Published Decision (SA and RA) s3

St Vincent's Aged Care

RACS ID: 7797 Approved provider: Catholic Homes Incorporated Home address: 224 Swan Street West GUILDFORD WA 6055

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 02 August 2020. We made our decision on 14 June 2017. The audit was conducted on 23 May 2017 to 24 May 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: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 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: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 3 Audit Report

Name of home: St Vincent's Aged Care RACS ID: 7797 Approved provider: Catholic Homes Incorporated Introduction This is the report of a Re-accreditation Audit from 23 May 2017 to 24 May 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: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 4 Scope of this document An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 23 May 2017 to 24 May 2017. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014. Details of home Total number of allocated places: 66 Number of care recipients during audit: 59 Number of care recipients receiving high care during audit: 59 Special needs catered for: Nil specified.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 5 Audit trail The assessment team spent two days on site and gathered information from the following: Interviews

Position title Number

Facility manager 1

Operational and executive managers 7

Clinical and registered nurses 2

Care staff 12

Administration assistant 1

Catering staff 2

Care recipients/representatives 12

Physiotherapists 2

Occupational therapists 2

Therapy staff 3

Laundry staff 1

Cleaning staff 2

Maintenance staff 1

Sampled documents

Document type Number

Care recipient agreements 2

Care recipient files 6

Medication charts 6

Personnel files 7

Treatment records and weight charts 17

Other documents reviewed The team also reviewed:  Accident, incident and hazard forms  Activity program, evaluations and therapy statistics

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 6  Agency orientation and staff handbook  Archive system and records  Audits, surveys, reports and actions  Care recipient information handbook and package  Comments and complaints file  Continuous improvement plan and ‘Have Your Say’ forms  Corrective and preventative schedule and maintenance records, inspection reports and cleaning schedules  Fire equipment, systems maintenance records and emergency manuals  Food safety manual, menus, refrigeration and food temperature record  Infection control and vaccination records  Life story books  Managers monthly report, including clinical indicators  Medical practitioner records  Medication registers  Meetings minutes, memoranda and communication books  Performance appraisal matrix and professional staff registration matrix  Police certificates and visa matrix  Policies and procedures  Position descriptions and duty statements  Referrals to other health professionals  Regulatory compliance file  Smoking risk assessments and self-medicating authority  Staff rosters, allocation sheets and staff training and orientation records  Training matrix and medication competencies. Observations The team observed the following:  Access to internal/external and advocacy information and secure suggestion box  Activity calendars displayed and activities in progress  Care recipients’ appearance, and interactions between staff and care recipients  Cleaning in progress  Equipment and supply storage areas, including clinical equipment and oxygen cylinders  Fire prevention and fire-fighting equipment  Information displayed for care recipients, representatives and staff including notices regarding the re-accreditation audit  Living environment

