Published Decision (SA And RA)

Abbey Gardens Aged Care

RACS ID: 3989 Approved provider: Alysium Gardens Pty Ltd Home address: 15 Tarwin Street WARRAGUL VIC 3820

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 20 October 2020. We made our decision on 31 August 2017. The audit was conducted on 25 July 2017 to 26 July 2017. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. Most recent decision concerning performance against the Accreditation Standards Standard 1: Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met Standard 2: Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement 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: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 2 Standard 3: Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community. 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional Support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and responsibilities Met Standard 4: Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors 4.1 Continuous improvement 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: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 3 Audit Report

Name of home: Abbey Gardens Aged Care RACS ID: 3989 Approved provider: Alysium Gardens Pty Ltd Introduction This is the report of a Re-accreditation Audit from 25 July 2017 to 26 July 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: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 4 Scope of this document An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 25 July 2017 to 26 July 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: 123 Number of care recipients during audit: 72 Number of care recipients receiving high care during audit: 69 Special needs catered for: Care recipients living with dementia. Audit trail The assessment team spent two days on site and gathered information from the following: Interviews

Position title Number

Care recipients and representatives 26

Residential care manager 1

Operations director 1

Senior clinical care coordinator 1

Nursing staff 5

Care staff 10

Occupational therapist 1

Physiotherapist 1

Administration/reception staff 2

Leisure and lifestyle coordinator and staff 4

Volunteers 2

Environment service coordinator 1

Hospitality staff 6

Maintenance staff 1

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 5 Sampled documents

Document type Number

Care recipients’ files 12

Medication charts 7

Care recipients agreements 4

Personnel files 7

Contractors’ service agreements 4

Other documents reviewed The team also reviewed:  Action plan  Activities calendar and lifestyle documentation  Audits and results  Care recipients’ information package  Care recipient survey results  Catering, cleaning and laundry schedules and related records  Clinical charting  Comments and complaints register and feedback forms  Communication dairies  Consent documentation  Consumer experience report  Continuous quality improvement plan  Contractors’ information pack and induction checklist  Education records  Emergency controller – team leader role flow chart  Essential service records  Food safety plan and third party audits  ‘Frequently asked questions’ information sheet for care recipients  Human resource documentation  Incident reports  Infection data  Maintenance records and schedule  Medication registers  Memoranda

