aged-care-standards-accreditation-agencyPennwood Village is once again proud to have been re-accredited against 44 expected outcomes of the Accreditation Standards.

The audit was conducted from 2 April 2012 to 3 April 2012. by The Aged Care Standards and Accreditation Agency Ltd.

The following report outlines the information on which The Aged Care Standards and Accreditation Agency based the major findings provided at the end of the audit. It gives their findings, the reasons for their findings and supporting information. It may also include suggestions for improvement or details of deficiencies that may need to be addressed.

You can download a copy of the report by clicking here or alternatively you can download the report from The Aged Care Standards Accreditation Agency by clicking here

 

 

Audit Assessment Information

Re-accreditation audit

Name of home Pennwood Village
RACS ID 6146

Scope of this document

A re-accreditation audit against the 44 expected outcomes of the Accreditation Standards was conducted from 2 April 2012 to 3 April 2012.
This report outlines the information on which we based the major findings provided at the end of the audit. It gives our findings, the reasons for our findings and supporting information. It may also include suggestions for improvement or details of deficiencies that may need to be addressed.

Next steps

Please consider the content of this report carefully. If you wish to make a written response the Accreditation Agency must receive it within 14 days. It will be considered when the decision is made about re-accreditation for the home. 
Please label your response ‘Response to Audit assessment information’ and send it to your

local Accreditation Agency office –
by email to: sa_nt@accreditation.org.au
or by facsimile to: 08 8212 8544
or by post to: Aged Care Standards and Accreditation Agency Ltd
GPO Box 620
Adelaide SA 5001

Total number of allocated places: 60
Number of residents during audit: 50
Number of high care residents during audit: 30
Special needs catered for: People from culturally and linguistically diverse backgrounds

Email address for submission of audit assessment information: anne@pennwood.org.au

Audit trail
The assessment team spent two days on-site and gathered information from the following:

Interviews 

Number Number

Residential care manager 1 Residents/representatives 7
Registered nurses 2 Care staff 2
Site manager 1 Catering staff 1
Quality coordinator 1 Cleaning staff 1
Lifestyle staff 2 Maintenance staff 1
Finance manager 1

Sampled documents

Residents’ files 11 Medication charts 6
Residents’ care plans 11 Personnel files 5
Residents’ lifestyle folders 5

 Other documents reviewed

The team also reviewed:

  • Audits, surveys and results
  • Building certification
  • Clinical care assessments and documentation
  • Continence product use chart and summary
  • Continuous improvement documentation
  • Drugs of Dependence records
  • Electrical test and tagging register
  • Emergency procedures documentation
  • Equipment calibration logs and reports
  • Fire system maintenance records and documentation
  • Food safety plan
  • Handover sheets
  • Hazard and various incident reports and data summaries
  • Human resource documentation
  • Lifestyle documentation
  • Material safety data sheets
  • Menu
  • Policies and procedures
  • Preventative and reactive maintenance records
  • Resident agreements and handbooks
  • Schedule 4 & 8 medication licence
  • Staff training and registration documentation
  • Various meeting minutes
  • Various cleaning records
  • Various staff communication books
  • Visitor sign in/out register

Observations

The team observed the following:

  • Activities in progress
  • Chapel
  • Cleaning in progress
  • Equipment and supply storage areas
  • Fire signage, suppression and surveillance
  • First aid box
  • Interactions between staff, residents and representatives
  • Internal and external living and working environment
  • Linen collection area
  • Meal service
  • Noticeboards
  • Personal protective equipment
  • Residents engaged in gardening activities
  • Site safe
  • Security systems and processes
  • Storage of chemicals
  • Storage of medications and medications in use
  • Suggestion box

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 residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

Pennwood Village is one of two homes operated by the Serbian Community Welfare Association of South Australia. The home has a continuous improvement framework to identify improvement opportunities and monitor performance against the Accreditation Standards. Improvement opportunities are identified through quality improvement forms, compliments, comments, suggestions and complaints forms, audits, surveys, resident and staff meetings and verbal feedback. Focus groups, consisting of management and staff are responsible for the monitoring of actions and timelines generated from continuous improvement projects. Staff and residents are encouraged to actively participate in the home’ continuous improvement program.

Examples of improvement activities and achievements relating to management systems,staffing and organisational development include:

  • In response to a staff suggestion, the home has introduced sealed payslips. Previously,payslips were printed on A4 paper, folded and stapled together. Staff have commented that the new payslips ensure privacy and confidentiality of staff information.
  • The home recognised that there was no formal process to gather feedback from students undertaking placement at the site. A student evaluation sheet has been developed to gather information on the students experiences at the home. Three evaluation forms have been completed since the form has been implemented and the comments have been positive. The home plans to use the feedback gathered to improve orientation processes and learning opportunities.

