Approved Provider: Bupa Aged Care Australia Pty Ltd

Bupa Berwick

RACS ID 3676 359 Narre Warren North Road NARRE WARREN NORTH VIC 3804

Approved provider: Bupa Aged Care Australia Pty Ltd

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 30 April 2020.

We made our decision on 02 March 2017.

The audit was conducted on 07 February 2017 to 08 February 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.

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: Bupa Berwick RACS ID: 3676 2 Dates of audit: 07 February 2017 to 08 February 2017 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: Bupa Berwick RACS ID: 3676 3 Dates of audit: 07 February 2017 to 08 February 2017 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: Bupa Berwick RACS ID: 3676 4 Dates of audit: 07 February 2017 to 08 February 2017 Audit Report

Bupa Berwick 3676

Approved provider: Bupa Aged Care Australia Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 07 February 2017 to 08 February 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: Bupa Berwick RACS ID: 3676 1 Dates of audit: 07 February 2017 to 08 February 2017 Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 07 February 2017 to 08 February 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: 120

Number of care recipients during audit: 118

Number of care recipients receiving high care during audit: 116

Special needs catered for: N/A

Home name: Bupa Berwick RACS ID: 3676 2 Dates of audit: 07 February 2017 to 08 February 2017 Audit trail

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

Interviews Position title Number General managers 2 Clinical manager 1 Care managers 3 Registered nurses 1 Care and lifestyle staff 5 Business administration staff 2 Care recipients 9 Representatives 8 Medical practitioner 1 Physiotherapist 1 Hospitality staff 5 Maintenance staff 2

Sampled documents Document type Number Care recipients’ files 15 Lifestyle individual activity plans and maps of life 15 Care recipient agreements 6 Medication charts 8 Personnel files 8

Other documents reviewed

The team also reviewed:

 Activity calendars, participation records, evaluations and resources

 Audits and audit schedule

 Care recipient orientation and admission assessment checklists

 Cleaning schedules and duties lists

Home name: Bupa Berwick RACS ID: 3676 3 Dates of audit: 07 February 2017 to 08 February 2017  Clinical care documentation including charting, directives, referral forms, communication books, specialised nursing care plans and directives

 Comments and complaints documentation including confidential logs

 Consolidated log of reportable incidents

 ‘Dangerous Drugs’ registers

 Dietary needs, supplement and preference documentation and change of meal details

 Education records and training calendars

 End of month (clinical indicator) reports, trending and analysis

 Fire and emergency services records

 Food safety program and monitoring records including kitchen external certifications

 Handover sheets including clinical handover sheet

 Hazard logs

 Human resource documentation

 Improvement logs

 Incident reports and incident report analysis

 Mail register

 Manual handling equipment register

 Medication reviews

 Medication self-administration assessment

 Meeting minutes

 Memoranda and correspondence

 Menu

 Newsletters, noticeboard and information resources for care recipients and representatives

 Pest control documentation

 Police certificates, statutory declarations, visa and professional registration registers

 Preventative and corrective maintenance documentation

 Risk assessments

Home name: Bupa Berwick RACS ID: 3676 4 Dates of audit: 07 February 2017 to 08 February 2017  Roster and staff availability list

 Safety data sheets

 Self-assessment

 Work instructions and flip charts.

Observations

The team observed the following:

 Activities in progress and resources

 Administration and storage of medications

 Archive system, records storage areas, shredder bin

 Bupa promise and values statement displayed

 Care recipient and staff interactions

 Cleaning and laundry service in progress

 Clinical/infectious waste, sharps containers and spill kits

 Emergency and firefighting equipment, evacuation maps and kits, emergency panel and egress routes

 Equipment and supply storage areas

 Feedback forms, external complaint and advocacy information displays and locked lodgement box

 Interactions between staff, care recipients, representatives and volunteers

 Internal and external living environment including village store, men’s shed and chicken coop

 Meal and refreshment service

 Noticeboards

 Notification to stakeholders of re-accreditation audit displayed

 Personal protective equipment, infection control resources and processes

 Short group observation in Wattle lounge

 The ‘Charter of care recipients’ rights and responsibilities – residential care’ displayed

 Waste and pest management systems.

Home name: Bupa Berwick RACS ID: 3676 5 Dates of audit: 07 February 2017 to 08 February 2017 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 actively pursues continuous improvement across the Accreditation Standards and shows improvements in management, staffing and organisational development. Management identify opportunities for improvement from sources including improvement logs, verbal feedback from stakeholders, customer focus sessions, meetings, audits, hazard and risk identification and clinical data. Management register opportunities for improvement on the organisational database. Key staff and management regularly analyse a range of quality indicator data, report and discuss performance indicators at local and organisational levels as appropriate and take necessary action to improve quality outcomes. Management monitor and evaluate improvement processes and outcomes through stakeholder feedback, meetings, audits and data analysis. Care recipients, representatives and staff are satisfied ongoing improvements occur.

