WIXLIB

ObservationsThe team observed the following: Australian Aged Care Quality Agency re-accreditation audit notice displayed Brochures including external and internal complaints mechanisms, advocacy informationleaflets, suggestion boxes Charter of residents’ rights and responsibilities displayed Chemical storage, safety data sheets Cleaning system and processes Dining rooms at meal times, the serving of meals, staff assisting residents with mealsand beverages, menu displayed, dietary information sheets Equipment and supply storage areas Fire safety instructions, equipment, evacuation plans, current fire safety statementdisplayed, emergency procedure flipcharts, residents’ individual evacuation backpacks,emergency kits with clinical and lifestyle requisites inspection tags on fire extinguishers,exit lights, colour coded emergency procedure flip charts and evacuation floor plans Handover between shifts Infection control resources and equipment including spills kits, outbreak box, personalprotective equipment, colour coded cleaning equipment, colour coded wastemanagement equipment, hand washing stations and hand sanitiser dispensers Interactions between staff, residents and relatives/representatives, visitors Laundry system and processes Living environment including grounds Manual handling equipment - lifting machines, mobility transfer belts, protective clothingworn by residents, residents using mobility equipment such as walking frames Medication storage and administration procedures Mobility equipment Notice boards containing resident activity programs and notices, menus, memos, staffand resident information Re-accreditation audit notice displayed Residents participating in the activities program Safety signage and staff safe work practices Secure document storage, archives and records management including storage ofresidents’ and staff documentsHome name: Allawah Lodge Aged Persons HostelRACS ID: 03065Dates of audit: 30 June 2015 to 01 July 2015

Security systems including phones, nurse call system, external lighting, visitors sign inand sign out book Short group observation in Aitken Logan wing Staff practices and courteous interactions with residents, visitors and other staff Staff practices, staff work areas, education resources reception and offices Vision, mission, values displayedHome name: Allawah Lodge Aged Persons HostelRACS ID: 03066Dates of audit: 30 June 2015 to 01 July 2015

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 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 continuousimprovement”.Team’s findingsThe home meets this expected outcomeThe home has a quality framework which enables the pursuit of continuous improvement andthe monitoring of the home’s performance against the Accreditation Standards. Areas forimprovement are identified through various processes including but not restricted to resident,staff and management meetings, surveys, the complaints process, reporting of incidents andaccidents, clinical data, observation and verbal feedback. Matters raised are registered,actioned and communicated to all relevant stakeholders. Staff and residents are able tocontribute to suggestions for improvement through approaching senior staff, attendingmeetings, completing suggestion forms and surveys. Interviews with residents andrepresentatives confirmed their satisfaction with management’s response to any feedback theyprovide. The home has made planned improvements in relation to Accreditation Standard One- Management systems, staffing and organisational development, including: Following information obtained during staff appraisals where staff indicated they wantedfurther education, management organised a mandatory education day. During thissession staff were provided with the mandatory education for the year as well as someother topics which had been requested by them. The education was held on twoconsecutive days and management indicated this approach for mandatory education willbe continued on an ongoing basis. Due to staff being unsure of how to use the existing accident/incident form, managementcreated two forms for accident and incident reporting. Staff are now using the correctforms for reporting accidents and incidents.Home name: Allawah Lodge Aged Persons HostelRACS ID: 03067Dates of audit: 30 June 2015 to 01 July 2015

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 that identify and ensure compliance with changes in relevantlegislation, professional standards and guidelines. Management accesses relevant informationfrom government departments, membership of an industry representative body, attendance atprofessional meetings, seminars and accessing the internet and other sources. Managementprovides information about changes to staff by memoranda, staff meetings and staff educationsessions. Compliance with regulatory requirements is monitored through audits, competencyassessments, staff appraisals and observations by management.Examples of regulatory compliance relating to Accreditation Standard One include: Procedures for police checks for staff and volunteers are in place. Interviews anddocumentation confirmed these have been completed. Management at the home ensured each resident and the resident representatives wereadvised in writing about the forthcoming re-accreditation audit. Information posters on the Aged Care Complaints Scheme are displayed within thehome.1.3 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 outcomeThe home has an education and training program to ensure staff have the appropriateknowledge and skills to perform their roles effectively. The review of documentation andinterviews with management and staff demonstrate training needs are identified. Mandatorytraining and programmed training opportunities ensure staff have the necessary knowledgeand skills to meet the needs of the residents in their care. Qualified staff, competencyassessments and external education opportunities are used to ensure a variety of training isprovided. There is an orientation process for new staff. All staff interviewed reported they haveaccess to education on a regular basis. Staff attendance records and other documentationhighlighted the following examples of training provided in relation to Accreditation StandardOne: TARS – Older persons legal service Aged Care Funding Instrument (ACFI) documentation and assessment Effective communication in the workplaceHome name: Allawah Lodge Aged Persons HostelRACS ID: 03068Dates of audit: 30 June 2015 to 01 July 2015