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 7  Meals and refreshment services, including staff assisting care recipients as required  Medication round  Mission, vision and values statements and Charter of care recipients’ rights and responsibilities displayed  Short group observation of an activity in the communal area  Storage of medications.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 8 Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The organisation actively pursues continuous improvement. Ideas for improvement originate from external sources and from within the organisation. The home ensures all stakeholders are aware of, and can contribute to, improving care and services. Continuous improvement is a standing agenda item at all meetings. Mechanisms feeding into the improvement process and where appropriate the continuous improvement plan, include ‘Have Your Say’ forms, accidents and incidents, hazards, feedback from meetings and surveys, results of audits and clinical data. Clinical indicators and other feedback are analysed and trends noted, staff are informed of results through memoranda, noticeboards and at meetings and data is discussed at corporate meetings. Staff, care recipients and representatives reported awareness of the continuous improvement process and provided feedback on completed improvements. Recent improvements undertaken or in progress relating to Standard 1 – Management systems, staffing and organisational development are described below.  Following a review of the organisation’s values and rebranding to refresh and redirect the organisation’s culture and support the ‘care with purpose’ philosophy, management identified an opportunity to review the feedback form. Management identified the form included information for management only and by removing this information made the form less cumbersome to complete. In addition, new feedback boxes located in the entrance are more visible and, as a result, documentation showed an increase in feedback forms had occurred. Management reported, and documentation reviewed showed, some of this feedback had resulted in improvements for care recipients and staff.  The organisation identified an opportunity to improve the leadership skill for managers by providing education and workshops across the group. Management reported, and documentation reviewed showed, a series of training intervention provided staff with management techniques to support the leadership and management of the group. Documentation reviewed showed good attendance and management reported formal evaluation of this program will occur once all workshops are completed. 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: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 9 Team’s findings The home meets this expected outcome The organisation has systems to ensure the home complies with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation receives updates on legislative and regulatory changes from the industry peak body and government sources. Head office notifies the home of any changes, and staff receive information as required in memoranda, notices, at meetings and via training sessions. Changes to procedures in line with legislation occur as required. The home ensures the provision and monitoring of statutory declarations and police certification for new and existing staff, volunteers and contracted professionals. Management monitors staff registrations. Staff and care recipients advised they receive information concerning compliance requirements as needed and complied with these. Care recipients reported management informed them of the re-accreditation visit by letter and at a meeting. 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The organisation ensures management and staff have the knowledge and skills to perform their roles effectively. An interview process, orientation, education, job descriptions, employee handbook and staff appraisals support recruitment processes. Mandatory training is undertaken and a training schedule is developed from information gathered through questionnaires, appraisals, feedback from meetings, staff suggestions, care recipient feedback and in response to regulatory requirements. Staff reported satisfaction with training and are confident they have the skills to perform their roles effectively. Care recipients and representatives reported management and staff are skilled, knowledgeable and effective in their roles. Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below.  Catholic care values  Corporate orientation  Leadership training. 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome There are processes to ensure care recipients and their representatives have access to internal and external complaints mechanisms. ‘Have Your Say’ forms are accessible in the lobby, as are brochures for external complaints processes. Care recipient welcome packs and agreements outline avenues for complaints, and care recipient and representative meetings encourage feedback with complaints a standing meeting agenda item. Staff are knowledgeable of the complaints mechanisms, and outlined ways they could assist care recipients to complain or make a suggestion. Care recipients and representatives interviewed reported satisfaction with access to comments and complaints mechanisms.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 10 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 home displays its vision, values, philosophy, objectives and commitment to quality in the lobby. Care recipients receive this information when they move into the home via the agreement and welcome pack. Staff are introduced to the organisation’s vision, values, philosophy, objectives and commitment to quality during induction and via employee handbooks. 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 There are processes to ensure employment of appropriately skilled and qualified staff sufficient to meet the needs of care recipients. The facility manager maintains staffing and the skills mix at levels designed to meet the care recipients’ changing care needs. Monitoring and review of staffing levels are through care recipient and staff feedback, audits and surveys and care recipients’ assessed needs. New staff receive orientation to the organisation’s systems, mandatory training and are initially ‘buddied’ with a more experienced staff member. Monitoring of staff practice is through performance appraisals and care recipient feedback. Staff reported they have enough time to do their work and management is receptive to feedback concerning workloads. Management and staff reported the facility manager and clinical staff are on call. Care recipients and representatives generally reported satisfaction with the responsiveness of staff support provided. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The home has systems to ensure stocks of appropriate goods and equipment for quality service delivery are maintained. Designated staff complete orders for supplies to keep optimal levels of stock in the home and regulate stock rotation as required. The organisation has a preferred supplier list and the home uses regular suppliers to maintain the quality of products and services. Staff are consulted about new equipment based on care recipient needs. New equipment is trialled to ensure quality and safety, and staff are trained in the use of all new equipment. There is a preventative and corrective maintenance program for maintaining and checking equipment. Staff stated they have access to appropriate goods and equipment to provide quality service. Care recipients reported the home provides goods and equipment necessary to meet care recipients’ needs. 1.8 Information systems This expected outcome requires that "effective information management systems are in place".

