Published Decision (SA and RA) s8

Carramar Hostel

RACS ID: 7153 Approved provider: City of Bayswater Home address: 23A Redgum Way MORLEY WA 6062

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 10 June 2020. We made our decision on 07 April 2017. The audit was conducted on 14 March 2017 to 15 March 2017. 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. 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 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. 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: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 2 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. 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional Support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and responsibilities Met Standard 4: Physical Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors 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: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 3 Audit Report

Name of home: Carramar Hostel RACS ID: 7153 Approved provider: City of Bayswater Introduction This is the report of a Re-accreditation Audit from 14 March 2017 to 15 March 2017 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: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 4 Scope of this document An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 14 March 2017 to 15 March 2017. 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: 40 Number of care recipients during audit: 40 Number of care recipients receiving high care during audit: 39 Special needs catered for: Nil specified.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 5 Audit trail The assessment team spent two days on site and gathered information from the following: Interviews

Position title Number

Residential manager 1

Area manager 1

Care coordinator 1

Administration assistant 1

Maintenance officer 1

Registered and enrolled nurses 3

Care staff 9

Occupational therapist and physiotherapist 2

Hospitality staff 5

Therapy staff 2

Care recipients/representatives 9

Sampled documents

Document type Number

Care recipient agreements 3

Care recipient files and care plans 6

Medication profiles and self-medication 10 authorisation forms

Personnel files 6

External service agreements 4

Other documents reviewed The team also reviewed:  Activities calendar and outings schedule  Agency orientation and site induction checklist  Allied health referral file  Annual audit schedule, completed audits, survey reports and actions

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 6  Archiving records, spreadsheet and action sheet  Care recipient assessment and care plan review schedules  Care recipient information package, including information handbook  Care recipients’ therapy programs and therapy statistics  Compulsory reporting incidents, reports and correspondence  Continuous improvement forms, logs and plans  Contractors induction file and asbestos register  Diary, handover sheets and communication book  Drugs of addiction register  Emergency and crisis guidelines  Family conference register  Food safety program, records of food and appliance temperature monitoring, and cleaning schedules  Incident, accident, hazard and infection reports and summaries  Kitchen dietary file and drinks and supplements lists  Maintenance schedules, requests, records, service reports, chemical register, fire and electrical equipment testing, logs and service  Meeting minutes, memoranda and newsletters  Menus, meal choices, surveys and dietary information  Monitoring list for police certificates, performance appraisals, visas and professional registrations  Policies and procedures  Position descriptions and duty statements  Regulatory compliance monitoring files  Rosters, staff allocations and handbook  Training calendar, attendance records, reports, analysis and evaluations  Various files relating to Standard two information  Volunteers’ information including inductions, police certificates and statutory declarations  Wound management file. Observations The team observed the following:  Access to internal and external complaints mechanisms, advocacy, locked suggestion box and noticeboards with displayed information  Activities advertised and in progress  Archived records storage  Emergency packs, evacuation plans and flipcharts  Equipment and supply storage areas

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 7  Exercise cards and continence plans in care recipients’ rooms  Interactions between staff and care recipients  Living environment and care recipients’ appearance  Meal and morning and afternoon tea services in progress  Safety data sheets, personal protective equipment, outbreak and spills kit  Short group observation of activity in the main hall  Storage of medications  Vision, mission, values statement and Charter of care recipients’ rights and responsibilities on display.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 8 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 services, 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 The organisation has systems and processes to promote, identify, capture and evaluate continuous improvement across all four Accreditation Standards. Opportunities for improvement are identified from observations, meetings, audits, surveys, incident data, complaints and suggestions. Staff, care recipients and representatives provide feedback and make suggestions about the care and services provided, collected within a continuous improvement log. Improvements implemented are recorded and tracked within the continuous improvement plan and evaluated to measure the effectiveness of the improvement. Continuous improvement is promoted and communicated to staff, care recipients and representatives at meetings and in newsletters. Staff confirmed they are encouraged to make suggestions and provide feedback to improve care and services. Care recipients and representatives are satisfied their suggestions are considered and management are responsive to feedback and ideas. Recent examples of improvements undertaken or in progress relating to Standard 1 – Management systems, staffing and organisational development are described below.  Management identified a need for additional clinical support after hours and have recruited enrolled nurses across all shifts. The recruitment of the additional staff has seen an improvement in reporting of clinical changes and has provided additional clinical support over the weekends. Feedback from care staff, care recipients and meeting minutes showed positive comments relating to the changes and care recipients feel the care has improved.  Following a suggestion from staff, weekly team meetings have been implemented to support new enrolled nurses recruited by the home, maintain consistent clinical care for care recipients and communicate across the clinical team, and meetings have commenced with the care coordinator, registered and enrolled nurses, and the residential manager. The residential manager also receives a written clinical handover from the enrolled nurses to identify any areas for discussion at the meeting. Verbal feedback regarding the change has been positive and clinical staff feel supported. 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

