Approved Provider: St Marys Gardens Aged Care Centre Pty Limited

SummitCare Penrith

RACS ID 0522 366 Jamison St EMU PLAINS NSW 2750

Approved provider: St Marys Gardens Aged Care Centre Pty 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 02 February 2020.

We made our decision on 21 December 2016.

The audit was conducted on 14 November 2016 to 16 November 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: SummitCare Penrith RACS ID: 0522 2 Dates of audit: 14 November 2016 to 16 November 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: SummitCare Penrith RACS ID: 0522 3 Dates of audit: 14 November 2016 to 16 November 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: SummitCare Penrith RACS ID: 0522 4 Dates of audit: 14 November 2016 to 16 November 2016 Audit Report

SummitCare Penrith 0522

Approved provider: St Marys Gardens Aged Care Centre Pty Limited

Introduction

This is the report of a re-accreditation audit from 14 November 2016 to 16 November 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.

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: SummitCare Penrith RACS ID: 0522 1 Dates of audit: 14 November 2016 to 16 November 2016 Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 14 November 2016 to 16 November 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.

Assessment team Team leader: Rosemary Chaplin Team member/s: Greg Foley

Approved provider details Approved provider: St Marys Gardens Aged Care Centre Pty Limited

Details of home Name of home: SummitCare Penrith RACS ID: 0522

Total number of allocated 95 places: Number of care recipients 90 during audit: Number of care recipients 90 receiving high care during audit: Special needs catered for: 40 bed dementia specific unit

Street/PO Box: 366 Jamison St City/Town: EMU PLAINS State: NSW Postcode: 2750 Phone number: 02 4721 2512 Facsimile: 02 4721 5204 E-mail address: [email protected]

Home name: SummitCare Penrith RACS ID: 0522 2 Dates of audit: 14 November 2016 to 16 November 2016 Audit trail

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

Interviews Category Number General manager 1 Group manager - Care and services 1 Group manager -Accommodation and services 1 Organisational relief manager 1 Manager -Care and services 1 Manager -Accommodation and services 1 Registered nurses 3 Team leader/Work health and safety committee chairperson 1 Administration officer 1 Care recipients/representatives 17 Leisure and lifestyle officers 2 Physiotherapy aide 1 Care staff 2 Catering staff 2 Laundry staff 1 Cleaning contractors 2 Maintenance contractor 1

Sampled documents Category Number Care recipients’ files including assessments, care plans, case 10 conference records, progress notes, medical and allied health documentation, hospital transfer summaries and pathology results Supplier/service provider agreements 7 Medication charts 12 Personnel files 5

Home name: SummitCare Penrith RACS ID: 0522 3 Dates of audit: 14 November 2016 to 16 November 2016 Other documents reviewed

The team also reviewed:

 Catering records including: dietary needs analysis forms, menu, dietary summary sheet, food safety program and records, NSW Food Authority licence and audit report and kitchen communication diary

 Cleaning manual, spring cleaning schedule and records, cleaners’ training program and records, housekeeping duties schedule and cleaning audits

 Clinical: monitoring charts including bowels, vital signs, neurological signs, blood glucose levels, weights, wounds, fluid input and output, peritoneal dialysis, catheters, behaviour identification and intervention, pain, pressure care, restraint application and physiotherapy program; continence aid allocation sheets; resident of the day schedule registered nurses’ care plan allocation list, case conference list, clinical care round audit list ; incident and accident reports

 Complaints records, register and complaints management policy and procedures

 Compliment and feedback forms

 Continuous improvement system including: continuous improvement plan, quality management system framework, quality schedule and audits, benchmarking reports, management monthly reports and internal audit checklist

 Education program including: orientation program, orientation checklist, training calendar, attendance records, evaluations, questionnaires, competency assessments, staff education spread sheet

 Emergency manual including disaster management and recovery plan

 Equipment inventory

 Fire safety equipment inspection and testing schedule, records and annual fire safety statement

 Handover sheets, staff work computer generated work logs

 Human resources management documentation including: position descriptions, duties lists, police certificate register, record of professional registrations, staff roster, allocation sheets, employee handbook and employee satisfaction survey

 Infection control: Infection register, infection reports, staff and care recipients’ influenza immunisation records, recent outbreak documentation

 Information package, Resident handbook and Resident and accommodation agreement

 Laundry missing item log, clothing and bedding lists, laundry infection control audits and linen change schedule

 Leisure and lifestyle: group exercise class participation list, care recipients’ social activity records, activity plans, risk assessment worksheets, activity evaluations,

Home name: SummitCare Penrith RACS ID: 0522 4 Dates of audit: 14 November 2016 to 16 November 2016 consents for bus trips and photographs, monthly activity calendars, music project documentation

 Maintenance manual, responsive maintenance log, programmed maintenance matrix, weekly maintenance reports, contractor contact details and service records

 Mandatory reporting register

 Medication management: schedule 8 drug register, insulin and medication refrigerator temperature checking charts, pharmacy order forms, psychotropic management forms, medication change order forms