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 11 Team’s findings The home meets this expected outcome The home has effective information management systems. Policies and procedures guide staff in the use, disclosure, storage, back-up, retrieval and destruction of information. The use of memoranda, clinical information, duty statements, handovers, emails, communication books, notices and meetings ensure effective communication. Management utilises information from collated clinical data, hazards and audits to inform staff and improve services. Staff reported they are educated regarding information management and confidentiality at orientation, and they have access to sufficient information to guide their work. Care recipients reported their satisfaction with the home’s information systems. 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 The organisation has systems and processes to ensure externally sourced services meet the needs and goals of the home. A preferred provider list and expected standards for contractors ensure the organisation has its requirements met by service providers. There are processes to monitor indemnity insurance and professional registrations. Management monitors the quality of services via various feedback mechanisms and reported service providers meet outlined expectations. Staff and care recipients reported satisfaction with the standard of externally sourced services.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 12 Standard 2 – Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 2 – Health and personal care, staff record care recipient accidents and incidents, and this information is collated and analysed for trends. Clinical audits are conducted to measure and review the clinical care systems. Care recipients and staff are satisfied the organisation actively promotes and improves care recipients’ physical and mental health. Examples of current or recent improvements in relation to Standard 2 – Health and personal care are described below.  Following feedback from an external health professional, management purchased a device to monitor the amount of distance walked a day for a care recipient living with dementia in order to support behavioural management issues. As a result of the identified care recipient’s refusal to wear the device, another care recipient experiencing the same behaviour trialled the product. The data found the care recipient required additional caloric intake to support the energy used and improved weight was noted. Staff stated they are trialling the device for another care recipient to monitor sleep patterns.  To improve the medication management and process for insulin dependent care recipients, staff reported they implemented a red file to include diabetic management information for staff to have current and easily accessible information to support the compliance of diabetic management for care recipients. Staff stated the red file is easier to find and current information is located in one place improving their knowledge of care recipients and their clinical needs. Care recipients and representatives reported satisfaction with clinical care service. 2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about health and personal care”. Team’s findings The home meets this expected outcome The organisation has systems and processes to identify and ensure the home meets regulatory compliance requirements in relation to care recipients’ health and personal care. Registered staff assess, plan and monitor care for care recipients. Medication is administered and stored in accordance with legislative requirements. Staff reported they are informed about legislation and regulatory compliance requirements at meetings, and through memoranda and education. Care recipients reported they receive information on changes in

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 13 relevant legislation or guidelines. Staff demonstrated knowledge of regulatory compliance issues and reporting requirements. 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 and staff have the knowledge and skills to provide appropriate health and care to care recipients. Refer to expected outcome 1.3 Education and staff development for a description of the system. Examples of education and training related to Standard 2 – Health and personal care are listed below.  Behaviour management  Continence management  Medication training  Palliative care. 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 and timely clinical care. Nursing staff complete comprehensive assessments for each care recipient following moving into the home, annually and as required. Detailed care plans correspond with assessment data and incorporate the preferences of the care recipient. Care plans are amended when a change in care needs is identified and are reviewed six monthly. The home regularly monitors and evaluates the clinical care provided via audits, surveys, incidents data, and staff and care recipient feedback. Staff are guided in the delivery of care by accessible care plans, policies and procedures, handovers, communication books and staff meetings. Staff are knowledgeable of care policies and practices, and reported they generally have sufficient time and resources to meet the care needs of care recipients. Care recipients and their representatives reported they are consulted about care recipients’ plans of care and are complimentary of the clinical care provided at the home. 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 qualified nursing staff meet care recipients’ specialised nursing care needs. Specialised nursing care currently provided at the home includes stoma care, oxygen therapy, complex wound management and diabetes management. Nursing staff assess care recipients’ specialised nursing care needs, develop specialised nursing care plans and document the care delivered. General practitioners are involved in the management of care recipients’ specialised nursing care needs, and external specialist services are accessed as required. Appropriate and sufficient equipment is available to meet care recipients’

