Riddell Gardens Hostel

RACS ID 3674 10 Spavin Drive SUNBURY VIC 3429

Approved provider: Allity Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 12 March 2020.

We made our decision on 05 January 2017.

The audit was conducted on 06 December 2016 to 07 December 2016. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision 1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met

Home name: Riddell Gardens Hostel RACS ID: 3674 2 Dates of audit: 06 December 2016 to 07 December 2016 Standard 2: Health and personal care

Principles:

Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.

Expected outcome Quality Agency decision 2.1 Continuous improvement Met 2.2 Regulatory compliance Met 2.3 Education and staff development Met 2.4 Clinical care Met 2.5 Specialised nursing care needs Met 2.6 Other health and related services Met 2.7 Medication management Met 2.8 Pain management Met 2.9 Palliative care Met 2.10 Nutrition and hydration Met 2.11 Skin care Met 2.12 Continence management Met 2.13 Behavioural management Met 2.14 Mobility, dexterity and rehabilitation Met 2.15 Oral and dental care Met 2.16 Sensory loss Met 2.17 Sleep Met

Home name: Riddell Gardens Hostel RACS ID: 3674 3 Dates of audit: 06 December 2016 to 07 December 2016 Standard 3: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.

Expected outcome Quality Agency decision 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and Met responsibilities

Standard 4: Physical

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

Expected outcome Quality Agency decision 4.1 Continuous improvement Met 4.2 Regulatory compliance Met 4.3 Education and staff development Met 4.4 Living environment Met 4.5 Occupational health and safety Met 4.6 Fire, security and other emergencies Met 4.7 Infection control Met 4.8 Catering, cleaning and laundry services Met

Home name: Riddell Gardens Hostel RACS ID: 3674 4 Dates of audit: 06 December 2016 to 07 December 2016 Audit Report

Riddell Gardens Hostel 3674

Approved provider: Allity Pty Ltd

Introduction

This is the report of a re-accreditation audit from 06 December 2016 to 07 December 2016 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

 44 expected outcomes

Home name: Riddell Gardens Hostel RACS ID: 3674 1 Dates of audit: 06 December 2016 to 07 December 2016 Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 06 December 2016 to 07 December 2016.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team Team leader: Mary Murray Team member: Gayle Heckenberg

Approved provider details Approved provider: Allity Pty Ltd

Details of home Name of home: Riddell Gardens Hostel RACS ID: 3674

Total number of allocated 74 places: Number of care recipients 69 during audit: Number of care recipients 67 receiving high care during audit: Special needs catered for: No

Street: 10 Spavin Drive City: SUNBURY State: VIC Postcode: 3429 Phone number: 03 9218 5200 Facsimile: 03 9218 5291 E-mail address: [email protected]

Home name: Riddell Gardens Hostel RACS ID: 3674 2 Dates of audit: 06 December 2016 to 07 December 2016 Audit trail

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

Interviews Category Number Acting director of nursing 1 Quality support manager 1 Care managers 2 Registered nurses 2 Care staff 5 Administration assistant 1 Physiotherapist 1 Care recipients 6 Representatives 6 Lifestyle staff 1 Laundry staff 1 Cleaning staff 3 Maintenance staff 2 Occupational health and safety representative 1

Sampled documents Category Number Care recipients’ clinical files 7 Medication charts 3 Lifestyle care plans 7 Incident report files 5 Personnel files 4

Other documents reviewed

The team also reviewed:

 Activity calendars

 Admission checklist

 Advanced care directive

Home name: Riddell Gardens Hostel RACS ID: 3674 3 Dates of audit: 06 December 2016 to 07 December 2016  Allied health and specialist referrals and reports

 Archive lists

 Audit schedule and audits

 Bed pole risk assessments and risk consultation forms

 Care consultation form

 Care recipient handbook

 Catering records

 Comments, complaints and associated documents

 Continuous improvement records and documents

 Education attendance records, evaluation forms and training evaluations

 Emergency management records

 Employee handbook and orientation information

 Incident reporting requirements flip chart

 Infection data collection form, register, reports and trend analysis

 Infection prevention and control quick reference flip chart

 Leisure and lifestyle records and documents

 Letter of compulsory training attendance

 Medication refrigerator temperature monitoring forms

 Meeting minutes and memoranda

 Pest control folder and service reports

 Policies and procedures

 Quality system monitoring documentation

 Scooter and electric wheelchair assessment

 Staff training needs survey and annual learning calendar

 Staff vaccination records

 Weight management reports.

Home name: Riddell Gardens Hostel RACS ID: 3674 4 Dates of audit: 06 December 2016 to 07 December 2016 Observations

The team observed the following:

 Activities in progress

 Clinical equipment, medical and pharmacy stocks

 Equipment and supply storage areas

 Interactions between staff and care recipients

 Internal and external living environment

 Meal and refreshment services

 Medication round in progress

 Noticeboards and information displayed

 Nurse initiated medication box and list

 Palliative care trolley and resources

 Secure archive area

 Short observation during lunch service

 Spill kits

 Storage of medications.