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 6  Minutes of meetings  Nurse registration summary  Occupancy certificate  Occupational health and safety documentation  Photographs of activities and care recipient participation  Poisons control plan and license  Police certificate register  Policies and procedures  Regulatory compliance documentation and certification  Rosters  Staff information handbook and pack  Volunteer information pack and handbook. Observations The team observed the following:  Activities in progress  Archived documents and paper shredders  Brochures, information displays and noticeboards  Cleaning and laundry in progress  Equipment and supply storage areas  Interactions between staff and care recipients  Living environment  Meal and refreshment service  Medication administration and storage of medications  Short observation in the ‘west wing’ dining room  Staff response to call bells  The 'Charter of residents' rights and responsibilities’  Vision, mission and values statement.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 7  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 Management and the organisation actively pursue continuous improvements across the Accreditation Standards and demonstrate improvements in management systems, staffing and organisational development. The continuous improvement program includes processes for identifying areas for improvement, implementing change, monitoring and evaluating the effectiveness of improvements. Management sources input from stakeholders through mechanisms such as comments and complaints, meeting forums, incidents, observations, the changing needs of care recipients and organisational projects or directives. Management and staff respond to improvement opportunities at the time and record this information on feedback forms, the improvement register and/or the continuous improvement plan. Both registers show timely response and identify the source, the improvement identified, action taken, progress and outcomes. Monitoring processes include feedback, consultation, quality activities and/or organisational management input to monitor the performance of the quality management system. Staff said management encourage them to raise improvements and are involved in the implementation and outcome of these ideas. Care recipients and representatives are satisfied when suggestions are raised management respond and provide feedback to them. Recent examples of improvements in Standard 1 Management systems, staffing and organisational development include:  In response to the increasing number of care recipients entering the home, management introduced a structured interview and orientation process. Staff said the orientation process is useful and prepares them well in regards to the organisations expectations and consumer focused care.  Following management observations and care recipient comments, management contacted their supplier to source more appealing looking double-handled cups. Various products were sourced and viewed by care recipients, with a china type cup chosen. Management said they have received positive comments from care recipients regarding the improvement initiative. 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”.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 8 Team’s findings The home meets this expected outcome The home has a system to identify relevant legislation, regulatory requirements and guidelines, and for monitoring these in relation to the Accreditation Standards. The organisation's management has established links with external organisations to ensure they are informed about changes to regulatory requirements. Where changes occur, the organisation takes action to update policies and procedures and communicate the changes to care recipients, their representatives and staff as appropriate. Compliance with relevant requirements is monitored through a planned schedule of internal audits and third party reviews. Staff have an awareness of legislation, regulatory requirements, professional standards and guidelines relevant to their roles. Examples of regulatory compliance obligations in relation to Standard 1 Management systems, staffing and organisation development include:  The home has a plan for continuous improvement  Management notified care recipients and representatives by letter of the re-accreditation audit within the required notice time.  Stakeholders are provided with and have access to information regarding advocacy services and the internal and external complaint mechanisms.  Established processes to ensure the currency of professional registrations for nursing staff.  A system to ensure compliance with police certificate requirements and statutory declarations as required for all relevant staff and generally volunteers and contractors.  Appropriate and secure information storage and destruction systems. 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Staff and management have access to education ensuring they have appropriate knowledge and skills to perform their roles effectively. Management have developed an education program in response to care recipients’ needs, organisational requirements, identified deficits in staff knowledge and/or skills, staff requests and other identified areas. Staff are notified of education opportunities through the displayed education calendar, meetings, memoranda and informative posters. Education systems include in-house services, self-directed learning packages, on line training, conferences, seminars, competency based assessments and onsite practical sessions. Management and staff attend ‘Round Robin’ mandatory training days and attendance is monitored to ensure all staff complete this training. Management and staff said the organisation supports them to access study leave for external education to further improve their skills and knowledge. Management and staff are satisfied with the education and training opportunities offered. Examples of recent education provided in relation to Management systems, staffing and organisational development include:  accreditation  commonwealth funding program  elder abuse and mandatory reporting