 Meeting calendar and meeting minutes

 Policies and procedures

 Restraints register, bedrail risk assessments, restraint consent forms

 Staff memorandum and messages

 Work health and safety documentation including: environmental audits, monthly reports, meeting minutes, security review, hazard identification log book, risk assessments

Observations

The team observed the following:

 Activities in progress

 Archives

 Care alert symbols in care recipients’ rooms

 Charter of care recipients’ rights and responsibilities on display

 Chemical storage and accessible material safety data sheets

 Cleaning in progress

 Complaints mechanisms, notices, brochures (multilingual), and forms available

 Equipment and supplies in storage and in use including clinical, continence, mobility, falls prevention and pressure relieving

 Evacuation kit, emergency procedures charts and evacuation plans on display

 Fire safety equipment and warning systems

 Group exercise in progress

 Infection control: colour coded cleaning and laundry equipment, instruction available to staff, secure contaminated waste bins, sharps containers, spill kits, outbreak kit, personal protective equipment, waste disposal systems

Home name: SummitCare Penrith RACS ID: 0522 5 Dates of audit: 14 November 2016 to 16 November 2016  Interactions between staff and care recipients

 Internal and external living environment

 IT equipment and backup system

 Manual handling instruction cards in care recipients’ wardrobes

 Meals and drinks service

 Medication round

 Monthly activity calendars displayed

 Nurse call bell system and sensor alarm mats in use

 Policies and procedures, instruction and guidelines available to staff

 Privacy policy displayed

 Re-accreditation audit notices on display

 Recreational activities resources

 Security systems including: keypad entry, CCTV surveillance, intercom and alarm system

 Short observation in Magnolia unit

 Staff noticeboard

 Staff practices

 Staff work areas

 Storage of medications including secure treatment rooms, schedule 8 cupboard, trolleys and refrigerators, non-packed medication opened dates,

 Vision, values, purpose, strategic plan and customer service charter on display

Home name: SummitCare Penrith RACS ID: 0522 6 Dates of audit: 14 November 2016 to 16 November 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

The home belongs to an organisation which provides a management structure and quality framework for the pursuit of continuous improvement. Areas for improvement are identified through input from all stakeholders using mechanisms that include: improvement logs, regular meetings, feedback mechanisms, a program of audits and surveys, and analysis of monitoring data. All opportunities for improvement that are identified are recorded on a continuous improvement plan that enables the planning, implementation and evaluation of the improvements. This process is coordinated by the management team. Care recipients/representatives and staff are encouraged to actively contribute to the process and those interviewed report they are aware of the ways they can make suggestions for improvement. They say management is responsive to suggestions and they are consulted and kept informed about improvements at the home.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard One and recent examples of this are listed below.

 Management identified there were a number of staff not attending mandatory training. In response the education calendar was re-organised so that mandatory topics were offered for extended periods and staff were given the option of participating in group sessions or doing the training individually online. The training is also being given extra promotion so staff are fully aware of the sessions. This has given staff more opportunities to attend the training and management state the attendance is much improved.

 Management introduced a new electronic clinical documentation system in 2015 to replace hardcopy clinical records. The system includes alerts for special needs and a message board for direct communication with staff. The new system provides a more efficient way of recording and accessing information and a more effective way for management to monitor clinical care.

 The employee satisfaction survey identified a number of areas for improvement. Management discussed these matters with staff and responded with new equipment and extra supplies to ensure staff had the appropriate resources to fulfil their duties. Further education was provided on bullying and harassment to build a positive culture amongst staff. Communications with staff were improved through utilising the electronic

Home name: SummitCare Penrith RACS ID: 0522 7 Dates of audit: 14 November 2016 to 16 November 2016 message board on the clinical documentation system, a new ‘need to know’ noticeboard where staff sign on, more regular meetings and management attendance at handover. There is also the acknowledgement of staff contribution to the home by having monthly barbeques for staff along with the celebration of birthdays. Staff are also invited to dress up for special events for the care recipients. These initiatives have helped improve the staff satisfaction at the home.

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 organisation to which the home belongs identifies all relevant legislation, regulatory requirements, professional standards and guidelines through information forwarded by government departments, peak industry bodies and other aged care and health industry organisations. This information is communicated to the home and disseminated to staff through updated policies and procedures, regular meetings, memos and ongoing training. Relevant information is disseminated to care recipients and their representatives through meetings, newsletters, notices on display in the home and personal correspondence. Adherence to these requirements is monitored through the home’s continuous quality improvement system, which includes audits conducted internally and by external bodies. Staff practices are monitored regularly to ensure compliance with regulatory requirements.

The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard One.

 Police certificates are obtained for all staff.

 Contracts with external service providers confirm their responsibilities under relevant legislation, regulatory requirements and professional standards, and include police certificates for contractors visiting the home.

 There is a system for the secure storage, archiving and destruction of personal information in accordance with privacy legislation and regulations relating to care recipients’ records.

 Care recipients/representatives were informed of the re-accreditation site audit in accordance with the Quality Agency Principles 2013.

