Approved Provider: Mercy Human Services Limited

MercyCare Joondalup

RACS ID 7241 21 Aldwych Way JOONDALUP WA 6027

Approved provider: Mercy Human Services Limited

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 18 March 2020.

We made our decision on 06 January 2017.

The audit was conducted on 12 December 2016 to 13 December 2016. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

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

Home name: MercyCare Joondalup RACS ID: 7241 2 Dates of audit: 12 December 2016 to 13 December 2016 Standard 2: Health and personal care

Principles:

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

Expected outcome Quality Agency decision 2.1 Continuous improvement Met 2.2 Regulatory compliance Met 2.3 Education and staff development Met 2.4 Clinical care Met 2.5 Specialised nursing care needs Met 2.6 Other health and related services Met 2.7 Medication management Met 2.8 Pain management Met 2.9 Palliative care Met 2.10 Nutrition and hydration Met 2.11 Skin care Met 2.12 Continence management Met 2.13 Behavioural management Met 2.14 Mobility, dexterity and rehabilitation Met 2.15 Oral and dental care Met 2.16 Sensory loss Met 2.17 Sleep Met

Home name: MercyCare Joondalup RACS ID: 7241 3 Dates of audit: 12 December 2016 to 13 December 2016 Standard 3: Care recipient lifestyle

Principle:

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

Expected outcome Quality Agency decision 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and Met responsibilities

Standard 4: Physical

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

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

Home name: MercyCare Joondalup RACS ID: 7241 4 Dates of audit: 12 December 2016 to 13 December 2016 Audit Report

MercyCare Joondalup 7241

Approved provider: Mercy Human Services Limited

Introduction

This is the report of a Re-accreditation Audit from 12 December 2016 to 13 December 2016 submitted to the Quality Agency.

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

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

 44 expected outcomes

Home name: MercyCare Joondalup RACS ID: 7241 1 Dates of audit: 12 December 2016 to 13 December 2016 Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 12 December 2016 to 13 December 2016.

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

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

Details of home

Total number of allocated places: 105

Number of care recipients during audit: 103

Number of care recipients receiving high care during audit: 92

Special needs catered for: Veterans and people from culturally and linguistically diverse backgrounds.

Home name: MercyCare Joondalup RACS ID: 7241 2 Dates of audit: 12 December 2016 to 13 December 2016 Audit trail

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

Interviews Category Number Service manager 1 Quality coordinator 1 Registered nurses 3 Clinical nurse 1 Enrolled nurse 1 Hospitality staff 5 Maintenance staff 1 Care recipients/representatives 15 Facilities manager 1 Physiotherapist 1 Occupational therapist 1 Care staff 8 Therapy staff 3 Occupational health and safety representatives 3

Sampled documents Category Number Care recipient files including assessments, care plans and 10 progress notes Care recipient bowel charts 23 Personnel files 9 Archived end of life assessment and care plan for deceased care 1 recipient Therapy care plans, assessments and evaluations 11 Electronic medication administration records 15 Resident self-medication storage 1

Home name: MercyCare Joondalup RACS ID: 7241 3 Dates of audit: 12 December 2016 to 13 December 2016 Other documents reviewed

The team also reviewed:

 Accident, incidents and hazard reports

 Audits and surveys

 Care recipient agreement template, information handbook, admission and care plan review schedules

 Care recipient medication records including pharmacy records and nurse initiated medication records, calibration records for medical equipment and medication fridge temperatures, and wound care records including summary file

 Care recipient restraint management records

 Cleaning records, corrective and preventative maintenance programs, pest control records and safety data records

 Clinical trending records, care plan evaluation records and medication incident report file

 Concerns files

 Continuous improvement plan and file

 Dietary supplementation records and care recipients’ weight records

 Education planner, flyers, evaluation records and orientation records

 Emergency procedures manual, fire detection system, log books, smoking assessment and care plan, evacuation backpack and care recipient mobility list

 Family conference review schedule and associated records

 Food safety program, menus and associated kitchen records

 General practitioner and allied health communication records including dental, hearing and optician referrals

 Meeting minutes

 Memoranda file, staff handbook, job descriptions, duty statements, staff roster and allocation records

 Policies and procedures, guidelines and templates

 Professional registrations, police certificates, mandatory training and performance appraisal matrices

 Therapy records including programs, evaluation of activities and attendance sheets.