Home name: Riddell Gardens Hostel RACS ID: 3674 5 Dates of audit: 06 December 2016 to 07 December 2016 Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

The home actively pursues continuous improvement across the Accreditation Standards to improve its effectiveness and enhance the lives of care recipients. Management promotes the continuous improvement system to care recipients on entry to the home, seek feedback at meetings and undertake surveys. A separate ‘Resident Committee’ chaired and run by care recipients periodically meets with management to raise ideas and give additional feedback. Staff log suggestions, track progress and monitor levels of satisfaction with outcomes. Meeting minutes, notice boards and newsletters inform people of continuous improvement activities. Care recipients, representatives and staff said they are encouraged to raise opportunities for improvement and are satisfied continuous improvement activities occur within the home.

Examples of improvement activities implemented by the home in relation to Standard 1 -Management systems, staffing and organisational development include:

 Management has reviewed the orientation pack for staff to include a suite of competencies and additional resources for care staff. Nursing staff oversee the training of care staff and assess their skills in taking blood pressures, blood glucose levels and the safe administration of medication. Staff said they keep their skills up to date through annual refreshers and felt the additional skills enable them to give timely information to the nursing team when they undertake clinical reviews.

 To ensure staff and management have appropriate information to perform their roles, corporate services have developed a quality management system to filter and disseminate information. Documents typically distributed via the system include policy updates, revised forms, industry alerts, information from peak bodies, government communiques, coronial reports and product recalls. Management said the system is easy to navigate and it ensures everyone has access to relevant and accurate information.

Home name: Riddell Gardens Hostel RACS ID: 3674 6 Dates of audit: 06 December 2016 to 07 December 2016 1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings

The home has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home receives notifications and information on updates to legislative requirements from peak bodies and via government communiqués. Management distributes information in line with the home’s reporting structure and make items available to staff and care recipients via meetings, memoranda and noticeboards. Monitoring of regulatory compliance occurs through audits and incident analysis. Staff said management informs them of legislative and regulatory updates and changes relevant to their role.

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

 The home has a system to ensure staff, volunteers and relevant contractors comply with police certificate clearance requirements.

 Policies guide staff in maintaining the privacy and confidentiality of documents, including their safe retention and secure destruction.

 Management informed care recipients of the Accreditation audit within the required timeframe.

1.3 Education and staff development

This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings

Management and staff have the appropriate skills and knowledge to perform their roles effectively. Corporate and site specific education calendars are developed and updated on a routine basis. Identification of education is through an annual training needs analysis, staff appraisals, feedback and observation. Staff access and complete e-learning modules and attend annual compulsory training. A training room and resources are available to provide onsite training programs. Management monitors attendance at education and the program’s effectiveness through audits, evaluations, competencies and observation of practice. Care recipients and representatives are satisfied with the knowledge and skills of staff and management.

Recent education relating to Standard 1 - Management systems, staffing and organisational development includes:

 aged care funding instrument training

Home name: Riddell Gardens Hostel RACS ID: 3674 7 Dates of audit: 06 December 2016 to 07 December 2016  bullying and harassment

 electronic care documentation training

 oxygen cylinder equipment use.

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

Management has a system to encourage comments, complaints and feedback from care recipients, representatives and other interested parties. Information packs distributed to care recipients and representatives outline the comments and complaints process. The right to complain and take action to resolve disputes is emphasised on entry to the home. Staff are aware of their role in actioning comments and complaints. Management is readily accessible, have an open door policy and act on verbal and informal feedback. Staff log comments and complaints to ensure timely follow-up of issues and monitor items for resolution as required. Care recipients and representatives said they feel comfortable giving feedback and are satisfied with the responsiveness of staff and management.

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 has documented the organisation’s vision and commitment to quality.

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’s human resource management system ensures sufficient and appropriately skilled staff deliver services in accordance with the Accreditation Standards and the home’s goals. Position descriptions outline the skills, qualifications and scope of practice relevant to each role. New staff participate in an orientation program and receive ongoing support and mentoring. The organisation monitors the training needs and professional development goals of management and staff on an ongoing basis. The roster is reviewed as care recipients’ needs change. Staff said there are processes for the replacement of planned and unplanned

Home name: Riddell Gardens Hostel RACS ID: 3674 8 Dates of audit: 06 December 2016 to 07 December 2016 staff absence. Care recipients, representatives and staff are generally satisfied with human resource management.

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 has a system to ensure equipment and consumables are available for quality service delivery. Key personnel monitor stock levels and the home has stock rotation and re- ordering processes. Staff monitor equipment for its safety and undertake regular maintenance and cleaning of items to ensure they remain fit for purpose. There is a maintenance program to support both planned and reactive maintenance processes. New equipment is trialled to ensure it meets care recipient and staff needs. Equipment, supplies, medications, chemicals and perishable goods are stored appropriately and securely. Staff and care recipients said there are sufficient supplies and equipment for their needs.