Home name: SummitCare Penrith RACS ID: 0522 8 Dates of audit: 14 November 2016 to 16 November 2016 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

There is a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. The recruitment process identifies the knowledge, skills and education required for each position. There is a comprehensive orientation program for all new staff and a buddy system is used to support the new staff during their first days of employment. There is an education program, including topics covering the four Accreditation Standards, which is developed with reference to care recipients’ needs, performance appraisals, regulatory requirements, staff input and management assessments. The program includes in-service training by senior staff, training by visiting trainers and suppliers, on the job training, on-line training and access to external training and courses. Records of attendance at training are maintained, the training is evaluated and the effectiveness of the training is monitored through performance appraisals and competency assessments. Management and staff interviewed report they are supported to attend relevant internal and external education and training. Care recipients/representatives interviewed say staff have the skills and knowledge to perform their roles effectively.

Education and training relating to Accreditation Standard One included such topics as: accreditation; bullying and harassment; duty of care and negligence; teamwork; and conflict management.

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

Care recipients and their representatives are informed of internal and external complaint mechanisms through the handbook for care recipients, discussion during orientation to the home, notices and at care recipient meetings. Forms for comments and complaints are available in the home and brochures about an external complaint mechanism are also available. Management maintains a log of all comments and complaints and we noted issues raised are addressed in a timely manner to the satisfaction of complainants. Care recipients and their representatives can also raise concerns and identify opportunities for improvement through care recipient meetings, satisfaction surveys and informally. Care recipients/representatives say they are aware of how to make a comment or complaint and feel confident concerns are addressed appropriately.

Home name: SummitCare Penrith RACS ID: 0522 9 Dates of audit: 14 November 2016 to 16 November 2016 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 vision, values, purpose and commitment to quality are well documented and on display in the home. They are also available to all care recipients and their representatives, staff and other stakeholders in a variety of documents used in the home. Vision, values and purpose are included in the orientation program to ensure staff are fully aware of their responsibility to uphold the rights of care recipients and the home’s objectives and commitment to quality. Feedback from care recipients/representatives and staff and observations of staff interaction with care recipients demonstrated the vision and values of the home underpin the care provided to the care recipients.

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

Management has systems to ensure there are appropriately skilled and qualified staff to meet the needs of the care recipients. New staff are screened through the recruitment process to ensure they have the required skills, experience, knowledge and qualifications for their roles. The orientation and education program, outlined in expected outcome 1.3 Education and staff development, provide the staff with further opportunities to enhance their knowledge and skills. There are position descriptions for all roles and policies and procedures provide guidelines for all staff. The staffing mix and levels are monitored by management to meet care recipients’ needs and any vacancies that arise in the roster are filled. The performance of staff is monitored through annual appraisals, competencies, meetings, audits, the feedback mechanisms of the home and ongoing observation by management. Staff interviewed said they have sufficient time to complete their designated tasks and meet the needs of care recipients. Care recipients/representatives report their satisfaction with the care provided by the staff.

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 demonstrated it has a system to ensure the availability of stocks of appropriate goods and equipment for quality service delivery. The home enters into service agreements with approved suppliers and there are processes to identify the need to re-order goods,

Home name: SummitCare Penrith RACS ID: 0522 10 Dates of audit: 14 November 2016 to 16 November 2016 address concerns about poor quality goods, maintain equipment in safe working order and replace equipment. Maintenance records show equipment is serviced in accordance with a regular schedule and reactive work is completed in a timely manner. We observed adequate supplies of goods and equipment available for the provision of care, to support the lifestyle choices of care recipients and for all hospitality services. The system is overseen by the management team and monitored through regular audits, surveys, meetings and the feedback mechanisms of the home. Staff confirm they have sufficient stocks of appropriate goods and equipment to look after care recipients and are aware of procedures to obtain additional supplies when needed.

1.8 Information systems

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

Team’s findings

There are information management systems to provide management and staff with information to perform their roles effectively and keep care recipients/representatives well informed. A password protected computer system facilitates clinical documentation, electronic administration and access to the internet, the organisation’s intranet and e-mail communication. Policy and procedure manuals and position descriptions clearly outline correct work practices and responsibilities for staff. Care recipients/representatives receive information when they come to the home and on an ongoing basis. Mechanisms for communication between and amongst management and staff include meetings, memos, electronic messages, communication books, handover, feedback and reporting forms, and noticeboards. All personal information is collected and stored securely and electronic records are regularly backed up. There are procedures for archiving and disposing of documents in accordance with privacy legislation. Staff and care recipients/representatives report they are kept well informed and consulted about matters that impact on them.

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

There is a system to ensure all externally sourced services are provided in a way that meets the home’s needs and service quality goals. Service agreements are entered into with contractors for the provision of services and all external service providers are required to have current licences, insurance and comply with relevant legislation and regulatory requirements. There are schedules for all routine maintenance work to be undertaken by contractors and there is a list of approved service providers who are used on a needs basis. Care recipients are able to access external services such as hairdressing, podiatry and other allied health professionals. The services provided are monitored by management at a local and organisational level through regular evaluations, audits and the feedback mechanisms of the home and there is a system for managing non-conformance of service providers. Care recipients/representatives, staff and management interviewed say they are satisfied with the external services provided.