Examples of recent improvement initiatives in relation to Standard 1 Management systems, staffing and organisation include:

 To ensure the roster is fully resourced, management reviewed the recruitment process. Following successful implementation of the ‘assessment centre’ process at the organisation’s commencing homes, management initiated the process at the home. This involves a session with 15 potential employees for different roles, initial introduction by the Bupa team and candidates, followed by team activities, written activities and one to one interviews. Following the process the team meet to discuss candidates’ strengths and weaknesses to identify the most suitable candidates. Management said the new process shows positive results.

 To improve the induction process for new staff, management created an induction manual/program. The manual provides comprehensive role specific induction checklists for lifestyle, maintenance, administration, care, nursing, kitchen, cleaning and laundry staff. New staff are provided with a manual which they use to ensure the required activities, training and assessment are completed at each of the key induction stages. Feedback is positive.

 An organisational initiative to ensure education opportunities are provided to meet the needs of staff and care recipients involves a clinical capability framework assessment to capture the knowledge base of clinical staff. Following analysis of the assessment

Home name: Bupa Berwick RACS ID: 3676 6 Dates of audit: 07 February 2017 to 08 February 2017 education will be provided to assist staff deliver a higher level of care. Management said staff were engaged in the process and staff said the capability framework was interesting to complete.

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

Management with the support of the organisation has systems to ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The organisation reviews information from a range of sources to assist with identifying relevant changes and advises the home’s management of any required action. Work instructions are developed, reviewed and updated according to required changes with links to relevant legislation available. Staff discuss regulatory compliance at relevant meetings and management disseminates information through memoranda, electronic mail, meeting minutes and education. Monitoring of ongoing compliance is through the quality processes. Staff said they are informed of regulatory changes.

Examples of regulatory compliance in relation to Standard 1 Management systems, staffing and organisational development include the following:

 Management ensured the notification of all stakeholders about the re-accreditation audit within the required timeframe.

 Confidential documentation is stored securely.

 There is a system to ensure all staff, volunteers and appropriate service providers have current police certificates, statutory declarations as applicable and appropriate credentials.

Home name: Bupa Berwick RACS ID: 3676 7 Dates of audit: 07 February 2017 to 08 February 2017 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

Management has a system to ensure all staff have appropriate knowledge and skills to perform their roles effectively. Management undertake training needs analysis for non-clinical staff and implemented a clinical capability framework to inform training needs over the next two years. The education program is informed by observations, audit results, requests and current care recipients’ identified needs. There is an annual mandatory training program and management ensure staff attendance. Staff are advised of education opportunities through an education calendar, via verbal and written reminders. Recruitment processes include minimal skill requirements and new staff undertake competency based orientation. Staff are encouraged to access training to develop skills or for career progression. A range of training options and competencies are available to meet staff needs. Management monitor attendance at training with evaluations undertaken. Staff are satisfied with the education available to them. Care recipients and representatives are satisfied staff have appropriate knowledge and skills.

Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include:

 Assessment centre

 Certificate IV in aged care

 Clinical capability framework

 ‘Workday’ training for digital champions, administration, leadership and staff.

Home name: Bupa Berwick RACS ID: 3676 8 Dates of audit: 07 February 2017 to 08 February 2017 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

Each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Management ensure internal and external complaint information is accessible and convey information about ways to comment and complain in information handbooks for care recipients and representatives, at meetings and during informal contact. There is a log system to provide staff, care recipients, representatives and visitors with a mechanism to raise comments, suggestions and complaints. The log system is accessible and when outcomes are evaluated they form part of the continuous improvement program. Care recipients and representatives are encouraged, through an open door policy to approach any member of staff, particularly the general manager, care manager or registered nurses with any issue. Meetings are conducted regularly and provide stakeholders with an opportunity to raise concerns. Staff and family members support care recipients who are less able to express their feedback independently. Care recipients, representatives and staff are aware of available feedback mechanisms.

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 Bupa promise and values statement and organisational commitment to care statements are documented, displayed and accessible to care recipients, representatives, visitors, staff and management. The Bupa purpose for longer, healthier, happier lives is aligned to the values of passionate, caring, authentic, accountable, open, courageous, extraordinary and underpin the home’s commitment to their customers, people and wider society.