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 9  formal handover of systems and processes at the completion of the building. 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome Care recipients, representatives and other interested parties have access to internal and external complaint mechanisms. Management provide this information to care recipients’ and/or their representative in relevant information packs, brochures and residential agreements. The home has feedback forms and envelopes accessible to ensure anonymous input and management encourages conversation to concerns through their ‘open door’ approach. Advocacy and external complaints brochures are accessible and referred to during care recipient and staff orientation, education and in residential agreements. Management acknowledge and address all comments made and record these onto a comments register and/or the continuous improvement plan, if required. Corporate management generate reports to identify trends or service gaps. Stakeholders have various opportunities for comments or complaints through relevant meeting groups, care recipient and/or representative consultation, surveys and informal interaction. Staff said they assist where required to advocate on behalf of care recipients. Care recipients and representatives are comfortable to approach management and staff with any issues. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The organisation has documented their mission, vision and values statement which includes their core values and commitment to quality. Management displays this statement prominently in the home and repeats them in a range of internal documents on their intranet and website. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome Management demonstrates there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the Standards and the home’s philosophy and objectives. Recruitment processes consider the skills of applicants to undertake the role and include reference, security and qualification checks prior to commencement of employment. Newly recruited staff attend a structured orientation and education program, complete competency assessments and work buddy shifts. Staff receive organisational documents, position descriptions and an orientation handbook to assist them to understand the expectations of their role. A registered nurse is on duty each shift and oversees care and service delivery. There are effective strategies to adjust staffing in response to additional care recipients numbers and changing care needs. Care recipients and staff are satisfied with the sufficiency of and the knowledge and skills of staff.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 10 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome Management ensure stocks of appropriate goods and equipment for quality care and service delivery are available. Management and designated staff monitor stock levels, order from preferred suppliers and ensure the rotation of stock occurs. Management review the range and quantity of supplies and equipment to reflect the changing needs of care recipients. Management and staff consider equipment trials at the organisation’s other home’s, input from professionals, suppliers and stakeholder comments, with purchases made. 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. Care recipients, representatives and staff 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 The home meets this expected outcome The organisation demonstrates they have an effective information management system at the home with confidentiality, privacy and security maintained throughout. All stakeholders have access to current information, activities and events as appropriate through various communication mechanisms including consultation, meetings, noticeboards, newsletters, electronic messages. Care recipients and/or their representative are provided with information prior to or upon entry to the home with ongoing consultation and updates. Management and staff have access to current policies, procedures and resource information to help them perform their roles. Key data is collected and discussed at relevant meetings. There are processes for the archiving and destruction of documents and a regular backup system of electronic information. Management review the effectiveness of the system through quality activities, reports, feedback and observation of staff practice. Staff said they receive appropriate and sufficient information to support their roles and responsibilities and reiterated privacy principles. Care recipients and representatives are generally satisfied with the level of information provided and their ability to access information. 1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome Management engages external service providers to assist the home meet care recipients’ and operational needs and quality goals. Organisational and site management are guided by policies and procedures for establishing contracted services which include selection criteria, negotiation and in support of local suppliers and contractors. Adhoc contractors are utilised and supervised while on site to ensure quality service. Product suppliers and service contractors sign service agreements which include standards of service, privacy and confidentiality protocols, insurance, license and qualifications as applicable. Monitoring and evaluation of contracted suppliers and services occurs through observation, informal and