Home name: SummitCare Penrith RACS ID: 0522 11 Dates of audit: 14 November 2016 to 16 November 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 information about the home’s system for actively pursuing continuous improvement.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Two and recent examples of this are listed below.

 Some care recipients were experiencing discomfort due to the medications used to treat their constipation. In response management have introduced non- pharmacological strategies such as high fibre diet and prune juice to improve regular bowel movement and reduce constipation. This has been done in consultation with a dietician and the care recipients/representatives and is proving effective in improving the comfort of care recipients.

 An incident occurred where there was staff confusion over a care recipients/representatives advanced care directive and direction relating to being ‘not for resuscitation’. Following this management identified all care recipients who have directives of ‘not for resuscitation’ and put identification stickers as visual prompts on each of these care recipients’ files. This provides immediate identification of the care recipient’s directive and gives the nursing team more confidence in communicating with families, medical officers and the hospital. It has also reduced disruption to care recipients through reduced hospitalisation.

 Management introduced a new systematic approach for discussing palliative care with care recipients and their families. It is a three stage process for raising the issue of dying with families and preparing them for the end stages of the care recipient’s life. Stage one commences about six weeks after the care recipient enters the home and here the background and values of the care recipient are discussed and a relationship between the family and management established. Stage two is commenced when the care recipient’s condition begins to decline and stage three is for when the care recipient is approaching the end stage of life. This staged approach helps improve the communication with the family and prepare them for the death of their loved one. It also helps the home identify specific palliative care needs and ensure appropriate services and equipment are available as needed.

Home name: SummitCare Penrith RACS ID: 0522 12 Dates of audit: 14 November 2016 to 16 November 2016 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

Refer to expected outcome 1.2 Regulatory compliance for details about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines.

The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Two.

 A record is kept of the current registration of registered nurses and other health care professionals.

 Medications are administered safely and correctly in accordance with current regulations and guidelines.

 Government and industry body resources are available to management and staff on topics relating to health and personal care.

 The home has a policy and procedures for the notification of unexplained absences of care recipients and maintains a register for recording these incidents.

2.3 Education and staff development

Team’s findings

Refer to expected outcome 1.3 Education and staff development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively.

Education and training relating to Accreditation Standard Two included such topics as: oral hygiene; falls prevention; dementia care; respiratory issues; restraint; understanding challenging behaviour; pain in dementia; clinical documentation; mental health - dementia, depression, delirium; bowel management; pain management; wound management; dysphagia management; and palliative care.

Home name: SummitCare Penrith RACS ID: 0522 13 Dates of audit: 14 November 2016 to 16 November 2016 2.4 Clinical care

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

Team’s findings

A comprehensive program of assessments is undertaken when a care recipient moves into the home and a care plan is developed using the computerised clinical care system. Care plans are reviewed and evaluated regularly. Medical officers review care recipients regularly and as requested and referrals to specialist medical and allied health services are arranged as required. Care conferences are held after entry to the home, annually and as required. A range of care based audits, clinical indicators, care recipient surveys, meetings and staff handovers are used to monitor the quality of care. Staff said they receive clinical care training, supervision and have access to appropriate supplies of equipment to ensure quality clinical care is provided for all care recipients. Care recipients/ representatives are satisfied with clinical care provided at the home and individual needs and preferences are respected.

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

Care recipients and representatives are satisfied with specialised nursing care at the home. There are systems to ensure care recipients’ specialised nursing care needs are identified and met by registered nurses. Specialised nursing care needs are assessed and documented in care plans when a care recipient moves into the home. A review of documentation including the clinical care system shows changes are documented in progress notes, clinical charts, specialist forms and charts and in care plans. Care plans are reviewed and evaluated on a regular basis. Staff said they receive training in specialised nursing care and the use of equipment. Care recipients/representatives are satisfied with the provision of specialised nursing care needs.

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

Care recipients and representatives are consulted when a referral is required and they are assisted to attend specialist appointments as needed. A review of documentation including care recipients’ files and interviews with staff show care recipients are referred to medical specialists and other allied health professionals such as podiatrist, wound specialist, speech therapist and dietician. Referrals occur in a timely manner and changes are incorporated into care planning. External providers of specialist services visit care recipients in the home when possible. Care recipients/representatives are satisfied with the home’s procedures for referral to other health and specialist services.

Home name: SummitCare Penrith RACS ID: 0522 14 Dates of audit: 14 November 2016 to 16 November 2016 2.7 Medication management

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

Team’s findings

The home demonstrates that care recipients medication is managed safely and correctly. There are processes to ensure medication orders are current and care recipient medication needs, including allergies and administration needs are identified and met. Medications are regularly reviewed by the care recipient’s medical officer and changes in medications are communicated and supplied in a timely manner. Medications are ordered, received, stored, administered, documented and discarded safely in line with policies and procedures and regulatory requirements. Medications are monitored by the registered nurses and administered by appropriately qualified staff. The medication management system is monitored, reviewed and improved through regular audits, pharmacy reviews and input from the medication advisory committee. Care recipients/ representatives said they are satisfied with the way medications are managed.