Home name: MercyCare Joondalup RACS ID: 7241 4 Dates of audit: 12 December 2016 to 13 December 2016 Observations

The team observed the following:

 Access to internal/external complaints, advocacy information and secure suggestion boxes

 Activities and hospitality services in progress

 Display of relevant information including mission and core values statement, Charter of care recipients’ rights and responsibilities, and notification of re-accreditation visit

 Equipment and supply storage areas including medications, continence supplies and wound care products

 Interactions between staff and care recipients

 Living environment

 Medical equipment including equipment for continuous administration of medications

 Palliative care box

 Short group observation in ground floor communal area

 Storage and documentation of archive records, equipment, medications including drugs of dependency and medication fridges

 Visitor/contractor signing register.

Home name: MercyCare Joondalup RACS ID: 7241 5 Dates of audit: 12 December 2016 to 13 December 2016 Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

There are systems and processes to identify, plan, implement and evaluate continuous improvement activities. Reporting and feedback mechanisms are available for staff and visitors to identify opportunities for improvement. Information from sources such as comment forms, audits, hazard/incident reports, surveys and meetings is generally recorded, analysed and actioned, and feedback given to stakeholders as required. Improvements requiring ongoing action are added to the plan for continuous improvement, discussed at meetings and are evaluated for effectiveness. Staff and care recipients are provided with information regarding continuous improvement activities via meetings and information posted on noticeboards. Staff and care recipients/representatives confirmed they are encouraged to provide feedback and are satisfied the home is actively pursuing continuous improvement.

Examples of current or recent improvements in relation to Standard 1 – Management systems, staffing and organisational development are described below.

 Management advised three registered nurses have undertaken training in massage therapy and equipment to assist the occupational therapist in meeting care recipients’ pain requirements in the pain clinic, which is held three times a week. Trained staff advised care recipients’ feedback and evaluation of the program confirms they find the massage and other treatments reduces their level of pain and they are more comfortable.

 Following an escalation in costs, management advised the clinical nurse has taken over the management of the continence and clinical supplies ordering, with the aim of making the process more efficient. The number of products ordered has been reduced to meet the identified needs of care recipients, accumulated stocks were used, and the number of suppliers used reduced. There are ordering systems, and the clinical nurse advised there are sufficient stocks available and the system is cost effective.

Home name: MercyCare Joondalup RACS ID: 7241 6 Dates of audit: 12 December 2016 to 13 December 2016 1.2 Regulatory compliance

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

Team’s findings

The home has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home receives legislative updates from the corporate office, who update policies as required. Management provides staff with information regarding changes through education, meetings and memoranda. The home monitors compliance through internal and external auditing programs and other feedback mechanisms. There are processes to monitor police certificates, professional registrations and working visas. Care recipients’ fees and charges are set according to legislation, and care recipients and representatives have access to external complaints processes. Care recipients and representatives reported they were informed of the re-accreditation audit via correspondence and signage within the home.

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’s education program ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Management identifies training needs through feedback and requests from staff, satisfaction surveys, audits, accident/incident reports and observation of work practices. Site orientation and buddy shifts are established for new staff, and the organisation uses specific software to schedule, record and monitor staff attendance at induction, mandatory training and site specific or optional training. Management collect evaluations of training from staff and monitor staff competencies. Staff reported they have access to a variety of training and education opportunities.

Recent examples of education related to Standard 1 – Management systems, staffing and organisational development are listed below.

 Competencies with the electronic care documentation program

 Orientation of new staff and ‘buddy program’.

Home name: MercyCare Joondalup RACS ID: 7241 7 Dates of audit: 12 December 2016 to 13 December 2016 1.4 Comments and complaints

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

Team’s findings

The home has processes to ensure care recipients, representatives and other interested parties have access to internal and external comments and complaints mechanisms. The home provides confidential and secure avenues for submitting anonymous feedback forms. The home displays information on internal and external complaints and advocacy services. Management advised the comment and complaint process is discussed with care recipients and their representatives on moving into the home, at care recipient/representative meetings, and is included in welcome letters and the handbook. Management actions all comments and complaints and provide feedback to the originator. The home measures the effectiveness of the comments and complaints process via satisfaction surveys and general feedback. Staff advised they are informed about the home’s comments and complaints process during orientation, and they advocate on behalf of care recipients as required. Care recipients and representatives generally reported confidence staff would address any concerns they might have.

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 organisation’s vision, mission statement, values and philosophy are documented in care recipient and staff handbooks, and displayed within the home. Senior management advised all staff, care recipients and representatives have had the opportunity to meet the new organisation’s management team following the change in ownership and complete a feedback form. All staff will attend orientation on the vision, mission, values and philosophy of the new organisation and any changes to systems and processes in the new year.