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 9 There are systems and process to identify and monitor compliance with relevant legislation, regulatory requirements, professional standards and guidelines across all four Accreditation Standards. The organisation receives advice and updates on legislative and regulatory changes from industry groups and government departments, and changes to processes or practices are made as required. Key personnel are notified of changes and relevant information is communicated to staff, care recipients and representatives via meetings, memoranda and newsletters or direct correspondence. Planned and responsive audits monitor compliance with legislation and regulatory obligations. The organisation and home have a system to obtain and monitor police certificates for current and new staff, volunteers and contractors. There are processes for collecting and monitoring employee working rights. Care recipients and representatives have access to information regarding the Aged care complaints commissioner, and were informed of the accreditation audit via direct correspondence, displayed notices and at meetings. 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’s systems and processes ensure management and staff have appropriate knowledge and skills to perform their roles effectively. New staff undertake an orientation and induction and complete ‘buddy shifts’ on commencing employment. Training and education is planned and delivered throughout the year and each employee must undertake a suite of compulsory education based on their role that is recorded and monitored. Management monitor the skills and knowledge of staff via observations, feedback, incident reports and performance appraisals and undertake a training needs analysis. Toolbox training is delivered on the job to enhance knowledge and support staff to perform their roles effectively. Training provided is evaluated and improvements made where identified. Management and staff confirmed they are encouraged to attend a range of education and training opportunities to maintain and improve their skills and knowledge and have upskilled to other roles. Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below.  Assessing the Accreditation Standards  Corporate orientation  Electronic clinical documentation system  Vision, mission and values. 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome There are systems and processes to enable each care recipient, their representatives and other interested parties to have access to internal and external complaints mechanisms. Care recipients and representatives are informed of comments and complaints mechanisms in the welcome pack, handbook, newsletter and care recipient agreement. Feedback forms, suggestions boxes, posters and brochures regarding external complaints mechanisms and advocacy services are accessible in various locations around the home. Care recipients

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 10 actively provide feedback through surveys, meetings and care conferences. Feedback is responded to in a timely manner, logged and analysed for trends and discussed at care recipient and staff meetings. Staff demonstrated how they assist care recipients to access feedback forms. Care recipients and representatives confirmed they have access to complaints mechanisms and are satisfied with the response to feedback. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The organisation’s documented vision, mission, values and commitment to quality are accessible and available to staff, care recipients and other interested parties. The statements are included in a range of publications and access points including the care recipient and staff information booklet, on the internal webpage and displayed around the home. The content of the statements is consistent across the publications. Staff confirmed they receive information on the vision, mission, values and commitment to quality at meetings and training. 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 Appropriately skilled and qualified staff are employed at the home to ensure care and services are delivered according to the home’s philosophy and care recipients’ needs. A process of recruitment and selection occurs against the criteria of each position. New employees are orientated within a four day program that outlines the organisation’s expectations and processes. There are position descriptions and duty statements to guide staff in their role. The skills and knowledge of staff are maintained through compulsory training and education specific to the organisation’s and home’s needs. Rosters and staffing allocations are amended to suit the requirements of the home and changing needs of care recipients and volunteers are utilised. Feedback is provided to staff on their performance at planned appraisals and through informal discussions. The home has processes to cover leave and access temporary staff as required. Staff confirmed they have sufficient time to complete tasks. Care recipients and representatives are satisfied with the care and services delivered by the home. 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 maintains adequate supplies of stocks and equipment to enable the delivery of quality care and services. Minimum levels of stocks and equipment are ordered and maintained by clinical, administrative and hospitality staff. There are preventative and corrective maintenance programs, and equipment is checked, serviced and repaired by the maintenance officer and external service providers. Staff are provided with training and instructions to use equipment safely and correctly, and confirmed they can readily access