Additional information

  • The source of continuous improvement activities is not consistently documented on the home’s continuous improvement register or on quality improvement forms. We discussed this with the management team who stated they would consider our suggestion.
  • The home uses continuous improvement evaluation forms to gather feedback from stakeholders about continuous improvement projects. However, feedback gathered from these forms is not consistently evaluated or used to identify further improvement opportunities for individual projects. We discussed this with the management team who stated they would consider our suggestion. 

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 home has systems and processes to identify and monitor relevant legislation, regulations and guidelines. Memberships with professional associations within the aged care industry advise the home of legislative changes. Legislative changes are a standard agenda item at focus group and residents/representative meetings. Policies and procedures are updated as required to comply with regulatory requirements. There are processes to record and monitor police clearances for staff, volunteers and contractors. Legislative compliance is monitored through meetings, surveys and scheduled audits. Staff are informed of legislative changes through the home’ communication processes.

 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 systems and processes to ensure that management and staff have the appropriate knowledge and skills to perform their roles effectively in relation to management, staffing and organisational development. Education needs are identified through training needs analysis, performance appraisals, work practices, comments and complaints, incident data and staff feedback. Training is scheduled throughout the year. Staff attendance at mandatory training is supported and monitored. Staff training relevant to management systems, staffing and organisational development includes strategic and business planning and training and workplace bullying. Residents and representatives are satisfied management and staff have the appropriate knowledge and skills to perform their roles effectively.

1.4 Comments and complaints

This expected outcome requires that “each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms”.

Team’s findings

The home meets this expected outcome

The home has a system for logging, tracking progress and reporting outcomes for all compliments, complaints and comments received. Internal and external complaints mechanisms are discussed with residents and representatives on entry to the home and forms and information are available in a number of languages appropriate to the resident mix. Comments and complaints received are dealt with by the management team with feedback provided through consultation processes. The home monitors the effectiveness of their comments and complaints process through surveys, audits and meetings. Staff are aware of the comments and complaints process and their role in assisting residents and representatives in a confidential manner. Residents and representatives are satisfied with the handling of comments and complaints and the response taken to issues raised.

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 home’s vision, philosophy and mission statements are documented and displayed throughout the home. Information describing the home’s vision, philosophy and mission statements are provided to residents, staff and other stakeholders through information handbooks, orientation processes and relevant policies. The home is guided by a five year strategic plan.

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 processes for identifying and assessing the required staffing levels and skills mix to meet residents’ needs on an ongoing basis. The home has processes to recruit and induct new staff. There are orientation processes for new staff and volunteers. The staff roster ensures adequate numbers of staff are maintained with vacant shifts filled by the home’s own staff as required. Registered staff are involved in the primary care of residents at the home. The home monitors resident and staff satisfaction with staffing through surveys, audits, meetings and incident statistics. Legislative requirements for police clearances, nursing registrations and mandatory training are monitored by the home. Staff are guided in their roles by duty statements, position descriptions, various policies and procedure and a staff handbook. Residents and their representatives are satisfied with the level of care and services provided by the home to meet residents’ needs.

Personnel working in the home during the week Sunday to Saturday the week before the visit

This table excludes volunteers and medical officers.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Shift description Personnel

Total hours of personnel EFT staff per resident

(circle or delete as appropriate)

RN 13 28.3 20.7 15.2 20.7 28.3 7.5

EN 13 18.5 20.5 20.5 13 13 7.5

Care personnel 18.5 13 16.5 16.5 16.5 18.5 29.5

Other

professional

personnel

4 4

AM

Other personnel 12 41.7 41.7 34.2 41.7 41.7 12

RN 6.5 6.5

EN 15 21.5 7.5 7.5 15 15 21.5

Care personnel 6.5 7.5 7.5 6.5 6.5

PM

Other personnel 7 7 7 7 7 7 7

EN 8 8 8 8 8 8 8

NIGHT

Care personnel 8 8 8 8 8 8 8

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 processes for identifying, maintaining, monitoring the performance and planning replacement of plant, equipment and goods. These include feedback at meetings, surveys, audits, workplace inspections, hazard and incident reporting, internal and external preventative and reactive maintenance services. Scheduled servicing and calibration checks and electrical testing and tagging of equipment are completed by contractors. Staff are assigned responsibilities for ordering and stock rotation. Residents, representatives and staff are satisfied there are adequate and appropriate stocks of goods and equipment to deliver 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

The home has an effective information management system for the collection, reporting and analysis of information. Information is stored securely and archived as required. Electronic data is backed up on a daily basis. The home monitors the effectiveness of their information systems through audits, meetings, surveys and the comments and complaints process.
Residents and representatives are satisfied they have access to information appropriate to their needs to assist them to make decisions about residents’ care and lifestyle choices on entry to the home and on an ongoing basis. Staff are satisfied they have access to current information to assist them with performing their duties.