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 has access to appropriately skilled and qualified staff to ensure services are delivered in accordance with care recipients’ needs. The clinical nurse and manager review staffing levels based on care recipients’ care needs and feedback from stakeholders. The home uses organisational processes to recruit and retain staff, as well as to monitor police certificates, working visas and professional registrations. A ‘buddy’ program provides new

Home name: MercyCare Joondalup RACS ID: 7241 8 Dates of audit: 12 December 2016 to 13 December 2016 staff with additional support from an experienced staff member. Staff performance is monitored via annual appraisals and feedback mechanisms such as surveys and audits. Relief cover is provided from a pool of casual staff or via an agency. Generally, care recipients and representatives reported satisfaction with the skill level and number of staff in place to provide care. Staff reported they generally have the time to complete their work otherwise would hand over to oncoming staff, and have the appropriate skills to conduct their roles effectively.

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 has adequate supplies of appropriate stock and equipment to enable the delivery of quality services. Staff undertake stocktakes, rotation of stock, and stock replenishments to meet the needs of the home. The home monitors the effectiveness of storage, condition and availability of goods and equipment via audits, inspections and reporting mechanisms. Corrective and preventative maintenance programs are managed by the organisation in conjunction with the service manager. Training is available for the appropriate use of electronic and mechanical equipment. Staff reported they have enough equipment and supplies to undertake their duties, and repairs are made in a timely manner. Care recipients and representatives reported satisfaction with the availability and suitability of goods and equipment to meet their needs.

1.8 Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings

The home has processes to facilitate the collection, analysis, storage, retrieval and archiving of information related to care and operational matters. The home and organisation has a schedule of meetings to ensure effective dissemination of information and provide a forum for raising opportunities for improvement, comments, complaints and suggestions. Electronic information is stored securely, password protected and backed up by the organisation. Standardised documents, policies and procedures are reviewed by the organisation, and key staff receive updates via memoranda, emails, through training and at meetings. Staff reported they have access to information relevant to their roles, attend regular meetings, and receive information via handovers, meetings, diaries and noticeboards. Care recipients and representatives reported satisfaction with the way the home collects and shares information with them.

Home name: MercyCare Joondalup RACS ID: 7241 9 Dates of audit: 12 December 2016 to 13 December 2016 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 ensures all externally sourced services are provided in a way that meets the home’s needs and quality of service. Established systems and processes assist in the purchasing of goods and services via a preferred suppliers list and service agreements describe the responsibilities of relevant parties. The quality of service is monitored through service records and feedback from stakeholders. Review of services is taken into consideration prior to renewing contracts. Care recipients, representatives and staff reported satisfaction with the quality of service they receive from external service providers.

Home name: MercyCare Joondalup RACS ID: 7241 10 Dates of audit: 12 December 2016 to 13 December 2016 Standard 2 – Health and personal care

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

Team’s findings

Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

In relation to Standard 2 – Health and personal care, staff record care recipient accidents and incidents, and this information is collated monthly and analysed for trends. Clinical audits are conducted to measure and review the clinical care systems. Care recipients and staff are satisfied the organisation actively promotes and improves care recipients’ physical and mental health.

Examples of current or recent improvement activities in relation to Standard 2 – Health and personal care are described below.

 Following delays with transport for care recipients attending hospital appointments, the clinical nurse held discussions with hospital transport services. An online booking service is now accessed by staff when organising transport. The clinical nurse advised the system is working well and staff are now able to check when transport is scheduled and the approximate time of pick-up.

 The physiotherapist advised the home has implemented a structured exercise program for care recipients. This is based on assessed needs and is fully documented to guide the physiotherapy assistants. Documentation includes the types of exercises, number of repetitions, frequency and attendance records so the physiotherapist can review the program and evaluate the effectiveness of the programs, and make changes where necessary. The physiotherapist advised there has been some improvements in the range of movements of some care recipients.

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

Systems and processes identify and ensure the home achieves and maintains ongoing regulatory compliance in relation to care recipients’ health and personal care. Clinical staff oversee initial and ongoing assessments of care recipients. Professional registrations for

Home name: MercyCare Joondalup RACS ID: 7241 11 Dates of audit: 12 December 2016 to 13 December 2016 nursing staff and other health professionals are monitored. Internal and external audits ensure medication storage and administration comply with relevant guidelines. The home monitors any changes in legislation and alerts the staff through meetings or memoranda. The home has a policy and procedure for unexplained absences of care recipients. Care recipients and representatives reported care services are received in accordance with specified care service requirements.

Team’s findings

Management and staff have the knowledge and skills to provide appropriate health and personal care to care recipients. Refer to expected outcome 1.3 Education and staff development for a description of the system.

Recent examples of education related to Standard 2 – Health and personal care are listed below.

 Care and transfer of deceased care recipients

 Continence management

 Dementia care

 Dysphagia competency

 Management of challenging behaviours

 Medication competencies

 Mental illness and physical health

 Opiate training for registered staff

 Parkinson’s training

 Wound care basics.