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 11 sufficient equipment appropriate to their requirements. Care recipients and representatives are satisfied repairs are timely and appropriate goods and equipment are provided 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 meets this expected outcome There are systems and processes to support effective information management. Policies and procedures are available to guide management and staff that are reviewed and updated in response to changes. Management and staff access information from a variety of sources that includes meetings, handbooks, internal webpage, memoranda, care plans, alerts, handovers, communication books and noticeboards. Care recipients and representatives receive information communicated from sources such as booklets, agreements, meetings and care conferences, and information is displayed around the home. Confidential information is stored securely, staff and volunteers sign a confidentially clause and electronic information is password protected. Archived information is stored appropriately and can be retrieved timely. Information is gained from the collection and analyses of audits, surveys and clinical data. Management staff have access to appropriate information to help them perform their roles. Care recipients and representatives are satisfied they have access to information appropriate to their needs. 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 Externally sourced services are provided in a way that meets the home’s service needs and quality goals. An asset and building team oversee external service agreements and providers. The home has access to a list of contractors and preferred suppliers, and the quality of goods and services are monitored on an ongoing basis through periodic reviews and feedback from management, staff and care recipients. The maintenance officer monitors the attendance and frequency of visiting contractors via a service schedule. Contractors sign in a register when they enter and exit the home and receive an induction on commencement. A contractor’s induction file and asbestos register is accessible in the reception area. Management, staff, care recipients and their representatives are satisfied with the level of service provided by external service providers.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 12 Standard 2 – Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 2 – Health and personal care, staff report on information and changes related to care recipients’ behaviours, skin and pressure injuries, medication incidents, behaviour responses and falls, and this information is collated, analysed for trends and improvements, and discussed at care recipient and staff meetings. Recent examples of improvement activities completed or in progress relating to Standard 2 – Health and personal care are described below.  Following a suggestion from the physiotherapist, a pain management program has been introduced involving providing care recipients with warm wax baths for arthritic hand pain and ultrasound treatments for muscular pain. The trial is currently in progress and early results have seen a reduction of pain and swelling, and a care recipient able to eat their meal without staff assistance following treatments with the wax bath. This improvement is yet to be formally evaluated.  A suggestion from the care coordinator has seen the introduction of an ultrasonic cleaner for maintaining care recipients’ dentures. The cleaner has been used to clean dentures, and care recipients are satisfied with the improvement in how their dentures feel and appear. 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 The home has systems and processes for identifying relevant legislation, regulatory requirements, professional standards and guidelines in relation to care recipients’ health and personal care. Care recipients are assessed and provided with care and services by appropriately qualified nursing and allied health staff. Medication is administered and stored safely and correctly. Professional registrations and qualifications for nursing and allied health employees are monitored and maintained for currency for all professional positions. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 13 Team’s findings The home meets this expected outcome Management and staff have the appropriate knowledge and skills to provide appropriate health and personal care to care recipients. Refer to expected outcome 1.3 Education and staff development for an overview of the home’s system. Examples of education and training related to Standard 2 – Health and personal care are listed below.  Dehydration in the elderly  Dementia care  Dysphagia and swallowing  Medication administration  Palliative care  Philosophy of care and communication. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients receive appropriate clinical care. The multidisciplinary team assess care recipients’ clinical needs when they move into the home using information from their medical histories and a range of clinical tools. Care plans are developed and reviewed according to the home’s policy and in consultation with care recipients and representatives via care conferences. There are processes to monitor and communicate care recipients’ changing needs and preferences, including regular review of care recipients by their general practitioners, six-monthly care plan reviews and shift handovers. Clinical audits are undertaken and clinical indicators are monitored and analysed. The provision of clinical and personal care is reviewed and evaluated. Care recipients and representatives reported satisfaction with the clinical 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 The home meets this expected outcome The home has processes to ensure registered and enrolled nurses identify and review care recipients’ specialised nursing care needs. Care recipients’ specialised nursing care needs are assessed when they move into the home, documented in a specific nursing care plan and reviewed six monthly or as required. The home has a clinical coordinator and a registered nurse on duty from Monday to Friday to provide care and direction for staff. Enrolled nurses are rostered after hours and during weekends. General practitioners, nurse practitioners and other health professionals are consulted as required. Examples of specialised nursing care include wound care, behaviour management, oxygen therapy and management of diabetes. Care recipients and representatives reported care recipients’ specialised nursing care needs are met.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 14 2.6 Other health and related services This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”. Team’s findings The home meets this expected outcome Care recipients are referred to a variety of health specialists in accordance with their initial and ongoing assessed needs and preferences. The home employs two occupational therapists and a physiotherapist to assess care recipients when they move into the home and annually and as required thereafter. A podiatrist visits the home regularly and attends to the needs of care recipients. Referrals are made to other health specialists as the need is identified, including a dietician, speech pathologist and the mental health team. Care recipients and representatives reported satisfaction with care recipients’ ongoing access to a variety of health specialists. 2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Processes are established for ordering, storing, administering, documenting and disposing of medications safely and correctly. Registered and enrolled nurses and competent care staff administer medications via a pre-packed system as per the general practitioners’ instructions. Specific instructions for the administration of care recipients’ medications and topical treatments are documented in their medication profiles. Medication audits and recorded medication incidents are used to monitor the system. An accredited pharmacist conducts reviews of care recipients’ medications and communicates findings to the general practitioners and the home. Care recipients and representatives reported care recipients’ medications are managed safely and correctly. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome There are systems to identify, implement and evaluate each care recipient’s pain management strategies to ensure they remain as free as possible from pain. Registered and enrolled nurses assess care recipients’ pain when they move into the home and, where pain is identified, the care recipient is referred to the therapy team for further assessment. Competent care staff review care recipients’ pain each day and report complaints of pain to the registered or enrolled nurse. Six-monthly pain assessments are conducted and care recipients with identified pain are assessed more frequently if required. Care plans are implemented that detail pain management interventions, including alternative therapies and the use of pain and pressure-relieving equipment. Where appropriate, the occupational therapist conducts regular therapeutic massage and staff administer heat packs to manage care recipients’ pain. The effectiveness of these treatments is monitored and recorded. Care recipients who do not respond to these interventions are referred to their general practitioners for review. Staff described their role in pain management, including identification and reporting of pain. Care recipients and representatives reported staff are responsive to complaints of pain and care recipients’ pain is managed appropriately.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 15 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome There are systems to ensure the comfort and dignity of terminally ill care recipients. Care recipients or their representatives have the opportunity to complete an advanced care directive when care recipients move into the home or at any time throughout their residency. Care recipients’ general practitioners, the home’s clinical and allied health personnel, and external palliative care specialists support care recipients during their palliation. Care recipients and representatives expressed confidence, when required, staff would manage care recipients’ palliative care competently, including the maintenance of their comfort and dignity. 2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Care recipients’ nutritional status is assessed when they move into the home and their individual dietary requirements and preferences are conveyed to relevant personnel. Registered and enrolled nurses assess each care recipient’s swallowing when they move into the home, and care recipients with identified swallowing deficits are ordered appropriately textured diets and fluids. Care recipients’ care plans outline their dietary requirements, including the level of assistance required. The clinical coordinator monitors care recipient monthly weights and, where weight loss is identified, the care recipient is placed on a supplementary nutritional drink and referred to the speech pathologist and/or the dietician as appropriate. Registered and enrolled nurses direct care recipients’ nutritional management. Care recipients and representatives reported they are satisfied with the nutrition, hydration and associated support needs received. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Registered and enrolled nurses conduct regular assessments of care recipients’ skin integrity and formulate care plans that state preventative skin care interventions. Registered and enrolled nurses attend to care recipients’ wounds and the registered nurse formally reviews each wound on a weekly basis. The home employs a number of preventative strategies including pressure-relieving mattresses, repositioning and moisturising lotions. Care staff monitor care recipients’ skin daily and report abnormalities to the registered or enrolled nurse. The home records and collates information regarding skin related incidents. Care recipients and representatives reported satisfaction with the home’s management of skin care. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 16 Team’s findings The home meets this expected outcome There is a system to identify, assess, monitor and evaluate care recipients’ continence needs when they move into the home and on an ongoing basis. Care recipients’ urinary and bowel continence needs are assessed and an individualised care plan is developed reflective of assessed needs. Staff use bowel charts to track bowel patterns and develop appropriate bowel management programs, and registered and enrolled nurses monitor the use and effect of aperients. Staff reported having sufficient continence aids and appropriate skills to enable them to manage care recipients’ continence needs. Care recipients and representatives reported being satisfied with the management of care recipients’ continence needs. 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome Care recipients’ behavioural management needs are assessed when they move into the home and when clinically indicated. Appropriate behaviour management interventions are developed and documented in a care plan. Effectiveness of behaviour management strategies is monitored via clinical indicators and observations. Care recipients are referred to therapy and mental health services when the need for further assessment of challenging behaviours is identified. Care recipients and representatives reported care recipients’ challenging behaviours are well managed and the impact of the behaviours on other care recipients is minimised. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome A physiotherapist, an occupational therapist and registered and enrolled nurses assess care recipients’ mobility, dexterity and associated falls risks when they move into the home. Care recipients are encouraged to maintain their mobility and dexterity by participating in the home’s activity program that includes a range of group exercises and physical activities to improve independent movement. Care recipients who are unwilling or unable to participate in group exercises are offered individual therapy sessions. Care recipient attendance at physiotherapy sessions is monitored. A range of seating and mobility aids are available to assist care recipients to maintain mobility and independence. Incidents related to mobility and dexterity are recorded and collated data is discussed at staff meetings. Care recipients and representatives reported satisfaction with the home’s management of care recipients’ mobility and dexterity needs. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome When a care recipient moves into the home, an oral and dental assessment is conducted to identify their oral function, hygiene and dental care needs and any potential impacts on swallowing and eating. Oral and dental care interventions are recorded in the