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 home has agreements with external agents for managing the nurse call system, pest control, waste, cleaning, security, servicing and calibration of equipment and fire detection systems. Agreements are in place for supply of clinical consumables and goods supporting hospitality services. Contracts are in place for providing allied health and pharmacy services. External contractor’s licences, certificates of currency and police clearance is monitored by management. Feedback on contractor performance is gathered from residents and staff and providers are changed if required. Staff and residents are satisfied with services provided by contractors.

Additional information

  • Management stated the cleaning contract is under review and as yet has not been re signed. The home is assessing additional time that will be required due to the inclusion of two additional houses.
  • We noted and discussed with management the expiry of five contracts. Management said the home is satisfied with services being provided and attempts had been made to arrange re signing. Management said this will be actively followed up. 

Standard 2 – Health and personal care

Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team.

2.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

In relation to Standard 2 Health and personal care, the home identifies improvements from resident and staff feedback, care reviews, audits, surveys, incident reports, observations and comments and complaints processes. Focus groups, consisting of management and staff are responsible for the monitoring of actions and timelines generated from continuous improvement projects. Staff and residents are encouraged to actively participate in the home’ continuous improvement program.

Examples of improvement activities and achievements relating to health and personal care include:

  • In response to staff suggestions, the home has purchased an INR monitoring machine. Staff have been trained in the use of the machine. The introduction of the machine has improved result response times and resident medication management. Residents have commented that the use of the new machine is less painful and invasive than the previous method.
  • In response to a staff suggestion, the home has increased the number of hypoglycaemic kits available on-site. Previously, staff had access to only one hypoglycaemic kit for the site. Kits are now available in four locations across the site. Staff have commented that they now have easy access to the kits and are able to provide care to residents more promptly.  

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 about the home’s regulatory compliance systems and processes.

The home has systems and processes to identify and monitor relevant legislation, regulations and guidelines in relation to health and personal care. Nurses’ registrations are obtained prior to commencing employment and are up-dated annually. There are processes to monitor prescribed care and services as outlined in the Quality of Care Principles 1997 and medication management. Legislative compliance is monitored through meetings, surveys, scheduled audits care reviews and staff and resident feedback. Management and staff are aware of the legislative requirements relating to health and personal care including the notification of unexplained absences.

 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 information about the home’s education and staff development systems and processes. The home has processes to identify, plan and monitor staff education based on legislative requirements, staff requests and residents’ care needs. Staff attendance at mandatory training is supported and monitored. Staff training relevant to health and personal care includes pain management, palliative care and nutrition and hydration. Staff are satisfied with the ongoing support provided to them to develop their skills and knowledge. Residents and representatives are satisfied management and staff have the appropriate knowledge and skills to perform their roles effectively.

2.4 Clinical care

This expected outcome requires that “residents receive appropriate clinical care”.

Team’s findings

The home meets this expected outcome

Residents receive clinical care appropriate to their needs and preferences. The home has initial and ongoing assessment tools to plan and review care needs. Information is gathered from a variety of sources and completion of a baseline assessment informs the interim care plan on entry to the home. A suite of assessments are completed over the following eight weeks to develop individualised care plans. Care is reviewed four monthly in consultation with the resident/representative. Staff use progress notes, incident reports, observation charts, clinical audits, and stakeholder feedback to monitor and review care on a daily basis. Resident incidents are analysed and trended over time. Changes in care are communicated via various communication books, progress note entries and handover. Staff have access to care plans, relevant policies and procedures and sign acknowledgement of entries in communication books. Staff are fluent in languages appropriate for residents living in the home. Residents and representatives said they are satisfied with the clinical care and consultation they receive.

2.5 Specialised nursing care needs

This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.

Team’s findings

The home meets this expected outcome

Initial and ongoing assessment, care planning and review are conducted by appropriately qualified and experienced registered nurses. Specialised nursing care needs are identified, assessed and documented on care plans. Consultation with general practitioners supports clinical decision making. The home has recently appointed a continence nurse advisor to assist care planning and continence management. Staff said the home is currently participating in a regional hospital avoidance project. Training in specialised nursing skills is being organised through this project. Residents and representatives are satisfied with specialised nursing care provided by the home. 

2.6 Other health and related services

This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”.

Team’s findings

The home meets this expected outcome

Residents are referred to appropriate allied health providers to meet their needs and preferences. Registered nurses identify the need for referral through staff, resident / representative feedback, incident reporting, care assessment and reviews and clinical observations and consultation with general practitioners. The home has a contract for provision of allied health specialists. These include physiotherapist, podiatrist, speech pathologist and dietitian. The physiotherapist visits the home at least weekly. A social worker and referral to western mental health is available as required. Staff assist residents to attend appointments off site when needed. Recommendations about care are documented in progress notes and care plans changed accordingly. Residents are satisfied with allied health services and referrals provided.

2.7 Medication management

This expected outcome requires that “residents’ medication is managed safely and correctly”.