2.4 Clinical care

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

Team’s findings

The home has systems and processes to ensure care recipients receive appropriate clinical care. Registered and enrolled nurses assess care recipients on arrival to the home and determine care needs via a range of validated assessments. The care recipients’ family or significant other supply further information, and general practitioners review the care

Home name: MercyCare Joondalup RACS ID: 7241 12 Dates of audit: 12 December 2016 to 13 December 2016 recipient throughout their stay. Registered nurses review care recipients’ care plans four monthly and as changes are identified, and conduct a review of assessments if care recipients’ care needs change. The home monitors care recipients’ clinical care outcomes through ‘as required’ reviews, clinical audits, and care recipient/representative feedback and annual family conferences. Staff report significant changes in care recipients’ health status to the attending general practitioner. Staff from each shift conduct a handover. Staff report, record and monitor clinical and behavioural incidents. Care recipients and representatives stated their satisfaction with the health and personal care provided to care recipients.

2.5 Specialised nursing care needs

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

Team’s findings

Registered nurses, in collaboration with other qualified staff, assess, plan, manage and review specialised nursing care. Staff access the clinical nurse or external specialist nurses to provide additional advice and support, for example complex wound care. Specialised nursing care plans and the progress notes record strategies recommended by specialist nurses. Monitoring of specialised nursing care occurs through care plan reviews, audits and feedback from care recipients and representatives. Care recipients and representatives stated satisfaction with the provision of specialised nursing care.

2.6 Other health and related services

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

Team’s findings

The physiotherapist and occupational therapist review all care recipients on moving into the home and as care needs change. A podiatrist visits the home, and all care recipients are reviewed and treated six weekly. Staff refer care recipients to other contracted allied health professionals such as speech pathologist and dietician when required. Access to audiologists, optometrists and a dental service are available either as visiting services or in the community. Specialists in dementia care visit the home when required. Documentation of assessments and prescribed treatments occur and staff enter specific information into care plans. Care recipients and representatives stated they are aware of the availability of allied health professionals.

Home name: MercyCare Joondalup RACS ID: 7241 13 Dates of audit: 12 December 2016 to 13 December 2016 2.7 Medication management

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

Team’s findings

Clinical staff and medication competent care staff administer medications from original and multi-dose packaging. Care recipient identification is clear and medication profiles fully describe where topical treatments are to be applied. A schedule of audits and checks of the medication system identifies gaps and areas for improvement, and there are documented processes to guide staff if a medication administration incident occurs. An independent pharmacist reviews medication charts on a regular basis, providing the attending general practitioner and the home with a report. Care recipients who wish to manage their own medication are assessed as safe to do so, and are provided with a locked drawer for safe storage. There is a safe disposal system. Care recipients and representatives stated the administration of care recipients’ medication is managed safely and effectively.

2.8 Pain management

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

Team’s findings

The identification of each care recipient’s past history and presence of pain occurs during the initial phase using validated assessment tools. Pain management strategies are reviewed if there is a change in care recipients’ cognition levels, clinical status, where there is a new episode of reported pain, and when ‘as required’ pain relief is administered over a period of time. Alternatives to medication are directed through a multidisciplinary approach using strategies such as limb massage, gentle passive stretching, prescribed exercise, scheduled repositioning, hot/cold therapies and individual diversional strategies. Pressure relieving equipment is available and the home has access to external pain specialists for additional support and advice. Care recipients and representatives stated they are satisfied with the home’s management of care recipients’ pain.

2.9 Palliative care

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

Team’s findings

Staff consult care recipients and representatives to plan care reflecting individual wishes and cultural beliefs to ensure the maintenance of comfort and dignity of terminally ill care recipients. Care recipients are offered the opportunity to complete an advanced care directive. Registered nurses reassess the care recipient’s needs when they enter the palliative phase of care, in collaboration with the family and/or significant others, the attending general practitioner and, if requested, palliative care specialists. An end of life care plan is implemented during the palliative phase and includes care recipient preferences such

Home name: MercyCare Joondalup RACS ID: 7241 14 Dates of audit: 12 December 2016 to 13 December 2016 as meals and drinks, nursing care required and reference to the care recipient’s final wishes. Family members are assisted to stay at the home during this time if they wish. The home has access to specialised equipment for the continual administration of pain relief and other medications to minimise symptoms. External chaplaincy services and counselling services are available to enhance care recipient and family support. Staff provide follow up support to bereaved relatives. Care recipients reported the home would, if required, provide palliative care to meet their comfort and dignity.