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 organisation and management has a system to ensure there are appropriately skilled and qualified staff sufficient to ensure the delivery of services to meet care recipients’ requirements. Recruitment processes include role specific criteria and qualifications with an assessment centre implemented to select the most suitable applicants. Police certificates, reference and qualification checks occur. Role specific orientation, ‘buddy’ shifts, the probationary process with offers of employment support staff retention in accordance with the

Home name: Bupa Berwick RACS ID: 3676 9 Dates of audit: 07 February 2017 to 08 February 2017 organisational philosophy of care. Duty lists and work instructions guide practice and management consider the current needs of care recipients, the skills and experience of staff when allocating shifts. Adequate staffing levels and skill mix is maintained with a registered nurse on duty daily. Management monitors staff performance through competency assessments, performance appraisals, observation and quality processes. Care recipients and representatives are satisfied with staff skills, knowledge and the manner in which staff provide care and services.

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

Management ensure stocks of appropriate goods and equipment for quality care and service delivery are available. Staff monitor stock levels, order from preferred suppliers and ensure the rotation of stock. Management review and update the variety and quantity of supplies and equipment to reflect the changing needs of care recipients. Goods are stored safely in secure areas and there are cleaning and maintenance programs to ensure equipment remains in good repair or replaced as necessary. There are processes to ensure staff are educated in the safe and effective use of new products and equipment. Staff, care recipients and representatives are satisfied with the quantity and quality of supplies and equipment available.

1.8 Information systems

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

Team’s findings

There are effective information management systems. The home uses the Bupa management system which provides access to information including current practices, tools and forms using flow charts, forms and work instructions. Specific information and changes to regulations and processes are communicated through manuals, education, meetings, newsletters, noticeboards, brochures, handbooks and memoranda. Sensitive care recipient and staff information is securely stored, archived and disposed of according to established procedures. Computer systems are password protected. Management monitor the information management system using audits, satisfaction surveys and discussions at stakeholder meetings. Stakeholders are satisfied with access to information and with communication processes.

Home name: Bupa Berwick RACS ID: 3676 10 Dates of audit: 07 February 2017 to 08 February 2017 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

Organisational processes ensure all externally sourced services meet residential, operational and service quality goals. Bupa’s central procurement team negotiate, approve and manage contracts. Management and staff monitor contractors’ service performance through observations of practice, stakeholder feedback and quality activities to ensure they consistently meet service agreement conditions. Contractors register their arrival on site, receive induction and orientation where necessary and are provided with suitable supervision whilst on site when required. Management, staff, care recipients and representatives are satisfied with the services provided by external contractors.

Home name: Bupa Berwick RACS ID: 3676 11 Dates of audit: 07 February 2017 to 08 February 2017 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

The organisation actively pursues continuous improvement in care recipients’ health and personal care. Care recipients, representatives and staff are satisfied the home pursues continuous improvement. For a description of the continuous improvement system, please refer to expected outcome 1.1 Continuous improvement.

Examples of improvement initiatives in relation to Standard 2 Health and personal care include:

 Management identified the practice of crushing medications when care recipients experienced difficulty swallowing tablets meant it was difficult to know if the full effect of the medication was obtained due to the different absorption rates of the crushed medication. The jam used as a mix with crushed medication is sugary, lingers on the teeth and has a potential to impair dental hygiene. A food based gel with no known interactions with medications was trialled within the home. The ingredients break down in the acidic environment of the stomach having minimal impact on the absorption of the medication. Feedback from both staff and care recipients is positive.

 Team members observed that some care recipients were no longer able to use cutlery and were experiencing difficulty at meal times. To alleviate any frustration and assist independence management provide finger foods for these care recipients. Kitchen staff created a different menu consisting of meals that are easier to eat with fingers and does not contain sauces and gravy. When care staff notify the kitchen staff that a care recipient is not managing their meals, the kitchen uses the alternate menu and care recipients are still able to enjoy their meals with fellow care recipients at the table. Feedback is positive.

 Following feedback from the customer satisfaction survey, management started ‘person first’ training for all staff. There are seven modules including communication and the environment. Trained coaches deliver the training and support staff in the workplace. There is positive feedback from staff.

Home name: Bupa Berwick RACS ID: 3676 12 Dates of audit: 07 February 2017 to 08 February 2017 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

Management has systems to identify and comply with all relevant legislation, regulatory requirements, professional standards and guidelines in the area of health and personal care. Refer to expected outcome 1.2 Regulatory compliance for further information about the home’s regulatory compliance system.

Examples of responsiveness to regulatory compliance relating to Standard 2 Health and personal care include:

 Management has work instructions to guide staff actions in the event of an unexplained care recipient absence.

 Medications are stored and managed according to legislated processes.

 Registered nurses plan and supervise the delivery of specialised nursing care.