 

Team’s findings

The home meets this expected outcome

Medications are managed safely and correctly in accordance with legislative requirements and professional guidelines. Residents’ needs and their ability to manage their own medication are assessed on entry to the home. A care plan is developed and the medication chart completed with required details. The home has a current schedule four and eight medication licence to hold imprest medications assisting emergency and after hours use. The home has processes for ordering, delivering, storing, managing and disposing of medications. Residents are able to use the pharmacy of their choice. Contracted pharmacy staff assist by checking pre-packaged medications weekly to identify discrepancies prior to use, provide education to staff as required and rotate imprest stock. The home has recently changed the medication packaging system. Staff have been provided with education. Medications are administered by registered and credentialed staff. The home monitors medication management through care reviews, incident reporting, required clinical observations, stakeholder feedback, credentialing practices, general practitioner reviews and medication advisory and focus group meetings. Medication incidents are analysed and trended over time. Residents and representatives are satisfied with how their medications are managed. 

2.8 Pain management

This expected outcome requires that “all residents are as free as possible from pain”.

Team’s findings

The home meets this expected outcome

Pennwood Village has initial and ongoing processes for identifying, assessing, planning and reviewing care strategies to minimise the potential for pain and manage residents’ pain effectively. Each resident has a pain assessment and care plan developed in consultation with the resident, physiotherapist and general practitioner. The impact of pain on sleep and  mobility is considered. Pain relieving interventions include use of heat packs, massage,  exercises and medications. The home maintains a pain kit containing goods to initiate pain relieving treatments as quickly as possible. The use of ‘as required’ pain relieving medication is monitored through progress notes, use of alert labels, stakeholder feedback and specific pain logs. The home monitors the effectiveness of pain management interventions through care reviews, stakeholder feedback and incident data. Staff said they have recently received education in pain management. Residents and representatives said they are satisfied with how their pain is managed. 

2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”.

Team’s findings

The home meets this expected outcome

The home provides palliative care to support the comfort and dignity of terminally ill residents. Staff at the home are bilingual in languages appropriate for residents and representatives, and have a cultural understanding of the sensitive approach required when preparing to discuss end of life care and specific spiritual and cultural needs and preferences. The home has a palliative care kit containing equipment to deliver pain relieving medications and support end of life care. Staff liaise with general practitioners, social  worker and external palliative care specialist services when required. The registered nurse reviews the care plan accordingly and regularly consults with representatives. The home has single rooms supporting family involvement during palliation and a chapel on site. The home monitors palliative care services by observation and stakeholder feedback. Feedback from representatives demonstrates satisfaction with palliative care services provided. 

2.10 Nutrition and hydration

This expected outcome requires that “residents receive adequate nourishment and hydration”.

Team’s findings

The home meets this expected outcome

The home has initial and ongoing assessment and review processes to identify and manage residents’ nutrition and hydration requirements and preferences. Each resident is assessed for nutritional status, ability to eat and drink and dietary needs and preferences when entering the home. The nutrition care plan and dietary advice form provide information to direct staff in preparing, serving and assisting with appropriate meals and fluids. Residents are weighed at least monthly and referred to the dietitian and speech pathologist when clinically indicated. Fortified meals and nutritional supplements are implemented as directed.

Nutrition and hydration needs are monitored through care reviews, progress note entries, regular weighs, clinical observations, stakeholder feedback and monitoring of wound healing. Staff are aware of how to support residents’ nutrition and hydration needs. Residents said they are satisfied with the support provided to meet their individual nutrition and hydration needs.

2.11 Skin care

This expected outcome requires that “residents’ skin integrity is consistent with their general health”.

Team’s findings

The home meets this expected outcome

The home has initial and ongoing assessment and review processes to identify and manage  residents’ skin integument issues and implement strategies to maintain skin integrity. Assessments completed on entry identify residents at risk of skin impairment. A care plan is developed and reviewed at least four monthly. Strategies to enhance skin integrity include application of skin emollients, use of pressure relieving equipment, nutritional supplements and application of prescribed topical medications. Wounds are assessed and management plans developed by registered nurses. A wound register is maintained to monitor healing. Registered nurses attend complex wound care and enrolled nurses attend simple wounds. An adequate supply of wound care products is appropriately stored at the home. The home monitors residents’ skin integrity through progress note entries, stakeholder feedback, care plan review, wound care assessment and incident reporting. Residents and representatives are satisfied with assistance provided to maintain skin integrity.  

2.12 Continence management

This expected outcome requires that “residents’ continence is managed effectively”.

Team’s findings

The home meets this expected outcome

Pennwood Village has initial and ongoing assessment and review processes to identify and manage residents’ individual continence needs. The home has recently employed a continence nurse advisor to assist with continence management. The home monitors continence management through progress note entries, infection surveillance reports, stakeholder feedback, care plan review, clinical observations, daily charting and resident surveys. The home has processes to support an adequate supply of continence products. Residents have en-suite bathrooms to support privacy and dignity. Residents and representatives are satisfied with support provided to manage their continence.  