2.10 Nutrition and hydration

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

Team’s findings

During the initial generic assessment, care recipients’ nutrition and hydration needs, food preferences, food allergies, intolerances/special diets, swallowing difficulties and weight management requirements are collected. Staff use this information to develop individual care plans. Care recipients are referred to a dietician and speech pathologist when required. Care recipients are weighed monthly or more frequently if required according to a validated protocol, and the clinical nurse and general practitioners monitor weight changes. A dietician is contacted and recommends individual strategies for those care recipients with unexplained weight loss or gain. Staff direct specific and relevant dietary information to the catering staff. A range of textured modified meals, drinks and assistive crockery and cutlery are available for those who need them. Supplements are provided to care recipients to enhance their nutritional status when required. Care recipients and representatives stated their satisfaction with the quality and quantity of meals, provisions for special diets, and associated support for care recipients.

2.11 Skin care

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

Team’s findings

Care recipients undergo a review of their skin integrity when they move into the home. The registered nurse identifies risks to skin integrity and the potential for pressure injury. Care recipients with diabetes, peripheral vascular disease, reduced mobility, receiving palliative care, post-surgery or who are frail receive specialised skin care. Staff use appropriate dressing protocols to support wound care management, and the home contacts external specialists for complex wound advice. The home formally monitors skin tears. Staff identify care recipients at risk of pressure injury and implement strategies such as specialised pressure relieving practices/equipment and formalised repositioning regimes. Emollients and barrier creams are used. Care recipients and representatives reported care recipients’ satisfaction with the provision of skin care.

Home name: MercyCare Joondalup RACS ID: 7241 15 Dates of audit: 12 December 2016 to 13 December 2016 2.12 Continence management

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

Team’s findings

Care recipients’ urinary and bowel continence needs are assessed on moving into the home and a care plan is developed. Bowel elimination is monitored each shift and interventions are documented. A range of interventions are used to manage care recipients’ continence needs including appropriate equipment, scheduled toileting and suitable continence aids. An external continence advisor visits the home on request to provide specialised advice. Infections are monitored via the infection control log and strategies implemented as necessary. Staff reported they have appropriate training and supplies to manage care recipients’ continence needs effectively. Care recipients and representatives reported they are satisfied care recipients’ continence is managed effectively.

2.13 Behavioural management

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

Team’s findings

On moving into the home, care recipients undergo behaviour management assessments after an initial settling in phase, or when behaviours change. Care plans are developed from assessment information, documented staff observations over a defined period of time, information from dementia advisory professionals, and family feedback. The home has protocols to minimise and manage the use of restraint. Care recipients who exhibit challenging behaviours are discussed at a focus meeting and causes and management strategies identified with family input. Activity and therapy equipment and resources are available and individualised according to the care recipient’s preference and previous lifestyle. Behaviour management strategies are evaluated for effectiveness. Staff stated their understanding of mandatory reporting requirements. All staff were observed interacting in a therapeutic manner with care recipients. Care recipients and representatives stated the behaviours of other care recipients do not impact on care recipients’ privacy.

2.14 Mobility, dexterity and rehabilitation

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

Team’s findings

On moving into the home, the physiotherapist, occupational therapist and registered nurses assess the care recipient’s mobility, dexterity and rehabilitation needs to maximise individual independence. The physiotherapist supports care recipients with prescribed individualised physiotherapy programs, and therapy staff incorporate gentle exercise into various activities throughout the week. Staff report, monitor, analyse and action all incidents related to care recipients’ falls and near misses. Management monitors and trends the number of care

Home name: MercyCare Joondalup RACS ID: 7241 16 Dates of audit: 12 December 2016 to 13 December 2016 recipients’ falls to identify potential improvements. Specialised equipment is available to alert staff when care recipients place themselves at risk. Care recipients and representatives stated their satisfaction with the exercise program available during the week.

2.15 Oral and dental care

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

Team’s findings

On moving into the home, registered nurses review care recipients’ oral and dental care needs. Care plans document individual preferences for cleaning natural teeth, dentures and other care and care recipients receive a scheduled change of toothbrush every three months. Referrals to the general practitioner and speech pathologist occur if the care recipient has swallowing difficulties. Staff have received training in the management of care recipients’ oral hygiene. Care recipients’ oral care is specialised during palliation and individualised when a care recipient receives inhaler therapy. Additional strategies such as specialised mouthwashes are available for those care recipients who find routine oral hygiene distressing. Dentists and denture manufacturers visit the home, and staff support care recipients to attend their own community dentist if wished. Care recipients and representatives stated their satisfaction with oral and dental care provided to care recipients.