 There is ongoing monitoring of registered nurse and medical practitioner registrations.

2.3 Education and staff development

Team’s findings

Management has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to health and personal care. Refer to expected outcome 1.3 Education and staff development for information about management’s education and staff development systems and processes. Work instructions and duty lists guide staff practices. Staff attend training related to a variety of clinical care topics.

Examples of education and training provided in relation to Standard 2 Health and personal care include:

 Behaviour management

 Clinical handover

 Deep brain stimulator

 Dysphagia, thickened fluids and choking

 Skin care, pressure areas and wounds.

Home name: Bupa Berwick RACS ID: 3676 13 Dates of audit: 07 February 2017 to 08 February 2017 2.4 Clinical care

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

Team’s findings

There is a system to ensure care recipients receive appropriate clinical care. Staff assess care recipients when they enter the home and the information collected guides immediate care needs. Staff develop care plans based on assessments and review these care plans regularly and when care needs change. Handover, progress notes, care and management plans inform staff of care recipients’ needs. Appropriately qualified staff provide or oversee care. Management and staff ensure effective management of clinical incidents through reviews and data analysis. If a care recipient is transferred to hospital, staff follow a process to ensure current information accompanies the care recipient and that discharge information is communicated to all relevant staff. Monitoring of effective clinical care is through care plan reviews, care recipient/representative conferences, audits, feedback and end of month clinical reports. Staff said they feel confident they have a thorough understanding of care recipients’ needs when attending to them. Care recipients and representatives are satisfied with the clinical care provided.

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

Management has a system to ensure appropriately qualified nursing staff identify and meet care recipients’ specialised nursing care needs. Care recipients with specialised care requirements have individualised directives and management plans and access to health professionals where required. Management facilitates the education of staff relevant to current care recipients’ needs. Monitoring of specialised nursing care occurs through regular reviews, quality reports, audits, meetings and feedback from care recipients and representatives. Staff said they have sufficient time and resources to provide specialised care. Care recipients and representatives are satisfied with the specialised care provided.

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

There is a system to ensure care recipients are referred to appropriate health specialists in accordance with care recipients’ needs and preferences. Care recipients are assessed by the physiotherapist on entry to the home and as required. Medical practitioners, physiotherapists and a podiatrist provide regular services at the home. Care recipients have access to other services such as medical specialists, dietitian, speech pathologist, ‘In Reach’ mobile hospital services, palliative care, auditory, dental, vision and behaviour management

Home name: Bupa Berwick RACS ID: 3676 14 Dates of audit: 07 February 2017 to 08 February 2017 services through referral or private arrangements. Management and staff provide support for care recipients to attend external appointments. Management monitors the provision of other health and related services through care plan reviews, care consultations, feedback, audits and meetings. Care recipients and representatives are satisfied referrals to other health and related services occur.

2.7 Medication management

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

Team’s findings

There is a system to ensure care recipients’ medication is managed safely and correctly. Medication is securely stored according to legislative requirements and staff practice is guided by the home’s medication work instructions. Staff complete assessments and ensure regular reviews for care recipients who choose to self-medicate. There are processes for monitoring opened eye drops and creams. Management has a system to ensure there are supplies of regular and after-hours medication. Management monitor medication administration through regular checks, audits, competency evaluations, incident analysis, meetings and feedback mechanisms. An accredited pharmacist conducts care recipients’ medication reviews. Care recipients and representatives are satisfied with medication management.

2.8 Pain management

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

Team’s findings

Management has a system to ensure all care recipients are as free as possible from pain. Staff complete pain assessments when care recipients enter the home and when required. Staff implement appropriate actions and evaluate and document the effectiveness of those interventions. Strategies used to assist care recipients to maintain their comfort levels include medication, exercises, massage, diversion, heat packs and repositioning. Management monitor the effectiveness of pain management through verbal feedback, pain charting and assessments, monitoring of administration of ‘as needed’ analgesia, care plan reviews and audits. Care recipients and representatives are satisfied with staff assistance to relieve care recipients’ pain.

2.9 Palliative care

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

Team’s findings

There is a system to ensure the comfort and dignity of terminally ill care recipients. Staff commence the process of advanced care planning with care recipients and representatives

Home name: Bupa Berwick RACS ID: 3676 15 Dates of audit: 07 February 2017 to 08 February 2017 on entry to the home or when appropriate. Resources and education are available to guide staff practice regarding the provision of palliative care. Care recipients have access to external palliative care services for consultative support of symptom management and cultural and spiritual support if requested. Management review and evaluate the palliative care process through care plan reviews, care discussions and feedback. Staff support care recipients and representatives during palliative stages and provide for the comfort and dignity of terminally ill care recipients.