2.13 Behavioural management

This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”.

Team’s findings

The home meets this expected outcome

The home has initial and ongoing assessment and review processes to identify and manage residents with challenging behaviours. Behaviour assessments are completed when residents enter the home and individual care plans are developed. Behaviour management plans include triggers and strategies to reduce the frequency of identified behaviours. Care is reviewed at least four  monthly. The home has no restraint in use and uses early warning alarms and closed circuit television surveillance to support resident safety, independence and mobility. The design of the home encourages residents’ to socialise. The home monitors behaviour management strategies through care reviews, incident reporting, stakeholder feedback and progress note entries. The home has  recently employed a behaviour link nurse to assist in behaviour management assessment and care planning and uses general practitioners and western mental health service when required. Residents and representatives are satisfied with the approach the home has to manage residents with challenging behaviours. 

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”.

Team’s findings

The home meets this expected outcome Residents’ individual mobility and dexterity needs are identified, assessed, managed and reviewed by the physiotherapist and registered nurses on entry and on an ongoing basis.

Consultation occurs with representatives, general practitioner and physiotherapist when a fall occurs. The home supports residents’ mobility and dexterity and minimises risk through activities included in the lifestyle program, design of pathways, under foot  materials in outdoor pergola areas, provision of electric beds and equipment to support mobility and dexterity, use of sensor alarms and hip protectors, individual physiotherapist directed exercise programs and raised garden beds. Care is monitored through progress note entries, incident reporting, stakeholder feedback, care reviews and audits. Suitable lifting equipment is available if required. Incident data is analysed and trended over time. Staff are provided with education in manual handling. Residents and representatives are satisfied with support provided to optimise their mobility and dexterity.

2.15 Oral and dental care

This expected outcome requires that “residents’ oral and dental health is maintained”.

Team’s findings

The home meets this expected outcome

Each resident’s oral and dental care needs and preferences are identified and assessed on entry to the home. An individual care plan is developed and reviewed at least four monthly. Residents are assisted to access external dental services when specific oral and dental issues arise. Residents and representatives are satisfied with support provided to maintain oral and dental health.

2.16 Sensory loss

This expected outcome requires that “residents’ sensory losses are identified and managed effectively”.

Team’s findings

The home meets this expected outcome

Each resident has all five senses assessed on entry to the home. Care strategies to manage identified losses and sensory aids are documented in care plans. Care is reviewed at least every four months. The home uses care reviews, internal audits and surveys, workplace inspections, incident and hazard reporting, progress note entries and stakeholder feedback to monitor the effectiveness of strategies implemented to manage residents’ sensory loss. Staff assist residents in fitting and managing sensory aids. Residents and representatives are satisfied with assistance provided to manage sensory loss.  

2.17 Sleep

This expected outcome requires that “residents are able to achieve natural sleep patterns”.

Team’s findings

The home meets this expected outcome

Residents’ preferences for achieving natural sleep are identified and assessed on entry to  the home and on an ongoing basis. Individual sleep strategies are documented on the care plan. Care reviews are completed at least four monthly. Strategies used to achieve natural sleep include hot drinks, pain management strategies, comfort measures and environmental preferences. Care is monitored through progress note entries, care reviews, incident reporting and stakeholder feedback. Residents and representatives are satisfied with home’s approach to promoting natural sleep patterns.

Standard 3 – Resident lifestyle

Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.

3.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

In relation to Standard 3 Resident lifestyle, the home identifies improvements from resident and staff feedback, surveys, activity evaluations, observations and comments and complaints processes. Focus groups, consisting of management and staff are responsible for the monitoring of actions and timelines generated from continuous improvement projects. Staff and residents are encouraged to actively participate in the home’ continuous improvement program.

Examples of improvement activities and achievements relating to resident lifestyle include:

  • In response to a staff suggestion, the home purchased the wrap ball game. The game has been introduced into the activities program. The activity promotes coordination, dexterity and interaction. Residents report and staff have observed that the residents enjoy the wrap ball activity.
  • As a result of discussion with residents, the home has commenced a resident walking group. The residents stated that they would love to go for walks to the local park. The activity has been included on the activities calendar. Residents have commented that they are thoroughly enjoying the group.

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 resident lifestyle”.  

Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes. 
The home has systems and processes to identify and monitor relevant legislation, regulations and guidelines in relation to resident lifestyle. Residential service agreements are managed on-site by the finance manager. Legislative compliance is monitored through meetings, surveys, scheduled audits, care reviews and staff and resident feedback. Staff are aware of regulatory requirements relating to residents’ lifestyle including mandatory reporting, protecting residents’ privacy and maintaining confidentiality of resident information. 

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 information about the home’s education and staff development systems and processes.