2.16 Sensory loss

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

Team’s findings

The occupational therapist conducts a formal assessment of each care recipient’s five senses when care recipients move into the home. The care plan outlines individual strategies to manage needs and sensory aids. Care recipients are offered an annual review by visiting optical and audiologist services. Resources such as large print books and talking books are available to care recipients with sensory losses. Staff offer massages, relaxing music, and walks in the garden and local park to further stimulate senses. Gentle stretching and relaxation therapies are provided to assist sensory stimulation for those with cognitive impairment. During palliation additional care such as aromatherapy ensures the enhancement of sensory care. Care recipients and representatives stated their satisfaction with the identification and management of care recipients’ sensory losses.

2.17 Sleep

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

Team’s findings

An assessment of the care recipient’s sleeping and rest patterns occurs after an initial settling period. In consultation with care recipients and/or representatives, care plans

Home name: MercyCare Joondalup RACS ID: 7241 17 Dates of audit: 12 December 2016 to 13 December 2016 nominate individual rising and settling times and other specific rituals. The home promotes the use of alternatives to medication where possible such as snacks, warm drinks, temperature or light adjustment. Staff consider previous life histories, pain management, continence care, immobility and behaviour management when assessing disturbed sleep patterns and planning individual strategies to enhance sleep. Care recipients and representatives reported care recipients sleep well and stated their satisfaction with the attention provided by night staff.

Home name: MercyCare Joondalup RACS ID: 7241 18 Dates of audit: 12 December 2016 to 13 December 2016 Standard 3 – Care recipient lifestyle

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

Team’s findings

Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

In relation to Standard 3 – Care recipient lifestyle, care recipient meetings and care recipient surveys are used to gather suggestions and trends. Staff encourage and support care recipients and others to provide feedback and suggestions.

Examples of current or recent improvement activities related to Standard 3 – Care recipient lifestyle are described below.

 Following negative feedback at the care recipient and representative meeting regarding the lack of any ceremony on Remembrance Day in 2015, a service was held with suitable poetry reading and a recital of the Ode of Remembrance. Attendance and feedback from care recipients indicated they appreciate the introduction of the service. The management team reported this ceremony will be continued in future years.

 After receiving a comment from a representative regarding a television program on the importance of music and dementia, the occupational therapist investigated implementing a similar program at the home. As a result, individual appliances and earphones have been purchased and suitable music downloaded for individual care recipients. This was done in consultation with representatives. Staff are aware of the program and advised the availability of the music helps settle some care recipients who become agitated. The improvement has not been formally evaluated.

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

Team’s findings

Care recipients are informed about their rights and responsibilities in information provided to them when they move into the home. Information updates are advised in writing and discussed at care recipient and representative meetings. The home provides each care recipient with an agreement outlining fees, level of care and services, and tenure arrangements. There are policies and procedures for the compulsory reporting of care

Home name: MercyCare Joondalup RACS ID: 7241 19 Dates of audit: 12 December 2016 to 13 December 2016 recipient assault and unexplained absence. Staff are informed of changes in legislation relevant to care recipient lifestyle through training, memoranda and meetings.

Team’s findings

Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation to care recipient lifestyle. Refer to expected outcome 1.3 Education and staff development for a description of the system.

Recent examples of education related to Standard 3 – Care recipient lifestyle are listed below.

 Compulsory reporting and unexplained absences

 Grief and loss

 Sexuality and wellness.

3.4 Emotional support

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

Team’s findings

Care recipients receive support in adjusting to life in the new environment and on an ongoing basis. Care recipients and their representatives are orientated to the home and receive additional support from staff during the initial six weeks. Written information is available in an information pack and care recipient handbook. Information is gathered from care recipients and their representatives including social and life history, personal routines, preferences and spiritual needs, and this is used to develop care plans which are regularly reviewed or as required. Staff described how they support individuals adjust to the home. Care recipients are encouraged to personalise their rooms, join in activities at the home and, where possible, maintain their links with the external community. Representatives and care recipients reported they are satisfied support provided by the home is effective in meeting care recipients’ needs and preferences.

Home name: MercyCare Joondalup RACS ID: 7241 20 Dates of audit: 12 December 2016 to 13 December 2016 3.5 Independence

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

Team’s findings

Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service. A comprehensive suite of assessments are completed after moving into the home, and care recipients’ level of assistance required in all activities are documented in care plans. Assistive devices such as mobility, hearing, vision and continence aids are provided as required, and adaptive crockery to maintain their independence during meals is available. Care recipients are encouraged to retain their links with the community and are assisted to attend concerts, bus trips and excursions. Assistance is given to enable care recipients to register for postal voting. Care recipients and representatives have input into the therapy program via quarterly resident meetings and surveys. Staff reported they encourage and prompt care recipients to do as much for themselves as they are able, in order to maintain independence. Care recipients and representatives reported they are satisfied with the assistance provided by the home in relation to independence.