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 17 care recipient’s care plan. An annual dental examination is offered to care recipients and follow-up treatment is arranged with family consultation. Staff are aware of care recipients’ individual oral hygiene requirements. Care recipients and representatives reported satisfaction with the support provided to care recipients to maintain their oral and dental health. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome An occupational therapist and registered and enrolled nurses assess care recipients’ sensory abilities and needs when they move into the home. Interventions for managing sensory losses are documented in care recipients’ care plans and are regularly reviewed by the clinical staff. An optometrist and an audiologist visit the home annually and care recipients are encouraged to access these services. Care recipients are assisted to access external specialist appointments and information following the appointment is communicated to the home’s staff. Care recipients and representatives reported satisfaction with the home’s management of sensory losses and needs. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome The home has established processes to assist care recipients achieve natural sleep patterns. Sleep assessments are conducted for care recipients to identify sleep patterns and disturbances. Interventions to assist care recipients establish appropriate sleep routines are documented in the care plan. Strategies used to promote restful sleep include settling routines, quiet environment, emotional support, pain management, warm drinks and night sedation. Staff described factors that can impact on care recipients’ sleep including noise, confusion, pain and continence issues. Care recipients and representatives reported care recipients are satisfied with the support provided to achieve restful sleep at night.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 18 Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 3 – Care recipient lifestyle, care recipient and representative meetings and surveys are used to gather feedback and suggestions to improve lifestyle. Observations and feedback are recorded and evaluated from lifestyle and care activities. Staff can contribute to improvements to care recipient lifestyle through feedback forms, training and networking with external service providers. The home encourages care recipients and their representatives to provide feedback and suggestions in relation to lifestyle and the program of events at the home. Recent examples of improvement activities completed or in progress relating to Standard 3 – Care recipient lifestyle are described below.  Following feedback from care recipients, the home has introduced an adopted greyhound as a pet visitor. The greyhound visits once per week and creates companionship and a discussion point for care recipients. The home has seen care recipients, who do not leave their room, frequently come out and engage with the greyhound, and meeting minutes showed care recipients are enjoying the visits. This improvement is yet to be evaluated.  To promote the pastoral team, the home has planned a pastoral week that will showcase services available to both care recipients and staff including counselling support, death and dying education, coping with grief and loss, and spiritual support. An afternoon tea is planned and all participants will receive a gift for being involved in the activity. This improvement is yet to be evaluated. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”. Team’s findings The home meets this expected outcome The home has an overarching system for identifying relevant legislation, regulatory requirements, professional standards and guidelines in relation to all four Accreditation Standards. In relation to care recipient lifestyle, the Charter of care recipients’ rights and responsibilities is provided to care recipients and representatives within the care recipient agreement and handbook and is displayed around the home. Care recipients have the opportunity to remain on the electoral roll and vote in state and federal elections. There are processes to identify and undertake reporting requirements for reportable assaults and unexplained absences. Management and staff confirmed how they identify and report reportable assaults as per the legislation and home’s policies and procedures.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 19 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 of the home’s systems for ensuring that management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of education and training related to Standard 3 – Care recipient lifestyle are listed below.  Advocare – care recipient’s rights  Choice and decision making  Elder protection and compulsory reporting  Therapy assistant development days. 3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home provides support to care recipients while they are adjusting to life in their new environment and on an ongoing basis. On moving into the home, care recipients’ needs and preferences are discussed and they are shown around the home and introduced to other care recipients and staff. Care recipients have increased monitoring in the early period and the occupational therapist assesses care recipients’ emotional and social needs with input from clinical staff. Individual care plans incorporate information relating to the holistic requirements of the care recipient, including their emotional and social wellbeing. Staff described strategies they use to provide care recipients emotional support, including extra time for frail care recipients. Emotional support is included in the audits conducted. Care recipients are encouraged to personalise their room, and join in activities at the home and in the community, where appropriate. Care recipients and representatives stated representatives are encouraged to visit the care recipients, and they are satisfied care recipients’ emotional needs are met by staff at the home. 3.5 Independence This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome An assessment of care recipients’ abilities and their wishes in relation to independence and lifestyle occurs when they move into the home. Care plans identify the support care recipients require to be as independent as possible, maintain friendships and participate in the life of the community. Therapy programs assist and maintain care recipients’ communication and mobility levels, and the occupational therapist and physiotherapist provide specific equipment to maintain care recipients’ independence. Care recipients are encouraged to maintain friendships, and regular bus trips are organised for care recipients to