2.10 Nutrition and hydration

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

Team’s findings

Management have a system to ensure care recipients receive adequate nourishment and hydration. Staff assess nutritional requirements with care recipients’ preferences, allergies, intolerances, specific dietary and adaptive crockery and cutlery needs identified. Staff complete dietary forms and provide the kitchen with current information. Staff review assessments and care plans regularly. Referral to a dietitian or speech pathologist occurs if required. Staff update dietary information and inform relevant care, lifestyle and hospitality services when changes are made. Management monitor the adequacy of nutrition and hydration for care recipients through allied health and care plan reviews, audits, surveys, meetings, monitoring of weight, food and fluid charting and verbal feedback. Staff demonstrated they are aware of care recipients’ dietary requirements and need for extra assistance. Care recipients and representatives are satisfied with management’s approach in meeting care recipients’ nutrition and hydration needs.

2.11 Skin care

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

Team’s findings

There is a system to ensure care recipients’ skin integrity is consistent with their general health. Staff assess care recipients’ skin integrity on entry to the home and develop care plans documenting each care recipients’ specific skin care risks, needs and interventions required. Staff monitor care recipients’ skin integrity during all care interventions. Staff employ interventions such as soap substitutes, creams, air mattresses, protective clothing, cushioning, repositioning and nutritional supplements to support skin care. Management of wound care involves assessments, specialised plans of care and regular monitoring of progress and treatment provided. Management monitors the effectiveness of skin care through ongoing observations, care plan and wound management reviews, audits and care recipient feedback. Care recipients and representatives are satisfied with the skin care provided.

Home name: Bupa Berwick RACS ID: 3676 16 Dates of audit: 07 February 2017 to 08 February 2017 2.12 Continence management

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

Team’s findings

Management has a system to ensure the effective management of care recipients’ continence. Staff complete continence assessments including charting of care recipients when they enter the home and develop individualised care plans, which are reviewed regularly. Care recipients’ continence is reassessed when required. Staff record urinary tract infections with monitoring of treatments and monthly analysis of data to identify trends. Details of required continence aids and toileting assistance are documented and staff ensure privacy at all times. Management monitors effective continence management through care plan reviews, feedback, audits, infection data and provide education to staff as required. Care recipients and representatives are satisfied care recipients’ continence needs are met.

2.13 Behavioural management

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

Team’s findings

There is a system to ensure the needs of care recipients with challenging behaviours are managed effectively. Staff assess care recipients’ behavioural needs on entry to the home and develop care plans in consultation with care recipients, representatives, staff, medical practitioners and other health professionals as appropriate. The care plans detail behaviours displayed and include triggers and strategies to manage these episodes. There is a process for referring care recipients to behaviour management advisory services if required. Staff review assessments and care plans regularly. Staff record behaviour incidents and management analyses data to ensure interventions remain appropriate and effective. Monitoring of effective behaviour management is through behaviour charting, feedback, care plan reviews, audits and analysis of incident data. Care recipients and representatives are satisfied staff attend to care recipients in a timely and appropriate manner.

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

Management has a system to ensure all care recipients achieve optimum levels of mobility and dexterity. Staff, including the physiotherapist, complete falls risk, mobility, strength and transferring assessments when care recipients enter the home and develop care plans from these assessments. Staff document incidents, complete post-fall risk assessments and review care plans. Management provide care recipients with mobility and dexterity aids if required and appropriate mechanical lifting equipment is available. Management and staff regularly review all recorded incidents and develop strategies to minimise future falls. Staff

Home name: Bupa Berwick RACS ID: 3676 17 Dates of audit: 07 February 2017 to 08 February 2017 said they have training in manual handling at orientation, annually and when required. Care recipients and representatives are satisfied care recipients are supported to achieve their maximum mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings

Management has a system to ensure care recipients’ oral and dental health is maintained. Staff complete assessments when care recipients enter the home and develop care plans detailing oral and dental needs in consultation with care recipients or their representatives. Staff support care recipients to access dental services through either in-home dental visits or attendance at external appointments. Staff refer care recipients to a speech pathologist if they are experiencing swallowing difficulties and texture-modified diets are available if required. There is a process for the cleaning and replacement of oral equipment such as toothbrushes and denture containers. Monitoring of the effectiveness of oral and dental care is through care plan reviews, audits and feedback. Care recipients and representatives are satisfied with the oral and dental care provided.