1.4 Comments and complaintsThis expected outcome requires that "each care recipient (or his or her representative) andother interested parties have access to internal and external complaints mechanisms".Team’s findingsThe home meets this expected outcomeThere are internal and external mechanisms for residents, representatives and otherinterested parties to provide feedback about comments and complaints. External and internalcomplaints information is accessible to residents and visitors. Complaints are registered andthe home ensures complaints are actioned and feedback is provided to the complainant in atimely manner. Information concerning complaint avenues and grievance procedures isdocumented in the resident and staff handbooks. Comments and complaints are discussed atthe home’s staff meetings. Residents and staff interviewed are aware of the home’s feedbacksystem and expressed satisfaction with the resolution of any concern they raised.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 outcomeThe home’s vision statement is documented and the commitment to quality is expressed in thestatement. Observations and document review demonstrates the home’s philosophy, vision,mission and values are available to all stakeholders in printed format and are displayed in thehome. Interviews with residents and representatives and our observations show managementand staff model behaviours consistent with the organisation’s vision, mission and values.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 outcomeThere are systems and processes for the provision of appropriately skilled and qualified staff,sufficient to provide services in accordance with the Accreditation Standards and the home’svision statement. The home has processes for recruitment, orientation and ensuring staff areeligible to work in aged care. Staffing levels are usually maintained at all times and there areprocedures to ensure vacant shifts are filled. Management stated the home increases staffnumbers as residents’ needs increase. Registers are maintained to monitor staff criminalhistory checks as well as staff professional registrations. Residents and representatives’ statestaff are knowledgeable, are responsive to residents’ needs and have a helpful and caringattitude.Home name: Allawah Lodge Aged Persons HostelRACS ID: 03069Dates of audit: 30 June 2015 to 01 July 2015

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 outcomeThe home has systems and processes to ensure that a stock of appropriate goods andequipment is available. Input from residents and staff through meetings is included in theprocesses of maintaining and introducing new equipment. Storage for equipment and goods isavailable at the home with staff able to access storage areas. Stock levels are ordered andmonitored by key personnel and are rotated and monitored for expiry dates. Preventativemaintenance schedules monitor equipment useability and this is documented by themaintenance officer. Corrective maintenance requests are reported to the maintenance officerthrough the completion of the maintenance register. Maintenance requests were noted to befollowed up in a timely manner. Faulty equipment is identified, removed from service andreplaced or returned to suppliers for replacement. Staff are satisfied with the stocks ofappropriate goods and equipment.1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".Team’s findingsThe home meets this expected outcomeThe home has an information management system that provides relevant information tostakeholders. The home’s communication system includes meetings, handbooks for staff,newsletters, policies and procedures, noticeboards, staff handovers and a clinicaldocumentation system. The home utilises these communication channels along with themanagers’ open door policy to disseminate information and to collect feedback. Access toconfidential information and records is controlled and limited to authorised personnel.Observations demonstrate residents’ and staff files are stored securely. Staff confirmed theyreceive and have access to relevant information that allows them to perform their roleseffectively. Residents and representatives stated they are well informed regarding residents’needs and all other matters appropriate to them.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 home’s externally sourced services are arranged primarily through contract agreements.Coolamon Shire Council has a designated process whereby specific criteria must be met inrelation to services to be supplied and references, insurance and police checks are made. Allmajor contracts are reviewed regularly through feedback by the home. Contractor nonperformance is recorded and actioned immediately if urgent or at the time of reviewing thecontract. To enable staff to contact an appropriate contractor/supplier, lists are maintained atHome name: Allawah Lodge Aged Persons HostelRACS ID: 030610Dates of audit: 30 June 2015 to 01 July 2015

the home and updated as required. Staff are informed of appropriate matters relating to theprovision of externally sourced services.Home name: Allawah Lodge Aged Persons HostelRACS ID: 030611Dates of audit: 30 June 2015 to 01 July 2015