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 14 specialised nursing care needs. Care recipients and representatives stated they are satisfied appropriate specialised nursing care is delivered to care recipients. 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 supported to access health and related services of their choice according to their assessed needs and preferences. The home employs physiotherapy and occupational therapy staff and accesses podiatry, dietician, speech pathology, dentistry, optometry, audiology, mental health and specialist nursing services as required. Care recipients choosing to access alternative service providers are assisted to arrange and attend their appointments as necessary. A report of the specialist’s assessment is provided to the nursing staff for actioning, and suggested plans of care are integrated into the care recipient’s care plan. Care recipients and representatives confirmed care recipients are referred to appropriate services when needed. 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 The home has systems and processes to ensure the safe and correct supply, storage, administration and disposal of medications. The home adheres to relevant legislation, regulatory requirements, practice guidelines and professional standards. Nursing staff and medication competent care staff deliver medications to care recipients. Medication profiles identify allergies and instructions for the preparation of medications for administration. The home monitors the medication management system via audits, incident data, pharmacist and general practitioner reviews, and dedicated multidisciplinary meetings. Care staff complete competency-based training and are knowledgeable in their role of administering medications to care recipients. Care recipients and representatives reported they are satisfied with the home’s management of 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 The home’s pain management approach aims to ensure all care recipients are as free from pain as possible. Nursing staff and physiotherapy staff undertake pain assessments on moving into the home and when new pain is identified or reported. The impact of pain on other aspects of the care recipient’s function and well-being are considered during assessment. A validated tool is used to assess pain of those care recipients who may be unable to verbally communicate about their pain. Staff described a range of pharmacological and non-pharmacological pain relieving strategies used including heat therapy, massage, wax baths, electrical stimulation and exercise programs. Pain management interventions are evaluated for their effectiveness. Care recipients and representatives confirmed they are satisfied with how the home manages care recipients’ pain.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 15 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome The comfort and dignity of terminally ill care recipients are maintained through a range of physical, emotional, spiritual and cultural practices followed in line with care recipient preferences. Future care wishes are sought from all care recipients who wish to document them. A palliative register identifies care recipients who are experiencing deteriorating health and general practitioner review and consultation with representatives is initiated. The general practitioner directs the implementation of a palliative care plan in collaboration with nursing staff, the care recipient and their family, and specialist palliative care service providers are accessed as required. Staff are knowledgeable of emotional, spiritual and comfort care measures that may be provided to care recipients at the end of their life. Pastoral care staff are accessible to care recipients and their families on a regular basis and as desired. Care recipients and representatives confirmed care recipients’ comfort and dignity are maintained and their wishes are respected. 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 The home demonstrates care recipients receive adequate nutrition and hydration. Assessment determines care recipients’ food and fluid preferences, factors impacting nutritional intake and assistance required to maintain nutrition and hydration. Care recipient’s preferences are noted in the care plan and a variety of assistive devices are provided to facilitate the care recipient’s intake of food and fluids. Clinical staff monitor monthly weights and care recipients with a two kilogram weight gain or loss are assessed, have appropriate interventions put into place and are referred as appropriate. All care staff attend training on identifying swallowing difficulties and modified diets. The home provides refreshment facilities in various communal areas throughout the home, and additional hydration is provided during warmer months. Care recipients and representatives reported they are satisfied with the home’s approach to 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 The home meets this expected outcome Care recipients’ skin integrity is consistent with their general health. Validated screening tools identify care recipients at risk of impaired skin integrity and a comprehensive skin integrity assessment is undertaken annually. Staff reported various preventative measures to maintain care recipients’ skin integrity including regular repositioning, daily application of emollients, protective and cushioning support of areas prone to pressure, and encouraging mobility. Nursing staff manage wound dressings, and external specialist services are accessed as required. Pressure areas and wounds are monitored and wound care is provided according to documented wound management plans. The home’s approach to skin care is monitored via audits, regular care recipient reviews and analysis of incident data.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 16 Care recipients and representatives reported they are satisfied with the care provided to care recipients in relation to skin integrity. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome The continence of care recipients is managed effectively. A series of assessment tools and records are completed to determine care recipients’ continence needs and monitor the effectiveness of continence management strategies implemented. Assessment considers the functional, medical and behavioural factors that may affect continence. Care plans for maintaining effective continence management are developed and reviewed six monthly and as clinically indicated. There are processes for appropriate continence aid ordering, stock control and supply. Staff receive training on continence management and reported they have adequate supplies to maintain care recipients’ continence needs. Staff described how care recipients’ privacy and dignity are maintained when assisting care recipients with continence needs. Care recipients and representatives reported care recipients’ continence needs are being met. 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 challenging behaviours and the impact of behaviours on other care recipients are managed effectively. Following a settling in period, those care recipients who exhibit behaviours have a behaviour assessment and record completed. Nursing staff review available information and determine a behaviour management plan in consultation with occupational therapy staff. Where strategies implemented are ineffective, referral to the general practitioner is initiated and follow on referral to external specialist services occurs as necessary. Staff reported some environmental modifications have minimised wandering behaviours and their impact on other care recipients. A restraint minimisation approach is adopted, and restraints in place are reviewed six monthly. Staff complete training on providing care to care recipients with challenging behaviours and demonstrated knowledge of a variety of strategies to support care recipients. Care recipients and representatives reported the home meets the care needs of care recipients with challenging behaviours. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome The home has a program to optimise the mobility and dexterity of care recipients. Each care recipient has falls risk, mobility and physiotherapy assessments completed on moving into the home and annually, and a detailed mobility and physiotherapy care plan is developed. Pain management, falls prevention and individual physical therapy programs are offered as appropriate to maintain or improve care recipients’ mobility and dexterity. A variety of physical therapy equipment is available and targeted therapy for non-mobile care recipients occurs. Assistive devices to optimise and maintain mobility and dexterity are provided and