2.8 Pain management

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

Team’s findings

Care recipients are assessed on entry and on an ongoing basis to ensure they are as free as possible from pain. Care recipients identified with pain, including those at risk of pain, are assessed by the registered nurse, referred to the medical officer and a pain management regime is put in place. Pain is monitored and regularly evaluated by registered nurses in consultation with the care recipient and representatives. Medication and alternative approaches to manage pain are used including massage, the provision of emotional support, exercise, and the use of pain relieving equipment including heat packs. Staff receive education in pain management and staff practice is monitored by management. Care recipients/representatives said they are satisfied with the way the care recipients’ pain is managed.

2.9 Palliative care

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

Team’s findings

Care recipients who are terminally ill are regularly assessed in consultation with their representatives and medical officer to ensure their comfort and dignity is maintained. On entry to the home care recipients are offered an opportunity to provide information regarding end of life wishes and advanced care directives if they wish. Interviews demonstrate that staff are aware of maintaining the respect and dignity of care recipients who are terminally ill, and of supporting their families. Music and aromatherapy are utilised in conjunction with medical

Home name: SummitCare Penrith RACS ID: 0522 15 Dates of audit: 14 November 2016 to 16 November 2016 and nursing interventions to maintain comfort. Care recipients’ emotional and spiritual needs and preferences are included in the care planning for terminally ill care recipients. The home provides facilities for families who wish to seek quiet private areas. We observed supplies of equipment used for palliative care including specialised pressure relieving equipment, electric beds and mechanical lifters.

2.10 Nutrition and hydration

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

Team’s findings

The home has systems to ensure care recipients receive adequate nourishment and hydration including initial and ongoing assessments of care recipients’ needs and preferences. Care plans are developed and reviewed regularly and as care recipients’ needs change. The registered nurse and dietician identify care recipients at risk of weight gain or loss and malnutrition by monitoring monthly weight records. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of care recipients’ preferences and special requirements such as any modified textured meals and fluids and special diets through the daily work logs, dietary preferences folders, dietary preferences lists in the serveries, beverage and supplement lists and the care recipients’ care plans. Care recipients have input into menu planning through resident meetings, comments and complaints mechanisms and informal discussions with staff. Care recipients are satisfied with the catering services provided and informed us they are offered choices.

2.11 Skin care

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

Team’s findings

The home has systems to ensure that each care recipient’s skin integrity is consistent with their general health. Care recipients’ skin integrity is assessed when they move into the home through the initial assessment process. Ongoing assessment occurs regularly and as care recipients’ needs and preferences change. Care staff confirm they monitor care recipients’ skin integrity as part of daily care and report any changes to the registered nurse for review and referral as appropriate. Complex wound management is carried out by registered nurses, in consultation with wound specialists when required. Wounds are assessed regularly using comprehensive wound assessment charts. Skin tears and infections are recorded and data is analysed by the management team. A podiatrist and hairdresser attend the home on a regular basis. A range of skin protective devices are available, if needed, including pressure relieving mattresses, hip protectors, skin emollients and limb protectors. These are available to all care recipients and are consistent with individual care plans and identified needs. Care recipients informed us they are satisfied with the provision of skin care and the range of equipment available to them.

Home name: SummitCare Penrith RACS ID: 0522 16 Dates of audit: 14 November 2016 to 16 November 2016 2.12 Continence management

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

Team’s findings

The home has systems to ensure care recipients’ continence is managed effectively. Clinical documentation review and interviews with staff confirms continence management strategies are developed for each care recipient, if required, following initial and ongoing assessment. Staff report they assist care recipients with their toileting regime and monitor skin integrity according to the care plans. Staff receive training and supervision in the management of continence and the use of continence aids. Designated staff ensure the home has sufficient stock of continence aids in appropriate sizes to meet care recipient needs. Care recipients and representatives are satisfied with the management of care recipients’ continence needs. Staff were observed being considerate of care recipients’ privacy and dignity at all times.

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 has systems to effectively manage care recipients with challenging behaviours. In consultation with care recipients and their representatives assessment and monitoring is undertaken on entry to the home and on an ongoing basis as care recipients’ needs and preferences change. Challenging behaviours, triggers that lead to challenging behaviours and successful interventions are identified and documented on care recipients’ care plans. Care plans are regularly reviewed and evaluated for effectiveness. Care recipients are referred to their medical officer and behaviour management specialists for clinical review and assessment when necessary. Care staff and leisure and lifestyle staff receive ongoing training. Care recipients and representatives report satisfaction with the management of the needs of care recipients with challenging behaviours.