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 11 formal feedback, quality activities and scheduled reviews. Care recipients, representatives and staff are satisfied with the quality of services provided by external service suppliers and contractors.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 12 Standard 2 – Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Management actively pursue continuous improvement in all aspects of care recipient health and personal care. Staff document incidents and key clinical staff analyse clinical data for trends. Care recipients are satisfied their health and personal care needs are met. Refer to expected outcome 1.1 Continuous improvement for information about the home's systems. Recent examples of improvements in Standard 2 Health and personal care include:  In response to feedback and results of quality activities, the organisation updated the commercially sourced electronic care system to the latest version in July 2017. Management and staff report the system now enables various clinical charts and reports to be generated. Although recently introduced, management said the report has already identified a trend and in response, have provided education to staff as to the finalisation of incidents. Other features enable management to view incidents and updates for the last 12 hours and respond to nursing staff remotely. Evaluation continues.  Following management’s implementation of the ‘guard of honour’ when a care recipient passes away, further discussions with care recipients, their family or representatives as to the care recipient’s ‘end of life’ wishes and palliative care needs occurred. Management said there has been an increase in completed advanced care plans and care recipients appreciated the open discussion. Management have also engaged a palliative care consultant to provide advice in areas such as staff skills, certified practise, resources, ‘life care’ documentation and equipment required. Although still being implemented, management said the project has been welcomed by care recipients and families in enabling a care recipient to remain in the home. The project continues. 2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about health and personal care”. Team’s findings The home meets this expected outcome Management with the support of the organisation have 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 information about the home's systems. Examples of regulatory compliance obligations relevant to Standard 2 Health and personal care include:  A registered nurse plans, supervises and undertakes specialised nursing care and oversees care recipients with high care needs.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 13  Generally, staff demonstrate compliance with the policy and legislative requirements relating to medication management and storage.  A documented system guides the actions of management and staff in the event of an unexplained care recipient absence. 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has systems to identify education and training needs for staff to assist them to perform their roles effectively in relation to care recipient health and personal care requirements. Refer to expected outcome 1.3 Education and staff development for details of the home's system and process. Examples of education provided in relation to Standard 2 Health and personal care include:  continence and catheter care  dementia management  Parkinson’s disease  stroke management. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome Care recipients receive appropriate clinical care. Staff are guided by an assessment and care planning system to identify and assess each care recipient’s clinical care needs and preferences on entry to the home. A newly established care evaluation process is assisting staff with identifying changes in care recipients’ needs and prompts reassessment and changes to care provision. Consultation with care recipients or their representative is occurring formally and informally. The monitoring of care recipients’ clinical care is occurring through care review processes, audits, clinical data, incident analyses and stakeholder feedback. Staff described clinical interventions used to meet care recipients’ clinical needs. 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 The home meets this expected outcome Appropriately skilled staff identify and meet care recipients’ specialised nursing care needs. Registered nurses assess, plan and evaluate care recipients’ specialised nursing needs in partnership with appropriate health specialists and general practitioners. Generally care plans detail care recipients’ individual specialised nursing needs and the strategies to manage these needs. Staff are supported with an education program to develop and maintain the appropriate knowledge and skills to provide specialised nursing care. Specialised nursing needs are monitored by stakeholder feedback, audits and clinical data analysis. Care recipients and representatives are satisfied care recipients’ specialised nursing care needs are managed by appropriately qualified staff.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 14 2.6 Other health and related services This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”. Team’s findings The home meets this expected outcome Care recipients are referred to a range of health specialists in accordance with their individual needs and preferences. Clinical systems assist staff to identify if care recipients would benefit from the advice and review of health specialists. Processes assist to capture, record, communicate and incorporate health specialists’ recommendations into daily care provision. In accordance with each care recipient’s needs and wishes staff assist care recipients to access visiting health specialists or health specialists of their choice within the wider community. Management monitor the systems effectiveness through care review processes, audits and stakeholder feedback. Care recipients and representatives are satisfied with the range of health specialists available. 2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Care recipients’ medications are generally managed safely and correctly. Medications are administered by a combination of registered nurses, medication endorsed enrolled nurses and medication competent care staff. A registered nurse manages the overall system. Clinical processes assist staff to identify, assess and review care recipients’ medication needs. Newly established processes are in place for the ordering, delivery and disposal of medications. Medications are stored safely and securely and in accordance with regulatory guidelines. Policies and procedures and current medication resources are readily accessible and guide staff practice. Generally, staff follow safe and correct medication practices. Management monitor the effectiveness of the system through care review processes, medication incident data, audits and stakeholder feedback. Care recipients and representatives are satisfied with how staff manage care recipients’ medications. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome Care recipients said are as free as possible from pain. Care recipients’ pain needs are assessed for pain. Care plans document specific details about care recipients’ pain, strategies and equipment required to maintain optimal comfort levels. Care recipients have individualised pain programs that are directed by an onsite occupational therapist in consultation with the clinical staff and the care recipient’s general practitioner. Staff reassess care recipients’ pain in a response to changes in the clinical status of a care recipient. Strategies used to promote optimal comfort levels include medication, active and passive exercise, heat therapy and massage. Management monitor pain management through care review processes, audits and stakeholder feedback. Care recipients and representatives are satisfied with the management of care recipients’ pain. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 15 Team’s findings The home meets this expected outcome The home maintains the comfort and dignity of terminally ill care recipients. Care recipients are encouraged to discuss their end of life wishes, and management and staff said they underpin the care provision during the palliative care stage. Family involvement in their loved one’s end of life care is both supported and respected. Care recipient’s own general practitioners work with senior clinical staff to ensure optimal comfort and symptom relief. The monitoring of palliative care occurs through feedback and observation. Recorded feedback shows representatives expressing gratitude for the attention their loved one received during their end of life. 2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Care recipients receive adequate nutrition and hydration. On moving into the home, staff identify and assess care recipients’ individual dietary and hydration needs and this information forms the basis of care provision. Staff monitor care recipients’ weight and hydration status and implement referrals to health specialists and general practitioners to address any clinical concerns. Assistive devices are available as required and modifications to food texture and alternative dietary items are available to care recipients with special needs or preferences. Monitoring of the system occurs through care reviews, observation and feedback. Care recipients and representatives are satisfied care recipients receive an adequate level of nourishment and hydration. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Care recipients’ skin integrity is consistent with their general health. Staff assess care recipients’ skin integrity and care plans document their needs and preferences, including the levels of assistance and equipment required. Skin breaks, tears or abrasions, are identified noted as an incident and clinical staff initiate follow up care. Wound care charts guide staff practice when wounds occur and access to a wound consultant is available. Staff have access to emollient creams, pressure relieving devices and a range of wound dressings. Management monitor the effectiveness of care recipients’ skin integrity through clinical data, care review processes, and stakeholder feedback. Care recipients and representatives are satisfied with the care provided in relation to care recipients’ skin care management. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome Care recipients’ continence is managed effectively. Staff are guided by the clinical system to identify, assess and plan for care recipients’ continence needs. Clinical processes assist staff to identify changes to care recipients ‘continence status and reassessment occurs. Staff said they have access to sufficient resources to meet care recipients’ needs and have knowledge of care recipients’ individual requirements. Management monitor the effectiveness of care

