation, regulatory requirements,professional standards and guidelines about health and personal care”.Team’s findingsThe home meets this expected outcomeThe organisation has systems to identify and ensure compliance with all relevant legislation,regulatory requirements, professional standards and guidelines in relation to health andpersonal care. Refer to expected outcome 1.2 Regulatory compliance for a description of thehome’s regulatory compliance system. Staff demonstrated knowledge of regulatoryrequirements and guidelines relative to Standard 2.Examples of regulatory compliance relating to Standard 2 include: Management and staff ensure the safe management, administration and storage ofmedications in accordance with legislative requirements. Registered nurses oversee residents’ high care clinical needs. Management and staff have access to policy and procedures to guide them should aresident be inexplicably missing from a home. Management maintain a consolidated reporting register with relevant informationregarding reportable incidents.2.3 Education and staff developmentThis expected outcome requires that “management and staff have appropriate knowledge andskills to perform their roles effectively”.Team’s findingsThe home meets this expected outcomeRefer to expected outcome 1.3 Education and staff development for information aboutmanagement’s education and staff development systems and processes. Examples ofeducation and training provided by management relevant to Standard 2, Health and personalcare include: dental rescue dysphagia palliative care skin integrity wound care and nutrition.Home name: Noble Manor Residential Aged CareRACS ID: 378312Dates of audit: 01 April 2014 to 02 April 2014

2.4 Clinical careThis expected outcome requires that “residents receive appropriate clinical care”.Team’s findingsThe home meets this expected outcomeThe home has an effective system to ensure residents receive clinical care appropriate to theirneeds and preferences. Senior nurses assess each resident’s clinical needs and preferenceson entry to the home using evidence based assessment tools, information provided by otherhealth professionals, the resident and their representatives. They then develop an initial careplan and ensure any risks for the resident are managed effectively. Longer and detailed careplans take the place of the initial care plan after one month and nursing staff review theseevery month or more often, to ensure they remain consistent with the resident’s needs andpreferences. Staff discuss and ‘handover’ daily details about the ongoing or changing careneeds of each resident between shifts and record relevant details in the progress notes. Seniornursing staff and the quality manager collect and analyse clinical incident data every monthand prepare a monthly report. They evaluate information and identify if any actions need to betaken. Staff at the home also regularly conduct comprehensive audits to ensure a highstandard of care, communication and documentation is maintained. Residents andrepresentatives said staff communicate relevant changes when residents’ clinical needschange.2.5 Specialised nursing care needsThis expected outcome requires that “residents’ specialised nursing care needs are identifiedand met by appropriately qualified nursing staff”.Team’s findingsThe home meets this expected outcomeThe home has a system to ensure appropriately qualified staff identify and meet residents’specialised nursing care needs. Senior nurses, in conjunction with the resident’s doctor orother health care consultants assess each resident’s needs and preferences on entry to thehome. They then develop an individual care plan and review and update this every month ormore frequently if required. Care plans reflect monitoring requirements, specific needs,equipment, resources, instructions and strategies to optimise care delivery. Staff receive anyaddition education if needed from senior staff at the home or external specialists. Residentssaid they are happy with the way staff meet their specialised care needs.2.6 Other health and related servicesThis expected outcome require

2.15 Oral and dental care Met 2.16 Sensory loss Met 2.17 Sleep Met . Home name: Noble Manor Residential Aged Care RACS ID: 3783 4 Dates of audit: 01 April 2014 to 02 April 2014 Standard 3: Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the .