2.16 Sensory loss

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

Team’s findings

Management has a system to ensure the effective identification and management of care recipients’ sensory losses. Staff complete sensory assessments for each care recipient and develop care plans that identify deficits and support needs. Staff use a range of communication strategies when interacting with care recipients and assist with the application of glasses and hearing aids if needed. Staff provide activities, programs and resources that stimulate the care recipients’ senses including herb and vegetable gardens and aromatherapy towels. There are well-lit, comfortable and safe living areas for care recipients with sensory loss to move around safely. Care recipients and representatives are satisfied with the management of sensory loss for care recipients.

2.17 Sleep

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

Team’s findings

Care recipients are able to achieve natural sleep patterns. Sleep assessments are completed when care recipients enter the home and care plans are developed detailing preferred settling routines, sleep patterns and rising times. Care plans include pharmacological and non-pharmacological interventions such as a late supper, reading or hot beverages to

Home name: Bupa Berwick RACS ID: 3676 18 Dates of audit: 07 February 2017 to 08 February 2017 facilitate sleep. Staff promote an environment conducive to comfort and sleep. Care plans are reviewed regularly and when care recipients’ needs change. Care recipients said it is quiet at night and they are able to achieve restful sleep.

Home name: Bupa Berwick RACS ID: 3676 19 Dates of audit: 07 February 2017 to 08 February 2017 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 continuous improvement system shows improvements in the area of care recipient lifestyle. Stakeholders are satisfied the organisation is actively pursuing continuous improvement. For a description of the home’s system of continuous improvement, refer to expected outcome 1.1 Continuous improvement.

Examples of improvement initiatives in relation to Standard 3 Care recipient lifestyle include:

 To expand links in the local community, management initiated care recipients’ attendance at a toddlers/mothers group called ‘mainly music’. Four care recipients attend, interact with the children and mothers and have morning tea with them. This has proved popular and successful with care recipient feedback that they enjoy interacting with the children and their families.

 Following care recipient enjoyment with the chicken hatching program and the donation of two chicken coops, hen-keeping was introduced. There is now a chicken coop and three hens. Care recipients enjoy spending time outside feeding, watching the hens and collecting the eggs.

 Music therapy commenced for care recipients who do not come out of their rooms. This provides additional one to one time with care recipients, feedback is that they are more relaxed and engaged. Management continue to monitor the initiative.

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

Management has systems to identify and comply with regulatory compliance obligations in relation to care recipient lifestyle. Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system.

Home name: Bupa Berwick RACS ID: 3676 20 Dates of audit: 07 February 2017 to 08 February 2017 Examples of responsiveness to regulatory compliance related to Standard 3 Care recipient lifestyle include:

 Care recipients and representatives receive information about their rights and responsibilities, privacy and consent issues in their information packs and residential agreements.

 The home displays the ‘Charter of care recipients’ rights and responsibilities – residential care’.

 Management has processes to ensure it meets mandatory reporting requirements.

Team’s findings

Management has a system to monitor and ensure staff have the knowledge and skills to enable them to effectively perform their roles in relation to care recipient lifestyle. Refer to expected outcome 1.3 Education and staff development for information about management’s education and staff development systems and processes. Care recipient and representative feedback, care plans and observations guide staff practices.

Examples of education and training provided in relation to Standard 3 Care recipient lifestyle include:

 Lifestyle education workshop

 Manual handling including wheelchairs and bus access

 'Person first dementia second' coach training

 'Person first dementia second' training.

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 ensures each care recipient receives support in adjusting to life in the new environment and on an ongoing basis. On moving into the home, care recipients receive support to socialise and are encouraged to participate. In consultation with the care recipient and their representatives, lifestyle staff identify care recipients’ emotional support needs and preferences. Staff assess emotional support needs on an ongoing basis and implement alternative strategies to ensure effective support, including offering support to representatives. Care recipients are encouraged to decorate their rooms with items of personal significance. Staff monitor the effectiveness of emotional support strategies through

Home name: Bupa Berwick RACS ID: 3676 21 Dates of audit: 07 February 2017 to 08 February 2017 observation, talking to care recipients, feedback and regular care plan reviews. Care recipients and representatives are satisfied with the care and quality of the ongoing emotional support provided.

3.5 Independence

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

Team’s findings

Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service. Staff identify care recipients’ preferences to enable staff to support their optimal social, physical, cultural and intellectual independence. Care recipients who wish to continue their membership of groups within the wider community are supported to do so. Staff provide adaptive equipment and support the use of mobility, sensory and communication aids to promote independence and involvement in activities of interest. Staff welcome visitors, provide access to tea or coffee making facilities, facilitate shopping options and assist care recipients wishing to pursue special interests. Care recipients and representatives are satisfied with the level of support and encouragement available to optimise 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

Management and staff recognise and respect each care recipient’s right to privacy, dignity and confidentiality. Assessment and review includes consideration of each care recipient’s specific cultural, spiritual or personal needs to promote privacy and dignity. The home has single and shared bedrooms with en-suites, accommodates couples and encourages personalisation of rooms. Strategies and processes for maintaining privacy and dignity are well established. Seating areas are available indoors and outdoors for care recipients to socialise or for personal use. Care recipient information is stored securely and staff respect confidentiality when speaking about care recipients. Staff are discreet when managing care needs. Care recipients and representatives are satisfied management and staff respect care recipients’ privacy and dignity.