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 17 well maintained. The physiotherapist reviews all care recipients who fall, and incident data is analysed weekly. Staff reported appropriate falls prevention and management strategies. Care recipients and representatives commented they are satisfied the home supports care recipients to achieve optimal 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 The home meets this expected outcome The home has systems to maintain care recipients’ oral and dental health. An oral and dental health assessment is undertaken on moving into the home and annually. Annual domiciliary dental review is offered to care recipients and required actions followed up by the nursing staff in consultation with the care recipient, their family and the general practitioner. There are specific strategies for maintaining the oral hygiene of care recipients with dementia. Oral care equipment is provided to care recipients and replaced regularly. All care recipients are assessed for swallowing difficulty by nursing staff and referred to speech pathology services as indicated. Staff report any change in care recipients’ oral health, eating or oral hygiene practices to nursing staff. Care recipients and representatives confirmed 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 The home identifies and manages care recipients’ sensory losses effectively. Assessments are conducted on moving into the home by nursing and occupational therapy staff addressing all five senses through care recipient history, functional assessment, reading and visual assessments, and observation. Care needs and preferences are detailed on relevant sections of the care plan, including the care and application of sensory aids and individualised strategies to manage sensory loss. Sensory activities on the activities program include cooking, gardening and concerts. Large print and audio books are available to care recipients. Care recipients and representatives confirmed they are satisfied with the home’s approach to managing care recipients’ sensory loss. 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 are supported to achieve natural sleep patterns. A sleep assessment identifies sleep difficulties, routines and preferences. Care recipients with unnatural sleep patterns are monitored and the general practitioner is consulted. Staff reported practices to encourage natural sleep include offering warm drinks, pain management, noise minimisation, providing food and fluids, and attending to continence needs. Care recipients experiencing disturbed sleep patterns have recently commenced having their activity and sleep monitored via an electronic device to facilitate comprehensive investigation of sleep patterns. Analysis of the data is undertaken enabling more targeted and effective measures to be implemented in order to facilitate more natural sleep patterns. Care recipients and representatives confirmed care recipients are supported to achieve natural sleep patterns.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 18 Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement systems and processes. In relation to Standard 3 – Care recipient lifestyle, care recipient and representative meetings and surveys are used to gather feedback and suggestions. Feedback and observations are regularly recorded and evaluated from lifestyle and care activities. Staff can contribute to improvements to care recipient lifestyle through feedback forms, training and networking with external health providers. The home encourages care recipients and their representatives to provide feedback and suggestions in relation to lifestyle. Examples of current or recent improvement in relation to Standard 3 – Care recipient lifestyle are described below.  Following staff and care recipient feedback care recipients would enjoy different experiences as part of the activity program, therapy staff researched ‘things to do in Perth’. As a result of the research, staff arranged for a group of care recipients to experience travelling on a driverless bus around the city. Staff reported the feedback was positive and the care recipients stated they enjoyed reminiscing about places they used to visit and discussing their many memories of past times. This activity may continue based on the feedback process discussed at therapy meetings.  As a result of the home discontinuing the newsletter and the organisation distributing a quarterly newsletter, the home decided to create a Facebook page for care recipients and families to view activities and share information as another form of communication. As a result of the Facebook page, families are kept abreast of news, activities and experiences of the care recipients. Staff reported they had received positive feedback from families regarding this initiative and they would continue to provide information through this technology. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”. Team’s findings The home meets this expected outcome The organisation has systems and processes to identify and ensure the home meets regulatory compliance requirements in relation to care recipients’ lifestyle. Management offer care recipients a residential agreement and conform to security of tenure requirements. Staff reported they are informed about legislation and regulatory compliance requirements at meetings, through memoranda and at education sessions. There is a mandatory reporting register at head office, and staff described reporting requirements for absconding care