3.6 Privacy and dignity

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

Team’s findings

Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Care plans and private documents are stored securely and are only accessible to authorised personnel. The home has mainly single bedrooms with ensuite bathroom that promote care recipients’ privacy and dignity. Staff sign a confidentiality agreement on commencement of employment and receive training on privacy and dignity. We observed staff knocking on care recipients’ doors and addressing them respectfully. Staff outlined strategies they use to maintain care recipients’ privacy and dignity such as conducting personal care in private and not divulging information about them to unauthorised personnel. Care recipients and representatives reported they are satisfied care recipients’ privacy, dignity and confidentiality are recognised and respected.

3.7 Leisure interests and activities

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

Team’s findings

Care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them. The occupational therapist and physiotherapist assess new care

Home name: MercyCare Joondalup RACS ID: 7241 21 Dates of audit: 12 December 2016 to 13 December 2016 recipients on moving into the home regarding their social history, past and current interests, and develop individual leisure and lifestyle care plans. The home provides a monthly activity calendar catering to care recipients’ preferences, and the activities are modified according to feedback from care recipients. There is a range of internal and external activities such as exercise, craft and games activities suitable for care recipients with mobility, sensory or cognitive impairment. Therapy staff encourage care recipients to attend activities, and non- attendance is documented in order to evaluate care recipients’ participation levels. Care recipients and representatives are encouraged to provide feedback through surveys, evaluations, and at the care recipient and representative meetings. Representatives and care recipients interviewed reported care recipients are supported to participate in activities and interests appropriate to their needs and preferences.

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

Care recipients’ individual interests, customs, beliefs, and cultural and ethnic backgrounds are valued and fostered. The lifestyle assessments conducted when a care recipient moves into the home capture information regarding cultural and spiritual life, customs and beliefs. Church services are held on weekends. Cultural themes such as Italian-theme days and Melbourne Cup day are included in the activity program. Days of significance such as Anzac Day, Christmas, Easter and Remembrance Day are celebrated, and monthly calendars identify care recipients’ birthdays. The home has access to multicultural resources such as cue cards, bilingual staff and an interpreter service. Care recipients and representatives reported they are satisfied the home values and fosters care recipients’ individual customs, beliefs and cultural backgrounds.

3.9 Choice and decision-making

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

Team’s findings

Care recipients and their representatives participate in decisions about services provided, and are enabled to exercise choice and control over their lifestyle while not infringing on the rights of other people. Assistance is provided to care recipients and representatives to participate in decision making about care and service delivery via consultation throughout the assessment and care planning process, case conferences, care recipient and representative meetings, surveys and the continuous improvement process. Choice is provided during activities of daily living such as preferred sleep hours, choice of clothes, meals and activities. Care recipients’ right to refuse is respected. Rights and expectations are outlined in admission documentation, residential and accommodation contracts, and on a displayed Charter of care recipients’ rights and responsibilities. Information regarding external advocacy and complaint services is detailed in agreements, and translated brochures outlining the external complaints process are also available. Authorised representatives are

Home name: MercyCare Joondalup RACS ID: 7241 22 Dates of audit: 12 December 2016 to 13 December 2016 consulted if care recipients are unable to make decisions for themselves. Care recipients and representatives reported satisfaction with the opportunities care recipients have to exercise choice and control appropriate to their needs and preferences.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings

Care recipients have secure tenure within the residential care service, and understand their rights and responsibilities. On moving into the home, care recipients or their representatives are provided with a residential and accommodation agreement that outlines care recipients’ rights and responsibilities and the security of tenure arrangements. An information package and orientation to the home assist care recipients and representatives to understand their rights and responsibilities. Consultation is undertaken with care recipients and their representatives regarding room transfers within the home and this is documented. Care recipients and representatives advised they feel secure in their tenure and are aware of their rights and responsibilities.

Home name: MercyCare Joondalup RACS ID: 7241 23 Dates of audit: 12 December 2016 to 13 December 2016 Standard 4 – Physical environment and safe systems

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

Team’s findings

In relation to Standard 4 – Physical environments and safe systems, staff conduct environmental audits and collect information in relation to hazards and incidents to identify trends. Surveys and feedback systems are used to measure and review the living environment and ensure safety of care recipients, staff and others. Care recipients and staff are satisfied management actively works to improve the home’s physical environment.

Examples of current or recent improvement activities in relation to Standard 4 – Physical environments and safe systems are described below.

 Following negative feedback about the noise between communicating care recipient rooms, management advised the adjoining doorway has been sealed, insulated and a wall built. This has resulted in both rooms now being more user-friendly and quieter.