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 16 recipients’ continence programs through the care review processes, observation and stakeholder feedback. Care recipients are satisfied with the continence care provided. 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The needs of care recipients with responsive behaviours are managed effectively. Staff assess care recipients’ mood, habits, level of engagement on a continual basis. Care plans identify behaviours, potential triggers and interventions needed. Referrals to general practitioners, a geriatrician and other relevant specialists occur as required. Staff are educated on contemporary methods for managing care recipients with responsive behaviours. Management and key staff monitor the systems effectiveness through care review processes, incident data, audits and stakeholder feedback. Care recipients and representatives are satisfied with how staff meet the needs of care recipients who display responsive 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 meets this expected outcome Care recipients’ optimum levels of mobility and dexterity are achieved. An onsite occupational therapist is actively involved in the assessment and development of individualised programs for care recipients to maintain optimal levels of mobility, dexterity and functional capacity. Care recipients at risk of falls are identified through a risk assessment and strategies such as hip protectors, sensor mats, mobility aids are used to minimise risk. Management monitor the effectiveness of the system through tracking and analysing falls data, staff feedback and the audit program. Care recipients and representatives are satisfied with how care recipients’ mobility, dexterity levels are achieved. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Care recipients’ oral and dental health is maintained. Oral and dental care assessments are conducted and care plans identify aids, equipment and the level of assistance required. Oral and dental health specialists are accessed for advice and treatment as needed. Management monitor oral and dental care through care reviews, audits and stakeholder feedback. Staff assist and provide support to care recipients with maintaining their oral and dental hygiene regimes. Care recipients and representatives are satisfied with how care recipients’ oral and dental health is maintained. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 17 Staff identify, assess and evaluate care recipients’ sensory needs to minimise the impact sensory loss has on the care recipients’ quality of life. Specialist services attend the home and provide advice in managing care recipients’ sensory losses. Care plans guide care provision such as the cleaning and maintaining of care recipients’ sensory aids. The living environment supports care recipients with sensory losses. Monitoring occurs through care reviews, observation and feedback. Staff are aware of care recipients’ individual needs and assist those who require assistance to fit and clean their aids. Care recipients are satisfied with how staff assist them to manage their sensory needs. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Care recipients said they are able to achieve natural sleep patterns. Assessment, care planning and review processes support care recipients to settle and enjoy restful sleep. Sleep variances are noted in progress notes, reassessed, and changes to sleep and settling regimes occur. Staff are aware of care recipients’ individual settling routines and described ways they assist care recipients to settle. Management monitor the system’s effectiveness through care review process, and feedback processes.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 18 Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Management actively pursue continuous improvement in relation to all aspects of care recipient lifestyle. Care recipients and representatives are satisfied with the assistance provided for care recipients to have control of their lives within the home and the community. Refer to expected outcome 1.1 Continuous improvement for information about the home's systems. Recent examples of improvements in Standard 3 Care recipient lifestyle include:  Following discussions and arrangements with a local community college, students provide pamper day once a month to care recipients. Management said they have received positive comments from those who attend the day of pampering and since February 2017, the number of care recipients who attend has doubled. Management and staff spoke of the excitement of care recipients attending the day and the laughter, reminiscing and social engagement with other care recipients and students. Management plan to start a ‘barber shop’ session to provide the same opportunities to male care recipients.  In response to a care recipient feedback about their enjoyment of gardening, management arranged for horticultural students and their educator to provide support, education and a social garden day at the home. Plants, cuttings and materials are sourced with training provided to care recipients and students as to gardening techniques such as soil composition and grafting. The potted plants are sold with proceeds going to purchase more materials. Management said and documentation confirms care recipients thoroughly enjoy the sessions, have developed friendships with students and are currently creating a sensory garden at the home for all to enjoy. Care recipients commented of having purpose and involved in their local community. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”. Team’s findings The home meets this expected outcome Management with the support of the organisation has systems to identify and comply with all relevant legislation, regulatory requirements, professional standards and guidelines in the area of care recipient lifestyle. Refer to expected outcome 1.2 Regulatory compliance for information about the home's systems. Examples of regulatory compliance obligations relevant to Standard 3 Care recipient lifestyle include:

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 19  Management maintains a mandatory reporting register. Policies and procedures guide management and staff actions in response to compulsory reporting obligations.  The organisation has policies and procedures to guide management and staff to uphold privacy principles and confidentiality of care recipient information.  Care recipients and/or their representative are provided with a residential agreement and provided information regarding specified care and services as appropriate.  The home displays the 'Charter of care recipients', rights and responsibilities' in key areas and within documentation. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has systems to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to care recipients’ lifestyle. Refer to expected outcome 1.3 Education and staff development for details of the home's system and process. Examples of education provided in relation to Standard 3 Care recipient lifestyle include:  dementia care programs  leisure and lifestyle course  privacy and dignity  social integration and community. 3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome Care recipients receive support to adjust to their new environment and on an ongoing basis. The home’s culture and staff provide a welcoming environment supporting care recipients on arrival and during their stay. Management provides an informative orientation tour and entry information outlining details of services provided. Lifestyle staff spend time with the care recipient and family offering support and information. Care and lifestyle staff identify and reassess care recipients’ emotional support needs on an ongoing basis and implement strategies to ensure effective support. Staff demonstrated insight into care recipients’ emotional needs and preferences describing provision of support and comfort. Care recipients and representatives are satisfied with the emotional support provided to care recipients. 3.5 Independence This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 20 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. Assessments consider care recipients’ cognitive, mobility and dexterity levels, emotional needs and preferences for social interaction. Assessment information contributes to the development of individual care plans detailing care recipient preferences and needs to enhance independence. Occupational therapy programs, specialised equipment, sensory and communication aids encourage care recipient’s independence with activities of daily living. Staff support care recipients to pursue their interests and membership of community groups according to their preferences. Visits by family, friends and other members of the community are encouraged. Care recipients and representatives are satisfied with the support for care recipients to maximise their independence. 3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Care recipients reside in single rooms with private bathrooms and there is accommodation suitable for couples. Orientation information for staff and care recipients includes details regarding privacy, dignity and confidentiality. Staff complete assessments identifying care recipients’ personal care, privacy and dignity preferences including this information in the care plan. Files are stored securely, electronic information is password protected, handover occurs discreetly and care recipients can secure their rooms. Staff ensure care recipients’ privacy and dignity attending to care in their room, addressing them by their preferred name and knocking on doors before entering. There are internal and external private areas available to entertain visitors and care recipients can utilise the private dining room. Care recipients and representatives are satisfied management and staff respect care recipients’ 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 meets this expected outcome Management and staff encourage and support care recipients to participate in a wide range of interests and activities of interest to them. Lifestyle profiles capture past and current interests, preferences for social interaction and community and family links. Staff use this information to develop a care plan incorporating goals, preferences and strategies to meet care recipient’s social, emotional and lifestyle needs. Staff inform care recipients of daily activities and regularly update noticeboards displaying the lifestyle program and activities scheduled for each day. Regular visits from community groups occur including schools, entertainers, gardening groups and therapy dogs. A team of volunteers provide additional support for a variety of activities including outings and special events such as the upcoming formal ball. Care recipients are encouraged to make suggestions for future activities and provide feedback about the program via meetings, feedback forms and informally with staff and management. Care recipients and representatives are satisfied care recipients are able to participate in a wide variety of activities of interest to care recipients. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 21 Team’s findings The home meets this expected outcome Management ensures care recipient’s individual customs, beliefs and cultural backgrounds are fostered and valued. Assessments and care plans document preferences, cultural, spiritual needs and practices, celebratory days, social contacts and palliative care wishes. The home holds religious services regularly and care recipients are able to attend the service of their choice. Staff support and facilitate a range of cultural and personal celebrations for care recipients and cultural care information is readily available. Cultural and volunteer groups are welcome and staff assist care recipients to attend community clubs and events. Care recipients and representatives are satisfied care recipients’ cultural backgrounds and belief systems are respected. 