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 20 undertake activities outside the home. Care recipients and representatives reported care recipients are provided with assistance from staff to maintain their 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 The home meets this expected outcome Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Confidential documentation is stored securely and accessed by authorised personnel. We observed staff interacting with care recipients in a respectful manner. Staff and care recipients advised general practitioner treatments occur in the privacy of care recipients’ rooms. Care recipients and their families have access to lounges, outdoor entertaining areas and small lounge areas. Staff described strategies for maintaining confidentiality of care recipient information, and strategies to maintain care recipients’ privacy and dignity. Care recipients and representatives reported they are satisfied care recipients’ privacy, dignity and confidentiality are maintained 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 The home meets this expected outcome Care recipients are encouraged and supported to maintain their interests and activities when they move into the home. Information about their social and cultural history is obtained through assessments and social history forms and their identified interests are used to develop individual therapy care plans. In conjunction with the occupational therapist, therapy staff develop a monthly activities calendar. Special events, individual sessions and community outings are incorporated into the program and delivered by therapy assistants. Feedback on the program is provided through care recipients’ participation, suggestions, evaluation of individual sessions, surveys and at meetings. Care recipients and representatives reported they are satisfied care recipients are supported to participate in a wide range of activities and leisure interests. 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 When care recipients move into the home their individual interests, customs and beliefs related to their cultural and spiritual life are identified, and this information is documented in the care plan. Specific cultural events are included in the activity program and staff support care recipients to attend these activities. Onsite Catholic and Anglican services are conducted each month, and the pastoral care coordinator visits care recipients weekly. Staff reported they use care plans to gain an understanding of care recipients’ specific cultural and spiritual practices. Care recipients and representatives reported staff respect care recipients’ customs, beliefs and culture. 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