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 19 recipients and the procedure in the event of suspected elder abuse. Staff, care recipients and representatives reported they receive information on changes in legislation or guidelines. 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 and staff have the knowledge and skills to provide appropriate knowledge and skills to perform their roles effectively. Refer to expected outcome 1.3 Education and staff development for an overview of the system. Examples of education and training completed relating to Standard 3 – Care recipient lifestyle are listed below.  Care with purpose  Elder abuse  Montessori leaders 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 meets this expected outcome Care recipients receive support in adjusting to life in the new environment and on an ongoing basis. Management and staff welcome and orientate care recipients and their families to the home, and provide verbal and written information regarding the services on offer. Information is gathered from care recipients and their representatives regarding social and life history, personal routines, preferences and specific emotional needs, and this is used to develop care plans. The pastoral care staff are available to have one-on-one time with care recipients who request this or have been identified by staff as potentially benefitting from this service. Medical practitioners refer care recipients to external mental health specialists as required. Care recipients and representatives reported they are satisfied the emotional support provided at the home is effective in meeting care recipients’ needs and preferences. 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 Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Assessments conducted on moving into the home identify the care recipients’ level of assistance required in all activities of daily living, and assistive devices for mobility, hearing, vision and continence, and eating or drinking are provided to assist care recipients to maintain their independence. Care recipients are encouraged to maintain their links with the community by retaining their preferred health professionals, visiting the community or going on the home’s weekly bus trips. Care recipients are assisted to administer their own medication should they wish to and the general practitioner authorises this. Some willing care recipients have small jobs to do

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 20 within the home, such as caring for the resident pet, gardening and collecting papers, and contributing to the daily running of the home. Assistance is given enabling care recipients to vote. Staff encourage and prompt care recipients to do as much for themselves as they are able, in order to maintain independence. Care recipients and representatives reported they are satisfied with the assistance provided by the home in relation to independence. 3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Care recipients’ confidential records are stored securely and only accessible to authorised personnel. Staff sign a confidentiality agreement on commencement of employment. The home has single and shared rooms with communal bathrooms. Staff reported how they maintain care recipients’ privacy and dignity, such as knocking on doors and waiting for an answer, conducting personal care in care recipients’ rooms with the curtains pulled around the bed space, being mindful of when and where discussions are had with or about care recipients, and coordinating one person at a time using the communal bathroom where possible. Care recipients and representatives reported care recipients’ privacy, dignity and confidentiality are respected. 3.7 Leisure interests and activities This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome Care recipients are encouraged and supported to participate in a wide range of activities of interest to them. The occupational therapist assesses new care recipients on moving into the home regarding their social/life history, past and current interests, and develops individual lifestyle care plans. Monthly activity calendars are developed by the lifestyle team according to evaluation forms, therapy statistics and feedback from care recipients. There is a range of internal and external activities provided including cognitive, sensory, physical, social, cultural and individual activities. Staff encourage care recipients to attend activities, however respect care recipients’ right to decline participation. Attendance is documented in order to evaluate care recipients’ participation levels, and representatives are encouraged to attend events and celebrations. Care recipients and representatives interviewed stated care recipients are supported to participate in activities and interests appropriate to their needs and preferences. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome Care recipients’ individual interests, customs, beliefs, and cultural and ethnic backgrounds are respected and fostered. The suite of assessments conducted when a care recipient moves into the home capture information regarding cultural and spiritual life, customs and beliefs. Catholic church services are held weekly and care recipients are supported to attend church services in the community. Memorials are undertaken at the home and funerals can be hosted