The home has processes to identify, plan and monitor staff education based on legislative requirements, staff requests and residents’ care needs. Staff attendance at mandatory training is supported and monitored. Staff training relevant to resident lifestyle includes privacy and dignity, elder abuse and dementia training. Staff are satisfied with the ongoing support provided to them to develop their skills and knowledge. Residents and representatives are satisfied management and staff have the appropriate knowledge and skills to perform their roles effectively. 

3.4 Emotional support

This expected outcome requires that “each resident receives support in adjusting to life in the new environment and on an ongoing basis”.

Team’s findings

The home meets this expected outcome

The home has processes for supporting residents to adjust to life in the home and addressing their emotional needs. Residents are presented with an admission pack on entry to the home. A baseline assessment is completed in consultation with the resident and/or representative and identifies past and present interests, including cultural, spiritual, lifestyle and social aspects. Additional emotional supports are implemented as required to meet residents’ emotional needs such as pastoral care, one-to-one activities and referrals to general practitioners and allied health services as required. The home monitors the effectiveness of meeting residents’ emotional needs through resident and representative feedback, care and lifestyle reviews and observations. Staff are aware of their roles in supporting the emotional needs of residents in the home. Residents and representatives are satisfied that residents receive support in adjusting to life in the home on entry and on an ongoing basis.

3.5 Independence

This expected outcome requires that “residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service”.

Team’s findings

The home meets this expected outcome

The home has processes for identifying barriers to residents’ independence. The baseline assessment form and care and lifestyle care plans identify residents’ physical, emotional, cultural and social needs and preferences. Independence is maintained by encouraging residents to personalise their bedrooms, maintain voting rights and financial independence. Residents are encouraged and assisted to attend appointments, outings and social groups outside of the home to enable them to maintain links within the community. The home monitors the effectiveness of strategies implemented to maintain residents’ independence through care and lifestyle reviews, surveys, audits and resident feedback. Staff confirm they promote, assist and respect residents’ rights to maintain independence. Residents and representatives are satisfied residents are assisted to achieve their maximum independence, maintain friendships and participate in the life of the community within and outside of the home.

3.6 Privacy and dignity

This expected outcome requires that “each resident’s right to privacy, dignity and confidentiality is recognised and respected”.

Team’s findings

The home meets this expected outcome

The home has processes for identifying and implementing strategies to meet residents’ individual preferences for privacy and dignity. The home’s orientation processes and policy and procedures outline residents’ rights to privacy, dignity and confidentiality. Staff are required to sign a confidentiality contract on commencement of employment. Residents and/or representatives are asked to sign a consent form for the gathering, use and release of personal information on entry to the home. Each resident has a single room with en-suite bathroom. Lockable drawers are available in all resident bedrooms. Resident information is stored securely. The home uses surveys, audits, lifestyle reviews, stakeholder feedback and observations to monitor staff practices. Staff are aware of their responsibilities and the importance of maintaining residents’ privacy, dignity and confidentiality. Residents and representatives are satisfied residents’ right to privacy, dignity and confidentially is recognised and respected.  

3.7 Leisure interests and activities

This expected outcome requires that “residents are encouraged and supported to participate in a wide range of interests and activities of interest to them”.

Team’s findings

The home meets this expected outcome

The home has processes to identify residents’ individual lifestyle needs and preferences. There are documented procedures to facilitate information gathering, lifestyle care plan development, consultation and review. A baseline assessment is completed on entry to the home and identifies activities of interest. A lifestyle care plan is developed and reflects individual interests and preferences. Staff consult with residents on an ongoing basis and update individual lifestyle care plans as required. A monthly activities calendar is developed and is displayed in each house and a copy is distributed to each resident. One-to-one and group activities are offered. Each resident receives one-to-one activities on a weekly basis or more frequently if required. Culturally specific group activities are conducted on a regular basis. Activities are evaluated in consultation with residents to ensure they remain appropriate and stimulating. The home monitors the effectiveness of the activity program through lifestyle reviews, surveys, audits, individual activity evaluations and resident feedback through consultation and meetings. Staff confirm they encourage and support residents to participate in activities of interest to them. Residents and representatives are satisfied that residents are supported and encouraged by the home to participate in a wide range of interests and activities of interest to them.  

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

The home has processes to identify individual residents’ cultural and spiritual needs and preferences. Residents are consulted regarding their cultural and spiritual needs and preferences on entry to the home. Residents’ religious affiliations are documented on the personal details page and strategies to support residents’ cultural and spiritual requirements are documented in the care and lifestyle care plan. Spiritual supports are provided in the home and there is a chapel on-site. Residents are supported to attend church services and cultural clubs and activities in the community as requested. Religious and significant days are recognised and celebrated with residents participating in celebrations and observations as they wish. The home’s culturally diverse staff assist with interpreting and co-ordinating resident care and services. The home monitors the effectiveness of meeting residents’ cultural and spiritual needs through surveys, audits, lifestyle reviews, evaluation, resident feedback and observations. Staff are aware of strategies to support residents’ cultural and spiritual needs. Residents and representatives are satisfied that the home values and fosters residents’ individual interests, customs and beliefs.  