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 meets this expected outcome The rights of care recipients to make decisions and exercise choice and control over their lifestyle is recognised and respected. Management provides care recipients, and/or representatives with information regarding rights and responsibilities, advocacy and complaints and feedback mechanisms available to them. Care plans detail care recipients’ choices and preferences and include management plans as required. Care assessments include provision for care recipients to take risks and to refuse care or treatment. Consent forms address the use of health records, identifying information and other care requirements. Care recipients and representatives said staff respect care recipients’ choices and preferences and they are encouraged to participate in decisions about care. 3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Care recipients have secure tenure within the home and there are processes to ensure they understand their rights and responsibilities. Care recipients and/or representatives receive information and a formal agreement, which includes information about security of tenure, termination of occupancy, rights and responsibilities, provision of care and services, privacy and confidentiality and complaints mechanisms. In addition, brochures and poster displays include information about care recipients’ rights, privacy and advocacy services. The ‘Charter of care recipients’ rights and responsibilities – residential care’ is on display and included with care recipients’ agreements. Management consult care recipients and/or representatives if a change in a care recipient’s room is under consideration. Care recipients and representatives confirmed care recipients have secure tenure within the home and are aware of care recipients’ rights and responsibilities.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 22 Standard 4 – Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Management actively pursue improvements to ensure care recipients live in a safe and comfortable environment. Examples of activities that inform improvements related to the environment are audits, third party reports and feedback from stakeholders. Staff and representatives are satisfied management actively improves the home’s physical environment. Refer to expected outcome 1.1 Continuous improvement for information about the home's systems. Recent examples of improvements in Standard 4 Physical environment and safe systems include:  In response to advice sort by ‘Alzheimer’s Australia’ regarding the memory support unit and the dining experience, management and staff sought the approval of various items for the area. White plates, bowls and cups with red colour rims were purchased and white table cloths to be introduced to provide contrast to the timber tables and floor of similar colour. The same staff sourced other research information and introduced a fish tank of colourful fish displayed in the dining room. Management said the changes has resulted in care recipients being more calmer, are independently eating and consuming more of their meal. Data results showing reduced incidents of behaviour and less use of supplements. 4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Management with the support of the organisation has systems to identify and comply with all relevant legislation, regulatory requirements, professional standards and guidelines in the area of physical environment and safe systems. Refer to expected outcome 1.2 Regulatory compliance for information about the home's systems. Examples of regulatory compliance obligations relevant to Standard 4 Physical environment and safe systems include:  Regular monitoring and maintenance of emergency and essential service systems occurs.  The organisation actively promotes and monitors workplace health and safety.  The home has appropriate infection control and outbreak policies and reporting procedures.  The home has current food premise registration, a food safety program and audit certification by external authorities.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 23 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management has systems to monitor the knowledge and skills of staff to enable them to perform their roles effectively in relation to physical environment and safe systems. Refer to expected outcome 1.3 Education and staff development for details of the home's system and process. Examples of education provided in relation to Standard 4 Physical environment and safe systems include:  chemical training  fire and emergency procedures  food safety  infection control and outbreak 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 The home meets this expected outcome Management and staff are actively working to provide a safe and comfortable environment for care recipients. The home accommodates care recipients with a single bedroom and ensuite. Several rooms have interconnecting doors or designed for bariatric needs. Care recipients have access to various lounge, dining, activity and smaller quiet areas with access to an onsite hairdressing salon and chapel/ cinema room. Outdoor areas include a barbeque gazebo area, sitting areas, paved walkways through gardens and/or views of the surrounding landscape. The home reflects the safety and comfort needs of care recipients including upholstered furniture, decorative features and comfortable temperatures throughout. The home’s layout promotes natural light and has power and water saving devices. The home has systems for the safety, security, maintenance and cleaning of the home. Management monitors the living environment through observations, incident and hazard reporting, quality activities and stakeholder feedback. Care recipients and representatives expressed satisfaction with the comfort and safety of the living environment provided. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome Management and staff demonstrate they are actively working to provide a safe working environment consistent with the organisation’s policy, regulatory requirements and industry guidelines. Staff participate in education for manual handling, emergency response, risks and hazard reporting during orientation and on an ongoing basis. Staff complete environment and