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 21 in the chapel. Pastoral care staff are at the home three days per week and as required to offer support to care recipients and staff. Cultural themes and events of cultural or spiritual significance are celebrated at the home including Australia, Polish and Indian Days, Anzac Day, Easter and Christmas. The home has access to multicultural resources and an interpreter service as required. Several care recipients go on outings with volunteers from similar cultural backgrounds. Care recipients and representatives reported they are satisfied the home values and fosters care recipients’ individual customs, beliefs and cultural backgrounds. 3.9 Choice and decision-making This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome Care recipients and their representatives participate in decisions about the services the care recipient receives and are enabled to exercise choice and control over his or her lifestyle. Care recipients and representatives are assisted to participate in decision making about care and service delivery via consultation throughout the assessment and care planning process, case conferences, meetings, surveys and the continuous improvement process. Choice is provided during activities of daily living such as preferred rising/retiring time, choice of clothes, meals and activities, and the care recipient’s right to refuse is respected. Care recipients are encouraged to direct types of activities or location of bus outings they would like to participate in. External advocacy service brochures and posters are displayed at the home. Authorised representatives are consulted if care recipients are unable to make decisions for themselves. Care recipients and representatives reported satisfaction with the opportunities care recipients have to exercise choice and control appropriate to their needs and preferences. 3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Care recipients have secure tenure within the residential care service and understand their rights and responsibilities. On moving into the home, the care recipient or their representative is provided with an agreement that outlines the rights and responsibilities and the security of tenure. The Charter of care recipients’ rights and responsibilities is included in the information booklet for care recipients and is displayed in the entrance to the home. Consultation is undertaken with care recipients and their representatives regarding changes to the provision of services and prior to room transfers within the home or to another residential care service. Care recipients and representatives advised they feel secure in their tenure and are aware of their rights and responsibilities.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 22 Standard 4 – Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. In relation to Standard 4 – Physical environment and safe systems, management and staff undertake environmental inspections and audits and report incidents and hazards. Those reports are collated, analysed for potential trends that require actions for improvement and recorded within a quality register. Staff, care recipients and representatives are encouraged to provide feedback regarding the environment. Mandatory and toolbox training is provided to staff to maintain their skills and knowledge relating to safety. Care recipients and representatives reported they are satisfied the home provides a safe and comfortable environment and their feedback and suggestions about the living environment are considered. Improvements undertaken or in progress in relation to Standard 4 – Physical environment and safe systems are described below.  Following an external consultant review of risk management across the organisation, it was identified the emergency response and resources manual required updating. As a result, facility managers and staff received the revised information and the organisation conducted a mock emergency evacuation of the home using the updated emergency response manual. Feedback received from staff and care recipients was positive and felt prepared if there was to be an emergency at the home. Care recipients interviewed reported feeling safe at the home.  Management and staff reported, to promote the Montessori approach, care recipients were consulted about a buffet style meal service. As a result, a trial buffet breakfast, lunch and dinner service provided care recipients the opportunity to experience a self- serve option whilst other care recipients received the table service. The initial feedback was mixed and staff reported it took them additional time. However, the trial had provided improved socialisation and communication amongst the care recipients. Management reported the buffet option will continue as a choice for care recipients’ meal services. 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 The organisation’s management has systems to identify and ensure ongoing compliance with regulations and legislation relating to the home’s physical environment and safe systems. Staff undertake mandatory training relating to fire and emergency procedures, and external