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 21 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 has systems to enable care recipients and their representatives to participate in decisions about the services care recipients receive and to exercise choice and control over care recipients’ lifestyle. Care recipients and representatives have the opportunity to provide feedback through feedback forms, care recipient meetings, informal and formal meetings and surveys. Care recipients are supported and encouraged to maintain control over their lifestyle within their assessed abilities. Staff described ways in which they encourage care recipients to make decisions about their care and lifestyle. Care recipients and representatives stated they feel comfortable providing feedback, and the choices and decisions of other care recipients and representatives do not infringe on the rights of other people. 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 The home meets this expected outcome Organisational systems and processes ensure care recipients have secure tenure within the home, and understand their rights and responsibilities. On moving into the home, a care recipient agreement is offered, detailing security of tenure and care recipients’ rights and responsibilities. There is a process to ensure care recipients and representatives are consulted and their agreement sought should there be a need to move rooms, although staff reported they have no knowledge of this occurring. External advocacy and guardianship administration are utilised as required. Staff are provided with education and training regarding care recipients’ rights. Care recipients and representatives interviewed reported they are satisfied care recipients have secure tenure in the home.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 22 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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement process. In relation to Standard 4 – Physical environment and safe systems, management and staff undertake cleaning and environmental inspections and audits, and report incidents and hazards. Those reports are collated, analysed for trends that require actions for improvement and recorded within the continuous improvement plan. Staff, care recipients and representatives are encouraged to provide feedback regarding the safety and comfort of the environment. Training is provided to staff to maintain their skills and knowledge relating to safety. Care recipients and representatives are satisfied the home provides a safe and comfortable living environment and their feedback is considered. Recent examples of improvements undertaken or in progress in relation to Standard 4 – Physical environment and safe systems are described below.  Management identified a need to improve meal times following observations of staff practice. A project was undertaken to improve the dining experience and prevent care recipients being rushed. Staff education was delivered involving all staff being served in an assimilated dining room and meal time and shown scenarios of good and unacceptable practices. Feedback from staff showed an improved awareness around meal times. Care recipient feedback and meeting minutes showed positive comments relating to the improvements of the dining experience, with one care recipient now attending meals at the table and their isolation being reduced.  Following an evaluation of a recent gastroenteritis outbreak, the home has implemented bed pans for each room and a hook on the wall to store the bed pans, to reduce the transmission of infection. The bedpans are in place of disposable pans and this assists when care recipients are not well and can be emptied and sanitised in the care recipient’s own room. This improvement is yet to be evaluated. 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 There are systems and processes to identify and ensure ongoing compliance with regulations and legislation in relation to the home’s physical environment and safe systems. External contractors regularly check the home’s fire systems, electrical equipment and residual current devices. There is a food safety program and staff complete training relating to food safety. Workplace inspections are carried out, and education is delivered relating to safe work practices. There are reporting mechanisms in use for accidents, incidents and hazards, and personal protective equipment is available. Safety data sheets and chemicals