3.9 Choice and decision-making

This expected outcome requires that “each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people”.

Team’s findings

The home meets this expected outcome

The home encourages residents and their representatives to participate in decisions about resident’s care. Information is obtained on entry regarding residents preferred needs, authorised representatives and contacts are identified on the residents’ personal details page. Information outlining residents’ rights and responsibilities is included in the resident handbook, resident agreement and is displayed in the home. The resident handbook and complaints and advocacy information is available in a number of different languages appropriate to the resident mix of the home. Staff are utilised as interpreters to further facilitate resident understanding of their rights and responsibilities. Residents are encouraged to raise concerns through the comments and complaints process, meetings and through consultation. The home monitors their processes regarding residents’ choice and decision making through audits and surveys. Resident and representative feedback and care and lifestyle reviews also contribute to monitoring processes. Staff understand their responsibilities in providing residents with the opportunity to make choices about the care and services they receive. Residents and representatives are satisfied with the consultation, choice and support provided to make decisions about issues that affect residents’ daily life.  

3.10 Resident security of tenure and responsibilities

This expected outcome requires that “residents have secure tenure within the residential care service, and understand their rights and responsibilities”.

Team’s findings

The home meets this expected outcome

Residents and representatives are informed of residents’ security of tenure and rights and responsibilities on entry to the home. Residents and representatives are provided with a handbook, residential services agreement and information on the home’s services. The residential services agreement includes information of fee structures, complaints resolution processes and the level of care and services to be provided. Aged care advocacy and internal and external complaints information is available in the home in languages appropriate to the resident mix. Monitoring of information provided to residents and their representatives is undertaken to ensure it remains current and meets legislative requirements. Staff are aware of residents’ rights and responsibilities. Residents are satisfied their tenure is secure and the home supports their individual needs and preferences where possible. 

Standard 4 – Physical environment and safe systems

Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.

4.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

In relation to Standard 4 Physical environment and safe systems, the home identifies improvements from resident and staff feedback, incident and hazard data, workplace inspections, observations, comments and complaints processes, maintenance requests and audits. Focus groups, consisting of management and staff are responsible for the monitoring of actions and timelines generated from continuous improvement projects. Staff and residents are encouraged to actively participate in the home’ continuous improvement program.

Examples of improvement activities and achievements relating to physical environment and safe systems include:

  • In response to an external audit, the home has upgraded the main kitchen. The audit identified that the kitchen cupboards were showing signs of wear and tear due to age and recommended the cupboards be sealed. The home installed a new, stainless steel kitchen. Staff have indicated they are happy with the new kitchen.
  • In response to a suggestion from a volunteer, the home has updated the resident drink charts. The charts have been updated to include resident photos which enable volunteers and new staff to easily identify residents when assisting with the delivery of meals and morning and afternoon tea. Feedback from volunteers has been positive. 

4.2 Regulatory compliance

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

Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes.

The home has systems and processes to identify and monitor relevant legislation, regulations and guidelines in relation to physical environment and safe systems. Legislative compliance is monitored through meetings, surveys, internal and external audits and staff and resident feedback. Occupational health and safety policies and procedures are in line with professional standards and guidelines. The home has an audited food safety program and a current triennial fire certificate. Staff are aware of regulatory requirements relating to physical environment and safe systems including infection control guidelines.

4.3 Education and staff development

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

Team’s findings

The home meets this expected outcome

Refer to Expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes.

The home has processes to identify, plan and monitor staff education based on legislative requirements, staff requests and residents’ care needs. Staff attendance at mandatory training is supported and monitored. Staff training relevant to physical environment and safe systems includes safe food handling, fire and evacuation and chemical safety. Staff are satisfied with the ongoing support provided to them to develop their skills and knowledge. Residents and representatives are satisfied management and staff have the appropriate knowledge and skills to perform their roles effectively. 

4.4 Living environment

This expected outcome requires that “management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs”.

Team’s findings

The home meets this expected outcome

Pennwood Village has recently completed a building project adding two additional houses. Residents are accommodated in single rooms with en-suite bathroom facilities and individual air conditioning units. They are encouraged to personalise their room. Communal dining, lounge, activity area, courtyard and pergola areas provide residents with opportunities to socialise with family and friends. Living areas are light and comfortably furnished. 

Hairdressing services are available on site. There is secure parking for residents’ cars. Residents have access to call bells. Residents are encouraged and assisted to participate in developing and maintaining garden areas. There are raised garden beds and pathways facilitate easy safe access to external areas. The home has early warning alarms to support resident safety. There is no restraint in use. Resident and representative meetings, surveys, hazard and incident reporting, preventative and reactive maintenance services, call bell response monitoring and internal audits monitor safety, comfort and satisfaction with the living environment. The home is participating in a community project for water-proofing the west maintaining wetlands and aquifer storage on site. Residents are satisfied with their living environments and staff response when they require assistance.