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 24 workplace inspections and participate in occupational health and safety programmes through meetings, designated notice board displays, incident and hazard reporting and safe work practices. Hazardous substances and chemicals are stored safely with current safety data sheets. Staff are aware of their workplace health and safety responsibilities and are satisfied management are providing them with a safe workplace. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome Management and staff actively provide a safe environment and incorporate safety services and practices to minimise fire, security and emergency risks. Maintenance and specialist services regularly service and maintain emergency and firefighting equipment. Egress areas are free from obstruction, exit signage and evacuation maps displayed that generally guide stakeholders to assembly areas. Staff have access to an evacuation kit, a current care recipient list and documented emergency procedures including the management of internal and external threats. The home has keypad security with regular checks of perimeter doors at night. Management utilise stakeholder feedback, internal and external audits and inspections to identify risks. Staff attend mandatory emergency response training when they commence work at the home and on an ongoing basis. Staff expressed knowledge of evacuation procedures and other emergencies and generally if they are the emergency controller. Care recipients are aware of what to do in the event of an evacuation and feel safe living at the home. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home can demonstrate they have an effective infection control program that detects, manages and monitors infections within the home. Infection surveillance is a newly established process and is used to identify any individual or group trends. Staff practice is guided by policies and procedures, the food safety plan and ongoing education. Cleaning schedules are followed throughout the home and contracts are held for pest control and the removal of sharps and infectious waste. Care recipients and staff vaccinations are encouraged and monitored. Monitoring of the effectiveness of the infection control program occurs through audits, infection rates and observation. Stakeholders are satisfied with the way infection control is managed. 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 home meets this expected outcome Hospitality services are provided in a manner to enhance care recipients’ quality of life and the staff working environment. Meals are prepared fresh on site with care recipient’s allergies and special dietary needs considered. Staff compliance with a food safety program ensures all food is stored, prepared and served according to recommended guidelines. An effective communication system ensures care recipients’ dietary requirements and changes are communicated to the kitchen. The results of the consumer experience report show that most

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 25 care recipients were satisfied with the food with a small number expressing mixed comments as to meals and meal service. Management is responding to care recipients’ comments. Cleaning staff follow cleaning procedures and schedules ensuring correct and timely cleaning of care recipients’ rooms, community and staff areas. Laundry staff process all linen and care recipients’ personal clothing on site. Labelling and ironing is available and the monitoring of linen quality and quantity occurs. A small laundry is available for care recipients to do their own laundry. Management monitors hospitality service performance through observation, audits, meetings and stakeholder feedback providing education updates as required. Care recipients and representatives are satisfied with the cleaning and laundry services provided.

Home name: Abbey Gardens Aged Care Dates of audit: 25 July 2017 to 26 July 2017 RACS ID: 3989 26