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 23 registers are available for chemicals and products used within the home. Infection outbreaks are reported and guidelines followed to minimise the spread of infection. 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 Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation to the physical environment and safe systems. For further information regarding the home’s systems, refer to expected outcome 1.3 Education and staff development. Recent examples of education and training completed relating to Standard 4 – Physical environment and safe systems are listed below.  Chemicals awareness  Effective hand hygiene  Fire and emergencies  Harassment, bullying and discrimination  Infection prevention and control  Manual handling and no lift training  Occupational health and safety and hazard identification  Positive dining experience  Safe food handling  Senior first aid. 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 The home meets this expected outcome The home’s management is actively working to provide a safe and comfortable living environment consistent with care recipients’ needs. A program of cleaning, preventative and corrective maintenance occurs to maintain the cleanliness, safety and comfort of the environment. There are accessible outdoor and indoor private and communal areas within the home where care recipients can sit and entertain friends and visitors. Equipment is trialled and purchased to suit the needs of care recipients and staff are shown how to apply and utilise assistive devices. Monitoring of the environment occurs through scheduled audits, and hazard identification and equipment is repaired or replaced as required. Call bells are accessible, the environment is temperature controlled and clutter free with areas for safe and accessible storage. Care recipients are satisfied the living environment is safe, clean, comfortable and home like. 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".