Standard 2 – Health and personal carePrinciple: Care recipients’ physical and mental health will be promoted and achieved at theoptimum level, in partnership between each care recipient (or his or her representative) andthe health care team.2.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuousimprovement”.Team’s findingsThe home meets this expected outcomeRefer to expected outcome 1.1 Continuous improvement for a description of the overall systemof continuous improvement. Resident and representative feedback indicates satisfaction withcare provision. Recent continuous improvement initiatives in relation to Accreditation StandardTwo include the following examples: Podiatry services increased in 2015. In the past the podiatrist attended every two weeksfor a few hours. At this time there were approximately four residents seen on eachoccasion. As the podiatrist did not always have all the required equipment available, notall treatment was able to be provided on the day the residents were seen. The podiatristnow visits every eight weeks and has all the necessary equipment available on each visitand is able to provide the required treatment to residents on each occasion. The staff identified that one of the residents required an alternative means of painadministration. The general practitioner arranged for the resident to be administered thepain relief using a transdermal patch. Staff indicated this has improved the pain relief ofthe resident and also reduced their aggression. Residents commented that the continence aids were not appropriate for their needs. Alocal clinical nurse consultant (CNC) reassessed residents’ continence needs and allresidents were provided with appropriate continence aids. The CNC also arranged forappropriate funding for all eligible residents with continence needs.Home name: Allawah Lodge Aged Persons HostelRACS ID: 030612Dates of audit: 30 June 2015 to 01 July 2015

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 outcomeManagement has systems to identify and ensure compliance with relevant legislation,regulatory requirements and professional guidelines as referred to in expected outcome 1.2Regulatory compliance.Examples of regulatory compliance relevant to Accreditation Standard Two - Health andpersonal care include: The home has a system to monitor and record registered nurses, allied healthprofessionals and medication practitioner’s professional registrations. The home ensures residents are provided with services, supplies and equipment asrequired under legislation.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 outcomeFor details of the home’s systems for ensuring that management and staff have appropriateknowledge and skills to perform their roles effectively, please refer to expected outcome 1.3Education and staff development.Examples of education provided under Standard Two include: First aid refresher course Basic foot care skills Palliative care Dementia dynamics course2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.Team’s findingsThe home meets this expected outcomeResidents receive clinical care that is appropriate to their individual needs and preferences.Residents’ care needs are assessed by the aged care manager/registered nurse and care staffHome name: Allawah Lodge Aged Persons HostelRACS ID: 030613Dates of audit: 30 June 2015 to 01 July 2015

following their entry to the home. Care plans are developed using a small range ofassessments and careful observation by care staff. Care plans are reviewed every threemonths. Any changes to residents’ health or care needs are communicated to staff at verbalhandovers, in communication diaries and handover reports, progress notes and care planupdates. The home is co-located with the multipurpose medical centre (local hospital) which isable to provide clinical support services to the home. The local medical officers visit the homeregularly. Arrangements are in place to ensure residents have access to after-hours medicaltreatment or transfer to hospital if required. Staff demonstrated their knowledge of individualcare requirements related to clinical care. Representatives said they are informed of changesin residents’ health status. Residents/representatives expressed satisfaction with the careprovided to residents.2.5 Specialised nursing care needsThis expected outcome requires that “care recipients’ specialised nursing care needs areidentified and met by appropriately qualified nursing staff”.Team’s findingsThe home meets this expected outcomeThe home ensures residents’ specialised nursing needs are identified and met by suitablyqualified staff or specialists. The manager, who is a registered nurse, assesses the residents’need for specialised nursing care and oversees any specialised nursing treatments.Equipment is supplied as necessary to meet identified needs. Staff said clinical specialists areconsulted and utilised for provision of information and training when required. The staff saidthey utilise the services of the area health service and the local hospital and they have theappropriate skills, resources, equipment and support from management to provide specialisednursing care for residents when required.2.6 Other health and related servicesThis expected outcome requires that “care recipients are referred to appropriate healthspecialists in accordance with the care recipient’s needs and preferences”.Team’s findingsThe home meets this expected outcomeResidents are assisted to access external medical specialists and allied health professionals.Referrals are arranged to specialists some of whom will visit the home including a podiatrist,physiotherapist and dietitian. Progress notes and care plans are reflective of specialist healthcare practitioners’ recommendations

books for the automatic fire detection and alarm system, fire sprinkler system, fire doors and exit and emergency lighting testing; current fire safety certificate, fire safety training records Human resource management: organisational chart, staff handbook, orientation . emergency kits with clinical and lifestyle requisites inspection tags .