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 has systems to ensure that optimum levels of mobility and dexterity are achieved for all care recipients. Documentation review and interviews with staff confirms all care recipients are assessed on moving into the home for mobility, dexterity and transfers, falls’ risk and pain management. The physiotherapist develops individual exercise and mobility programs for care recipients with identified needs. The physiotherapy and exercise programs are implemented by the physiotherapy aide, care staff and leisure and lifestyle staff. Programs are regularly reviewed and evaluated by the physiotherapist and registered nurses. Staff are trained in falls prevention, manual handling and the use of specialist

Home name: SummitCare Penrith RACS ID: 0522 17 Dates of audit: 14 November 2016 to 16 November 2016 mobility and transfer equipment. Assistive devices such as mobility frames, mechanical lifters and wheelchairs are available if required. Falls incidents are referred to the physiotherapist, documented and the data is analysed by the management team. Care recipients/representatives informed us they are satisfied with the management of 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 has systems to ensure care recipients’ oral and dental health is maintained. A review of documentation shows that care recipients’ oral and dental health is assessed when they move to the home and individual care plans are regularly reviewed and evaluated to meet changing needs. Diet and fluids are provided in line with the care recipient’s oral and dental health needs and preferences and specialist advice for care recipients with swallowing problems is sought if needed. Dental appointments and transport are arranged in accordance with care recipients’ needs and preferences, if required. Care staff have received training in oral and dental care. Care recipients informed us staff provide assistance with their oral and dental care as required or as requested.

2.16 Sensory loss

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

Team’s findings

Initial assessment of care recipients’ sensory loss is identified when they move into the home. Management strategies are implemented, regularly reviewed and evaluated in consultation with the care recipient and referral to specialist services is arranged as needed. Optometry and hearing services are accessed as needed or arrangements are made for care recipients who wish to visit external providers of services. We observed the environment to have good lighting, including natural light, and that rooms and walkways are spacious and uncluttered to facilitate care recipient safety. Staff said they use a variety of strategies to manage care recipients’ sensory loss, including appropriate equipment and support to promote independence. Care recipients informed us staff are attentive to their individual needs, including the care of glasses, hearing devices and if needed assistance to move around the home.

Home name: SummitCare Penrith RACS ID: 0522 18 Dates of audit: 14 November 2016 to 16 November 2016 2.17 Sleep

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

Team’s findings

Care recipients’ sleep patterns and known strategies to assist sleep are assessed when they move into the home and their care plans are regularly reviewed and evaluated by appropriately qualified staff. Care staff and the registered nurse are available to assist care recipients during the night. Care recipients’ preferences for rising and retiring are respected and accommodated by staff. A review of documentation and discussions with staff show care recipients are offered comforts such as soft music, heat packs, aromatherapy, snacks, warm milk and other support to assist them achieve natural sleep patterns. Disturbances in sleep patterns are monitored and referred to the medical officer as needed. Lighting and noise levels are subdued at night. Care recipients report satisfaction with the management of their sleep and the night time environment.

Home name: SummitCare Penrith RACS ID: 0522 19 Dates of audit: 14 November 2016 to 16 November 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

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Three and recent examples of this are listed below.

 Inspired by research into the transforming power of music for care recipients living with dementia, the leisure and lifestyle team is working to introduce an individualised music therapy program at the home. A leisure and lifestyle officer participated in training in music therapy and established a trial with five care recipients to determine the effectiveness of this strategy. The results are being monitored and have been very positive. The music engages the care recipients and they appear to be enjoying it. The care recipients seem calm and content and it has reduced challenging behaviours. The trial will be formally evaluated in November 2016 with a view to expanding the program to include other care recipients.

 Due to the limitations of accessing the resources of the public library, the leisure and lifestyle team have established an in-house mobile library. The mobile library is a trolley with a range of books, magazines and newspaper that is taken around to care recipients every two weeks. One of the care recipients assists with looking after the mobile library, sorting books and visiting the care recipients. It is working well and the leisure and lifestyle team say the care recipients are happy with the mobile library.

 At the suggestion of the leisure and lifestyle team, flower arranging has been added to the activities program. Flowers are delivered weekly and the arrangements are used to decorate the home. The leisure and lifestyle team say it engages the care recipients in a meaningful activity and also allows for passive participation and social interaction for those who are unable to participate directly. Care recipients report they enjoy the flower arranging.

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 is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Three.

 Information is provided to care recipients and their representatives in the resident handbook and the resident and accommodation agreement regarding care recipients’ rights and responsibilities including security of tenure and the care and services to be provided to them.

 The Charter of care recipients’ rights and responsibilities is included in the resident and accommodation agreement and displayed in the home.

 Staff are trained in care recipients’ rights and responsibilities in their orientation program and also sign a confidentiality agreement to ensure care recipients’ rights to privacy and confidentiality are respected.

 The home has a policy and procedures for the mandatory reporting of alleged and suspected assaults and maintains a register of these incidents.

 Training has been provided for staff on the mandatory reporting of elder abuse.

Team’s findings

Refer to expected outcome 1.3 Education and staff development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively.

Education and training relating to Accreditation Standard Three included such topics as: dignity in care; compulsory training on protecting older people from elder abuse and mandatory reporting; wellness training; loss and grief; and privacy and confidentiality.

Home name: SummitCare Penrith RACS ID: 0522 21 Dates of audit: 14 November 2016 to 16 November 2016 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 has systems to ensure each care recipient is supported adjusting to life when they enter the home and on an ongoing basis. Care staff and leisure and lifestyle staff spend one to one time with care recipients during their settling in period and thereafter according to the identified needs. The entry process includes gathering information from care recipients and their representatives to identify care recipients’ existing care and lifestyle preferences. Religious clergy, volunteers and/ or visitors provide services and individual support as needed. Feedback about care recipients’ levels of satisfaction with the provision of emotional support is gained through meetings, audits and formal and informal feedback. Care recipients/representatives expressed satisfaction with the level of emotional support and assistance staff provide to care recipients on entry to the home and on an ongoing basis.