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 24 Team’s findings The home meets this expected outcome Management are actively working to provide a safe working environment that meets regulatory requirements. Occupational health and safety (OHS) information and policies are accessible and provided to staff at induction, orientation and ongoing training. Compulsory education is revisited yearly, including manual handling and safe work practices. The home maintains an OHS committee that meets regularly, and two health and safety representatives undertake audits and inspections to monitor the safety of the workplace. Hazards and incidents are investigated and risks eliminated or minimised. Areas for action are addressed and discussed at health and safety meetings and outcomes relating to audits, hazards and incidents are discussed at staff and care recipient meetings. Staff described the process to report hazards and incidents and are satisfied the work environment is safe. 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 There are safe systems of work that minimise fire, security and emergency risks within the home. Evacuation maps are on display and exits are illuminated. An emergency and crisis manual with flip charts are located in each house to inform staff of actions to take in the event of any risks or emergencies. Evacuation packs and emergency contact numbers are accessible. Fire detection, suppression and firefighting equipment is maintained and serviced periodically by approved fire professionals. Electrical equipment is checked and tagged and residual current devices tested as safe. The building is secured within a secured village, staff check and lock up at the commencement of the afternoon shift and a security company monitors the building throughout the night. A designated area for smoking is available with a fire blanket and equipment to extinguish cigarettes. Staff could describe how to maintain the security of the building and respond in the event of an emergency. Care recipients confirmed they know how to respond when they hear the alarm sound, and feel safe and secure in the home. 4.7 Infection control This expected outcome requires that "an effective infection control program". Team’s findings The home meets this expected outcome The home has an effective infection control program. The care coordinator is responsible for the infection control program and described the processes to identify, manage and minimise actual or potential infections. An infection control advisor is accessible to support the program and regular meetings occur to review infections, policies and processes. Monitoring occurs through environmental audits and infection surveillance completed by the home’s staff. Information on outbreak management and infection rates is maintained and communicated to staff. There are care recipient and staff vaccination programs to prevent infection outbreaks. A range of single use items, personal protective equipment, outbreak and spills kits, and hand washing and sanitising stations are available. Staff described actions taken in response to a gastroenteritis outbreak and confirmed they have sufficient equipment for effective infection control. 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".

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 25 Team’s findings The home meets this expected outcome Catering, cleaning and laundry services are provided in a manner that enhances care recipients’ quality of life. A program of scheduled and spot cleaning is undertaken throughout the home and staff complete cleaning audits to monitor the standards of cleaning. Personal clothing is laundered and delivered daily to care recipients’ rooms, and flat linen is outsourced to an external provider. Care recipients have a choice of meals and snacks from a seasonal rotating menu, and staff undertake training on food safety and positive dining experience. There is a food safety program, and regular care recipient surveys are undertaken to measure satisfaction and take into account personal preferences. Care recipients and their representatives are satisfied in the manner which catering, cleaning and laundry services are provided by the home.

Home name: Carramar Hostel Dates of audit: 14 March 2017 to 15 March 2017 RACS ID: 7153 26