 Management advised, following the change in ownership of the home, new thicker pressure relieving mattresses have been purchased for all beds. Staff advised they like the mattresses as date labels indicate when the mattress requires rotation. Care recipients stated they find the beds comfortable.

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 has management systems to ensure ongoing regulatory compliance in relation to the physical environment and safe systems. Workplace, building, catering and fire emergency preparedness are routinely inspected and audited. Safety data sheets are stored with chemicals, and infection control guidelines are available. The home has a food safety program to provide staff guidance. Interviews with staff confirmed their knowledge of regulatory compliance requirements.

Home name: MercyCare Joondalup RACS ID: 7241 24 Dates of audit: 12 December 2016 to 13 December 2016 4.3 Education and staff development

Team’s findings

Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation physical environments and safe systems. Refer to expected outcome 1.3 Education and staff development for a description of the system.

Recent examples of education related to Standard 4 – Physical environment and safe systems are listed below.

 Basic fire and evacuation training

 Chemical safety

 Fire extinguisher training

 Hand hygiene.

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 care recipients’ care needs".

Team’s findings

Management and staff provide a safe and comfortable secure environment consistent with care recipients’ needs. The rooms include an ensuite bathroom, and care recipients are encouraged to personalise their space with small items of furniture and mementos. There are areas inside and outside the building so care recipients can socialise with family and friends. Monthly audits are carried out to ensure the physical environment is safe and comfortable. Staff described the ways they ensure the safety of care recipients through hazard reporting, tagging and reporting of non-functioning equipment. The environment appears well- maintained, clean, clutter and odour free with enough furniture to meet care recipients’ requirements. Care recipients and representatives expressed their satisfaction with temperature, noise, safety and comfort of the living environment.

Home name: MercyCare Joondalup RACS ID: 7241 25 Dates of audit: 12 December 2016 to 13 December 2016 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

Management and staff actively provide a safe working environment that meets regulatory requirements. Staff are oriented to their occupational health and safety responsibilities, and organisational safety policies and procedures guide and direct staff practice. Management and staff regularly assess the physical environment, report risks, identify potential and actual hazards, and analyse accidents and incidents. Staff receive information on their occupational health and safety responsibilities during orientation, general meeting and via memoranda. Occupational safety and health representatives and other staff described how they identify and report hazards and accidents, and stated management is proactive in providing a safe working environment.

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 has systems and processes to provide a safe environment and reduce the risk of emergencies, fire and safety breaches. Organisational fire, security and emergency procedures are available to staff, care recipients and visitors, and inform them how to proceed in the event of an emergency. The building is equipped with a range of fire prevention and firefighting equipment. Contracted services carry out routine inspections and the testing of fire systems. There is a sign-in/sign-out register at the front door/reception for visitors and contractors to the home. Entry to the home is controlled and observed by closed circuit camera. There is restricted access after-hours for the security of staff and care recipients. Staff attend regular training and fire drills and other emergencies. Staff interviewed described procedures to be followed in the event of a fire or other emergency. Care recipients and representatives reported they feel confident staff would assist them during an emergency.

4.7 Infection control

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

Team’s findings

The home has an effective infection control program. An infection control manual, guidelines and outbreak kit are available to staff. The service manager holds the infection control portfolio. Monthly reports track and monitor infections and are used to assess effectiveness of infection control strategies. Signage, personal protective equipment, sharp disposal units and hand sanitisers are readily available to assist, reduce and respond to infection risk. The home has a food safety program and vaccinations are offered to care recipients and staff.

Home name: MercyCare Joondalup RACS ID: 7241 26 Dates of audit: 12 December 2016 to 13 December 2016 Staff undertake infection control training and demonstrated awareness of preventative infection control strategies. Care recipients and representatives reported satisfaction with the home’s infection control program.

4.8 Catering, cleaning and laundry services

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

Team’s findings

There are systems and processes for catering, cleaning and laundry services. Food is cooked daily onsite according to a four-weekly rotating menu. Menus are developed in consultation with a dietician. Care recipients have input into the menu via surveys, meetings and individual verbal feedback. Care recipients’ dietary needs, allergies and preferences are identified through assessments, changing needs and monitored in consultation with relevant staff. Scheduled tasks and duties guide laundry services, and there is a marking and sorting system to prevent loss of linen and clothes. Staff undertake cleaning in accordance with cleaning schedules and use colour-coded equipment to maximise infection control practices. Staff stated the home’s hospitality services are effective in enhancing the work environment. Care recipients, representatives and staff reported satisfaction with hospitality services.

Home name: MercyCare Joondalup RACS ID: 7241 27 Dates of audit: 12 December 2016 to 13 December 2016