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 encouraged to entertain at the home and visitors and relatives are made to feel welcome when they visit. Staff facilitate care recipient participation in the local community, for example, through the arrangement of bus trips. Many community groups visit the home including entertainers, special interest groups and school children. Regular exercise programs and the mobility programs assist care recipients to maintain their mobility levels and independence. Care recipients are able to decide whether they wish to remain on the electoral roll and assistance is provided to them to vote if they wish to do so. Observations and interviews confirm staff promote care recipients’ independence when assisting with their activities of daily living. Care recipients are satisfied with the opportunities available to them to participate in the life of the community within and outside the home.

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 has systems to ensure each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Care recipients’ care plans and progress notes provide evidence of consultation regarding their preferences for the manner in which care is provided. Individual preferences are documented and known by staff. Care recipient records are securely stored and the organisation’s privacy policy is displayed in the home. All staff

Home name: SummitCare Penrith RACS ID: 0522 22 Dates of audit: 14 November 2016 to 16 November 2016 have signed privacy and confidentiality agreements. Staff address care recipients in a respectful manner by their preferred names. Staff were observed to knock on care recipients’ doors before entering. Care recipients/representatives informed us staff respect their privacy and dignity.

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 has systems to ensure care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them. Social and life history assessments are undertaken when care recipients move into the home in consultation with care recipients and/or their representatives. Care plans are developed and evaluated regularly. Leisure and lifestyle staff plan monthly activity calendars which include a variety of events and activities in consultation. One on one activity is included in the calendars to cater for those who prefer not to attend group activities. Activity programs are displayed for care recipients to remind them of the program available. Care recipients are consulted and encouraged to provide feedback through meetings and informally regarding the activity program. Information is evaluated to make improvements to the program on an individual and group basis. Care recipients informed us they enjoyed the activities and particularly enjoyed the flower arranging, concerts, sing-alongs, outings, bingo and exercise classes.

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 are assessed on entry to the home for their individual customs, beliefs and cultural and ethnic backgrounds. A variety of religious services and devotions are held regularly at the home and care recipients are assisted to attend services outside the home if they prefer. Specific cultural days such as ANZAC Day, Australia Day, Christmas and Easter are commemorated with appropriate festivities. Care recipients’ birthdays are recognised and celebrated monthly. Interviews confirm the leisure and lifestyle staff and care staff have knowledge of and respect for the care recipients’ individual backgrounds and beliefs. Care recipients/representatives informed us they are satisfied with the cultural and spiritual life offered at the home.

Home name: SummitCare Penrith RACS ID: 0522 23 Dates of audit: 14 November 2016 to 16 November 2016 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

The home has systems and processes to ensure care recipients and their representatives participate in decisions about the services they receive and are able to exercise choice and control. Mechanisms providing this include regular case conferences, discussions with staff, residents’ meetings and through the comments and complaints processes. Care recipients/representatives informed us they are involved in decisions about their care routines and their participation in the activity program. Care recipients’ choice of medical officer and allied health services is respected. Care recipients have personalised their rooms with memorabilia and items of their choosing including furniture and pictures. Care recipients/representatives are satisfied with the level of choice and decision making offered.

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

All care recipients/representatives are provided with an information pack prior to coming to the home which outlines the rights and responsibilities of the care recipient. This includes a handbook for care recipients which gives detailed information about all aspects of life at the home. These matters are discussed with the care recipient/representative prior to moving into the home. All care recipients/representatives are offered an agreement on entry to the home. The resident and accommodation agreement includes information for care recipients about their rights and responsibilities, complaints handling, fees and charges, care and services provided, their security of tenure and the process for the termination of the agreement. The home’s customer service charter is included in the handbook and the Charter of Care Recipients’ Rights and Responsibilities is clearly displayed in the home and included in the resident and accommodation agreement. Care recipients/representatives are aware of care recipients’ rights and are satisfied they are being upheld.

Home name: SummitCare Penrith RACS ID: 0522 24 Dates of audit: 14 November 2016 to 16 November 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

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard Four and recent examples of this are listed below.

 To improve the appearance of pureed meals and enhance the dining experience for care recipients, management sourced and trialled the use of moulded pureed meals. The trial was found to be successful with meals looking more appealing and care recipients eating more. Management have put in a request from the organisation for a new combi oven so that the moulded pureed meals can be provided to all the care recipients who require them.

 The organisation holds regular forums for key staff from their homes. The catering forum has created a consolidated menu from the best of each home across the organisation. This has been reviewed by a dietician. The consolidated menu offers greater choice for care recipients and greater options for catering staff.

 The tags used on meal trays which identify the individual dietary needs of care recipients have been reviewed. In place of a dot colour code system a new template is being introduced. Identification photographs have been added. Colour coding is still used but an explanation has been added. Allergies, portion size and assistance required are now added to the tags along with specific requirements such as thickened fluids. The information is presented in a much clearer way and extra information is now included.