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 23 contractors undertake scheduled checks of the home’s fire systems. There is a food safety program, and appropriate staff receive training relating to safe food handling. Workplace inspections are carried out, and education relating to workplace safety is provided. There are reporting mechanisms in use for accidents, incidents and hazards ensuring these are investigated and actioned in a timely manner. Staff have access to personal protective equipment, safety data sheets for chemicals used within the home and infection control outbreak guidelines. Health guidelines are followed to minimise the spread of infection. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation to the physical environment and safe systems. For information regarding the home’s systems, refer to expected outcome 1.3 Education and staff development. Examples of education and training completed relating to Standard 4 – Physical environment and safe systems are listed below.  Chemical training  Fire and emergency evacuation  Food safety  Infection control  Manual handling  Occupational health and safety. 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 actively works to ensure care recipients live in a safe, comfortable environment which meets their needs. The environment is comfortable and homely and temperature controlled. Bell entry, keypad locks, sign-in/out books and fire doors provide security. Care recipients have access to communal and quiet areas for social interactions and activities. Environmental audits and inspections are regularly undertaken and actioned, and a maintenance program provides linkage to hazard management. Care recipients and representatives reported feeling safe and comfortable in the home and stated they enjoyed the gardens, decorated corridors, lounge room and dining room spaces. 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

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 24 There are systems and processes to ensure management is actively working to provide a safe working environment that meets regulatory requirements. The occupational health and safety program is directed from head office with three monthly meetings being held for facility representatives and other stakeholders who contribute their relevant expertise. Management, maintenance and occupational health and safety representatives and staff monitor the safety of the working environment using audits, feedback and monitoring mechanisms. Personal protective equipment and safety data sheets are available, and equipment and buildings are subject to routine and preventative maintenance. Staff are made aware of safety management processes through induction and mandatory training, displays and via meetings, and reported management is active in providing a safe working environment. Meeting minutes, hazard forms and memoranda demonstrate the home effectively identifies prospective hazards, informs staff and takes appropriate action. 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 The home has systems and processes to provide a safe environment and to reduce the risk of emergencies, fire and security breaches. Fire security and emergency procedures are available to staff, care recipients and visitors informing them of how to proceed in the event of an emergency. Contracted fire services carry out routine inspections and the testing of fire systems and equipment, and the home acts on any recommendations. Maintenance staff and management monitor electrical equipment coming into the home and electrical tagging is carried out annually or as needed. The building is equipped with fire prevention and fire- fighting equipment. Entry and exit to the home is monitored with sign-in/out books, and entry is via key pad. There are procedures to check doors and windows at night as well as care recipients. Staff attend fire and safety training and are able to report the process in the event of an emergency. Care recipients and representatives reported an awareness of the process to follow should the fire alarm sound. 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 has an effective infection control program that includes policies and guidelines, an infection control consultant, a portfolio holder, preventative measures and management of care recipients’ infections, mandatory training and resources for the management of outbreaks. The home monitors and reviews the infection control program through a system of collecting data on infections, undertaking relevant surveillance and auditing staff practices. Infection trends are analysed, actioned as required and discussed at clinical meetings. Equipment and signage is in use to lessen the risk of infection, and there are facilities for cleaning, disinfecting and sanitising equipment and laundry items. Staff described examples of infection prevention strategies including vaccination programs, hand hygiene, pest control, containment of sharps and food safety controls. 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

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 25 The home provides catering, cleaning and laundry services that enhance the care recipients’ quality of life and staff working environment. The home informs care recipients about hospitality services and dining arrangements via the welcome pack and menus, and feedback mechanisms are available to express satisfaction about the service provided and the manner of their provision. Meals are cooked onsite and the chef obtains and acts on care recipients’ feedback. The menu provides two hot meal options at lunch time and salad or sandwiches. The menu is displayed on a noticeboard daily and a monthly menu is also available. Housekeeping services are provided throughout the week and include cleaning of rooms, general areas and living environment, and laundry services include personal items, whilst linen is washed by an external provider. Laundry staff label and fold clothing and place it in labelled baskets or on hangers. Management monitors the home’s systems via feedback and audits. Care recipients and representatives reported satisfaction with the laundry services and meals, and generally expressed satisfaction with cleaning.

Home name: St Vincent's Aged Care Dates of audit: 23 May 2017 to 24 May 2017 RACS ID: 7797 26