Home name: Bupa Berwick RACS ID: 3676 22 Dates of audit: 07 February 2017 to 08 February 2017 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

Management and staff encourage and support care recipients to participate in a wide range of interests and activities of interest to them. Staff identify and document preferences and interests in discussion with care recipients and representatives and continue to invite participation to support new interests. Staff provide activities in small and large groups or on an individual basis and consider cognitive and physical ability. A bus is available for regular outings to the local community or further away and staff support care recipients to participate in community activities. Visits to and from community groups including children and entertainers occur, with volunteers supporting the program. There is a village store for the purchasing of a range of items, men’s shed and chickens. Active seeking of feedback, observations, activity evaluations and discussion inform staff in implementing the program. Care recipients and representatives are satisfied with the activity program and the support provided to participate.

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

Management and staff meet care recipients’ individual interests, customs and beliefs. Cultural and ethnic backgrounds are valued and fostered. Staff consider care recipients’ cultural, religious, spiritual and ethnic preferences in planning care and activities. Lifestyle staff work collaboratively with staff and care recipients to develop activities to meet care recipients’ needs. Staff diversity assists the understanding of care recipients’ cultural and linguistic diversity and communication aids are available. The home prepares for and celebrates significant personal, cultural, spiritual and commemorative events. Staff support care recipients to access spiritual support with regular visits occurring, or in the community if preferred. Staff support care recipients during illness and at the end of life as preferred. Care recipients and representatives are satisfied with the cultural and spiritual support provided.

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

Each care recipient or relevant representative participates in decisions about services and care recipients exercise choice and control over their lifestyle without infringing on the rights

Home name: Bupa Berwick RACS ID: 3676 23 Dates of audit: 07 February 2017 to 08 February 2017 of other care recipients. Assessments record choices and preferences. Staff use a range of strategies including offering timely choices, inviting participation and responding to requests to support choice and decision-making. Care plans, dietary likes, dislikes and records of activities document personal preferences which staff review regularly. Care recipient and representative discussions occur and staff communicate information informally, by display or in writing to support choice and decision-making. Care recipients and representatives are satisfied staff respect care recipients’ choices and preferences and they are encouraged to participate in decisions about care and give feedback.

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

Management and staff demonstrate there are processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. When care recipients move into the home, they receive information about services provided, fees and charges and security of tenure. Management assist care recipients to understand their rights and responsibilities through responding to individual queries, meetings and information displays. All care recipients and representatives have the opportunity to sign a contract which includes a copy of the ‘Charter of care recipients’ rights and responsibilities – residential care’. Consultation occurs with care recipients and representatives if there is any alteration to specified care and services and preceding a room change. Care recipients and representatives are satisfied with the security of tenure provided by the home.

Home name: Bupa Berwick RACS ID: 3676 24 Dates of audit: 07 February 2017 to 08 February 2017 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 continuous improvement system shows improvements in the physical environment and safe systems. Stakeholders are satisfied the organisation is actively pursuing continuous improvement. For a description of the home’s system of continuous improvement, refer to expected outcome 1.1 Continuous improvement.

Examples of improvement initiatives in relation to Standard 4 Physical environment and safe systems include:

 To improve the security of the home, management commenced a program to install CCTV. This is a staged approach and commenced with installation in the foyer and the nurses stations. Care recipients and staff have expressed appreciation of the safety improvements.

 To ensure safety in the event of a power outage emergency, management installed a generator on site. Appropriate staff received education in the use of the generator. Feedback is positive.

 Following results of the quarterly food survey which showed dissatisfaction with meal service, management identified areas to improve. Management instituted food focus meetings, introduced a new menu, improved the choice and the service of meals. The chef now seeks feedback directly from care recipients about meals. Further survey results show greater satisfaction with meals and service which continue to improve.

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

Management has systems to identify and ensure regulatory compliance obligations in relation to physical environment and safe systems. Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system.

Home name: Bupa Berwick RACS ID: 3676 25 Dates of audit: 07 February 2017 to 08 February 2017 Examples of regulatory compliance related to Standard 4 Physical environment and safe systems include:

 Procedures are in place for recording, managing and reporting infectious diseases and outbreaks.