 To improve the security around the home and for improved care recipient safety a closed circuit television system has been installed. Cameras have been installed throughout the home and these are monitored by management. An intercom has also been added at the entrance for after-hours access.

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 is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard Four.

 Fire safety equipment is being inspected, tested and maintained in accordance with fire safety regulations, staff have fulfilled the mandatory fire awareness and evacuation training and the annual fire safety statement is on display in the home.

 The home has a disaster management plan in accordance with the NSW Healthplan as required for all hospitals and health care facilities.

 The home has a NSW Food Authority licence as required by the Vulnerable Persons Food Safety Scheme and the home has a food safety program.

 The home has an infection control program that is managed in accordance with government health regulations and guidelines.

 The home has developed a work health and safety management system in line with the Work Health and Safety Act 2011.

Team’s findings

Refer to expected outcome 1.3 Education and Staff Development for details about the home’s system for ensuring management and staff have appropriate knowledge and skills to perform their roles effectively.

Education and training relating to Accreditation Standard Four included such topics as: fire safety and evacuation; emergency response; infection control and outbreak management; manual handling; safe chemical handling; workplace health and safety; risk management; and incident reporting.

Home name: SummitCare Penrith RACS ID: 0522 26 Dates of audit: 14 November 2016 to 16 November 2016 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 is actively working to provide a safe and comfortable environment consistent with the needs of care recipients. Care recipients are accommodated in shared and individual rooms and have personalised their own rooms. The home has a secure wing for care recipients living with dementia and there are a number of communal areas and lounge rooms as well as courtyards and outdoor areas. The living environment is clean, well furnished and free of clutter. It is well lit and has a heating/cooling system to maintain a comfortable temperature. The buildings and grounds are well maintained with a program of preventative and routine maintenance. The safety and comfort of the living environment is monitored through environmental inspections, care recipient/representative feedback, incident/accident reports, audits and observation by staff. The care recipients/representatives interviewed expressed their satisfaction with the living environment.

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 has a system to provide a safe working environment that meets regulatory requirements. There is a work health and safety/infection control committee which has representatives from all departments of the home and has regular meetings to oversee work health and safety within the home. All staff are trained in manual handling, work health and safety and fire awareness and evacuation procedures during their orientation and on an ongoing basis. Equipment is available for use by staff to support safe work practice, minimise risks and assist with manual handling. There is a maintenance program to ensure the working environment and all equipment is safe. The home monitors the working environment and the work health and safety of staff through regular audits, risk and hazard assessments, incident and accident reporting and daily observations by the management and staff. The staff show they have a knowledge and understanding of safe work practices and were observed carrying them out.

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

There is a system to provide an environment and safe systems of work that minimise fire, security and emergency risks. A trained fire safety officer oversees fire safety at the home

Home name: SummitCare Penrith RACS ID: 0522 27 Dates of audit: 14 November 2016 to 16 November 2016 and all staff take part in mandatory training in fire awareness and evacuation procedures. The home is fitted with appropriate firefighting equipment and warning systems and external contractor records and equipment tagging confirms the fire safety systems are regularly inspected and maintained. The current annual fire safety statement is on display and emergency procedures charts and evacuation plans are located throughout the home. There is an emergency manual with a disaster management plan for the site and an emergency evacuation kit. Security is maintained with a surveillance system, electronic access, security lighting and lock-up procedure at night. The systems to minimise fire, security and emergency risks are monitored through internal audits, external inspections and at staff and management meetings. Staff indicate they know what to do in the event of an emergency and care recipients say they feel safe in the home.

4.7 Infection control

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

Team’s findings

The home has systems and processes to ensure there is an effective infection control program. Quality data includes the routine collection, monitoring and identification of infection trends. Management provides a staff and care recipient vaccination program to minimise risk of infection. There are designated procedures in place to manage an infectious outbreak and regular audits are carried out. Hand sanitisers and hand washing facilities are located throughout the home. Observations and interviews show staff are knowledgeable about infection control requirements including the use of personal protective equipment and the use of colour coded equipment.

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

The hospitality services provided are meeting the needs of care recipients and are enhancing their quality of life. There is a rotating menu that provides choice and variety of meals and all meals are cooked fresh on site. The menu has been assessed by a dietician and caters for special diets and for the individual needs and preferences of care recipients. The home is cleaned by full time contracted cleaners. The cleaning is carried out according to a schedule and the quality of the cleaning is monitored by the management and staff of the home and the contractor supervisor. We observed the home to be clean and care recipients/representatives state they are very satisfied with the results. Personal clothing and linen is laundered off site by a laundry contractor. The contractor provides a pick-up and delivery service five days per week and the home employs a laundress to sort and distribute the freshly washed clothing and linen. The hospitality services are monitored through audits, surveys, meetings and the feedback mechanisms of the home. Care recipients/representatives say they are satisfied with the hospitality services provided.

Home name: SummitCare Penrith RACS ID: 0522 28 Dates of audit: 14 November 2016 to 16 November 2016