4.5 Occupational health and safety

This expected outcome requires that “management is actively working to provide a safe working environment that meets regulatory requirements”.

Team’s findings

The home meets this expected outcome

Penwood Village has systems and processes to provide a safe working environment that meets regulatory requirements. The Occupational Health and Safety committee has met since November 2011 and reviews safety at the home. The site manager is the responsible officer. Processes for providing and monitoring a safe work environment include policies and procedures, use of appropriate work and safety equipment, staff education, hazard and incident reporting, internal audits and workplace inspections. Staff consultation occurs through meetings, surveys and information sharing processes. The home manages return to work programs and offers staff a confidential employee assistance program. External contractors service and calibrate equipment. Staff are aware of their work responsibilities.  

4.6 Fire, security and other emergencies

This expected outcome requires that “management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks”.

Team’s findings

The home meets this expected outcome

The home has systems and processes to provide an environment and safe systems of work that minimise fire, security and emergency risks. These include policies and procedures, hazard and incident reporting, emergency response cards carried by each staff member, signage displayed throughout the home in both Serbian and English. The home has an emergency management plan, designated smoking area and relevant resident risk assessments. The home’s security is maintained through key pad operated internal and external doors, garden and driveway gates, closed circuit television surveillance, sign in register and staff duress alarms. The system is  monitored through internal and external audits, scheduled system inspections, incident and hazard reporting. Fire and emergency training is conducted annually. Residents are provided with secure storage facilities and information to support their security within  and away from the home. The home has a current fire safety triennial certificate and certification certificate for the recent extension of two additional houses. Contracted external and internal maintenance services monitor and maintain fire and emergency systems and electrical equipment testing and tagging. Fire safety equipment inspections and fire service attendance is recorded. The home has recently changed the external fire services contractor. Staff are aware of their responsibilities in the event of an emergency. 

Additional information

  • The new fire services contractor began services 2 March 2012. We noted the ‘Maintenance and Services Report’ inspection for March 2012 could not be located. The contractor has provided the home with a new folder ‘Essential Safety Provision Manual – Ministers Specifications SA 76’. The folder contains various logs for the contractor to complete when attending and recording work completed, an annual inspection schedule identifying the frequency of inspections and procedures for the contractor to follow to complete checks and inspections of the fire protection system. The site manager contacted the contractor and discussed our findings. The site manager stated the contractor is providing the home with a ‘Maintenance and Services Reports’ book and will attend the site within 24 hours to address our findings. We discussed with management the control of documents relating to fire system inspections. We noted: 
  • Various logs contained within the folder did not reference the name of the home
  • The attendance log page noted contractor attendance at the site on 14 March 2012.
  • Fire sprinkler system log noted attendance on 6 March, 13 March and 20 March 2012.
  • The check was noted to be weekly with no deficits identified.
  • Automatic fire detection and alarm systems log noted attendance at the site on 20 March 2012. The check was noted as monthly with no deficits identified.
  • The inspection schedule does not identify required weekly checks. Monthly checks are recorded as fire doors/smoke doors (AS 1851.7). Completion of this work was not recorded on the appropriate log.
  • The home provided additional information following the site audit which addresses points one and three.

4.7 Infection control

This expected outcome requires that there is “an effective infection control program”.

Team’s findings

The home meets this expected outcome 

Pennwood Village has processes to maintain an effective infection control program consistent with guidelines. These include policies and procedures, resident infection surveillance, sufficient supplies of stock and equipment and hand washing facilities. The home has effective processes for managing waste, pests, linen, cleaning and food. The home has an infectious gastroenteritis kit and provides staff training. Immunisation is promoted to both residents and staff. The home monitors the effectiveness of the program through internal and external audits, hazard and incident reporting. Staff confirm they have access to sufficient supplies of equipment and information to perform their roles.  

4.8 Catering, cleaning and laundry services

This expected outcome requires that “hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment”. 

Team’s findings

The home meets this expected outcome

Hospitality services are provided in ways that enhance residents’ quality of life and staff working environments. Residents’ dietary preferences, requirements and allergies are recorded, updated and distributed to relevant staff as required. There are processes for delivery and return of stock. Residents and representatives are provided with information to support safe transport and storage of food to the site if choosing to do so. Processes are used to support residents’ in the safe storage of food in their refrigerator. Internal feedback processes are used to plan winter and summer menus. The home has a four week rotating menu. Schedules direct cleaning of resident rooms, internal and external communal areas and maintenance of external areas. A laundry is situated in each house. Residents are assisted to attend their laundering if wishing to do so. Staff have policies, procedures, work related documents and sufficient supplies of equipment to assist them in their role. The home uses internal feedback and monitoring processes to assess the effectiveness and satisfaction with hospitality services. Residents and representatives are satisfied with hospitality services provided by the home.