 A current food safety program is in place, certification by third party audits and inspections related to food safety occur.

 The home’s systems ensure monitoring and maintenance of emergency and essential service systems.

Team’s findings

Management have a system to monitor the knowledge and skills of staff members and enable them to effectively perform their role in relation to physical environment and safe systems. For details regarding the system, refer to expected outcome 1.3 Education and staff development. Care recipient and representative feedback, work instructions, duty lists and observation guide staff practices.

Examples of education and training relating to Standard 4 Physical environment and safe systems include:

 Fire training

 Food safety refresher and supervisor training

 Outbreak management, infection control (influenza) and norovirus update

 Safety alert - hot weather

 Waste management.

4.4 Living environment

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

Team’s findings

Management and staff work actively to provide a safe and comfortable environment consistent with care recipients’ care needs. There are both single and double rooms available. There is safe access to clean, comfortable and well-maintained communal, private, dining and outdoor areas with sufficient and appropriate furniture. Management and relevant staff monitor the environment of the home via stakeholder feedback, audits, incident and

Home name: Bupa Berwick RACS ID: 3676 26 Dates of audit: 07 February 2017 to 08 February 2017 hazard reporting mechanisms. Keypads, call bells, security arrangements and provision of equipment such as mobility aids promote safety. Preventative and corrective maintenance processes, cleaning regimes and the electrical test and tag program ensure a comfortable and functional environment for care recipients and staff. Care recipients and representatives are satisfied with the safety and comfort of 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 and staff demonstrate they actively work to provide a safe working environment consistent with the organisation’s work instructions, regulatory requirements and industry guidelines. The system, supported by the organisation includes work instructions, education and training, hazard and incident reporting, risk assessments, equipment evaluation and trials, maintenance and various monitoring mechanisms. The workplace health and safety committee meet regularly and documentation show actions are taken as a result of feedback, discussion and reporting mechanisms. Chemicals and oxygen are stored safely and current safety data sheets are accessible. Staff said they have access to appropriate inventory, equipment, education and information resources to promote safe work practices.

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

Management and staff work actively to provide an environment and safe systems of work that minimise fire, security and emergency risks. There are procedures to respond to a range of internal and external emergencies. External contractors maintain fire safety equipment and there are processes to ensure essential services equipment is maintained. Management display emergency evacuation plans and ensure emergency exits and egress routes are free from obstruction. There are processes to maintain current emergency evacuation lists and response packs. All staff are required to complete fire and emergency training. Management facilitate a secure environment through the provision of keypad entry and exit points, sign in processes, an alarm system, nurse call emergency buttons, secure medication and personal record systems. Care recipients and representatives are satisfied the home is safe and secure.

Home name: Bupa Berwick RACS ID: 3676 27 Dates of audit: 07 February 2017 to 08 February 2017 4.7 Infection control

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

Team’s findings

The home has an infection control program in place. Key staff and management records infections, analyses trends and implements strategies to prevent recurrence. Staff participate in infection control education including hand hygiene competencies at orientation, on an annual basis and where identified as requiring further training. We observed hand hygiene stations, accessible personal protective equipment, blood and chemical spill kits, infectious disease outbreak kits, sharps disposal and contaminated waste bins. There is a current food safety plan and pest control program in place. Infection control work instructions assist staff to reduce the risk of infection and to manage infection outbreaks. Staff described infection control practices related to managing and preventing infections. Care recipients and representatives are satisfied with the management of infection control processes.

4.8 Catering, cleaning and laundry services

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

Team’s findings

There are processes to ensure hospitality services enhance the life of care recipients and the staff working environment. Meals are prepared daily on site in line with the organisation’s food safety program and a dietitian approved cyclical four week, seasonal menu. Catering staff have relevant information identifying specific nutrition and hydration requirements, allergies, preferences and choices. Meals provide a social environment for care recipients in the dining rooms or care recipients can remain in their rooms if preferred. Cleaning staff follow schedules and duty lists to maintain care recipients’ rooms and communal areas and have access to adequate supplies and equipment. Laundry staff complete all laundry on site, provide ironing when needed and there are established processes to reduce lost property. Catering, cleaning and laundry practices adhere to appropriate infection control work instructions. All hospitality services staff undertake training relevant to their role on commencement of employment and regularly thereafter. The home monitors its hospitality services through internal and external audits, surveys, meetings and formal and informal feedback mechanisms. Care recipients and representatives are satisfied with catering, cleaning and laundry services provided.

Home name: Bupa Berwick RACS ID: 3676 28 Dates of audit: 07 February 2017 to 08 February 2017