1.8 Information systems

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

Team’s findings

The organisation and home has processes to ensure an effective information system is in place. An electronic care documentation system provides staff with access to current clinical information. Regular meetings, email communication, newsletters and memoranda provide effective distribution of information. Formal reviews of policies and procedures occur to ensure information remains relevant and current. Information technology systems are ‘backed up’ routinely and an on line intranet provides staff with further resources and support. Information is archived and stored securely. Staff said they have access to information required to perform their roles. Care recipients and representatives said they receive sufficient information regularly.

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

External service providers work with the organisation to deliver services consistent with the needs of the organisation. A maintenance management company contracted to the home co- ordinates, subcontracts and manages all preventative, planned and ad hoc maintenance tasks. A centralised procurement department manages other contractor arrangements, appointing preferred suppliers via service agreements. Agreements outline the scope and standard of work and regulatory compliance requirements. Management regularly reviews

Home name: Riddell Gardens Hostel RACS ID: 3674 9 Dates of audit: 06 December 2016 to 07 December 2016 the ability of external suppliers to deliver on the home’s requirements and quality expectations. A process exists to monitor non-conformance with contractual arrangements and resolve disputes. Staff and care recipients are satisfied with the products and services currently supplied to the home by external providers.

Home name: Riddell Gardens Hostel RACS ID: 3674 10 Dates of audit: 06 December 2016 to 07 December 2016 Standard 2 – Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team.

Team’s findings

The home has a continuous improvement system that demonstrates ongoing improvement in care recipient health and personal care. For a description of the system refer to Expected outcome 1.1 Continuous improvement.

Examples of recent improvements relating to Standard 2 - Health and personal care include:

 Attendance at a wound management conference prompted staff to develop a guideline on appropriate selection of wound products. The guideline recommends the best product for each particular wound type in line with current evidence based practice. Registered nurses monitor staff’s adherence to the guideline and said it is being consistently followed by staff.

 A staff survey identified an opportunity to improve palliative care practices. Staff identified having a palliative care ‘box’ on each unit was unnecessary and the boxes did not provide any resources for visiting families. A proposal to re-purpose a medication trolley into a single mobile palliative care kit was endorsed by staff. The trolley, which can be positioned discretely in the care recipient’s room, provides easy access to items staff require and now includes an ‘overnight bag’ for visiting families with items such as toothbrushes and toothpaste.

2.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”.

Team’s findings

Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines in relation to health and personal care.

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

 Registered nurses manage medications and specialised nursing care.

Home name: Riddell Gardens Hostel RACS ID: 3674 11 Dates of audit: 06 December 2016 to 07 December 2016  Medication administration and storage is in accordance with legislative requirements and staff’s scope of practice.

 There is a system for recording, reporting and managing unexplained care recipient absences.

Team’s findings

Refer to Expected outcome 1.3 Education and staff development for a description of the system. Management and staff have the skills and knowledge to provide appropriate health and personal care.

Recent education and staff development relating to Standard 2 - Health and personal care include:

 catheter care

 medication management competency assessment

 Parkinson’s disease

 pressure injury prevention and care.

2.4 Clinical care

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

Team’s findings

Management demonstrates there is a system for ensuring care recipients receive appropriate clinical care. An initial transition assessment and care plan provides information to staff on care recipients’ health care needs on entry to the home. Comprehensive charts and assessments are completed according to scheduled timeframes. Care plans are developed and contain detailed information to guide staff practices with reviews occurring three monthly and as care needs alter. Nursing staff communicate with medical practitioners, specialists and allied health professionals routinely and conduct care consultations with family members as required. Management assists nursing staff in their clinical practice by providing current policies, guidelines, resources and equipment. Care recipients and representatives are satisfied with the clinical care provided by the home.

Home name: Riddell Gardens Hostel RACS ID: 3674 12 Dates of audit: 06 December 2016 to 07 December 2016 2.5 Specialised nursing care needs

This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.

Team’s findings

Care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. Consultation occurs with medical practitioners and specialists with recommended advice and treatments documented on care plans to provide staff with current information. Visiting specialists and services to the home include a dietitian, speech pathologist and palliative care team. Nursing staff have access to relevant equipment and complete appropriate training to support their clinical practice. Care recipients and representatives said regular treatments are provided and attendance at specialist appointments occur when necessary.

2.6 Other health and related services

This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.

Team’s findings

Care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences. Visiting services include physiotherapy, optometry, audiology, podiatry and dementia advisory specialists. Staff assist care recipients to attend external appointments to additional health specialists when necessary. Regular consultation occurs with medical practitioners and representatives regarding recommended treatments. Care recipients and representatives are satisfied with the access provided by the home to health related services.

2.7 Medication management

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

Team’s findings

Management and staff demonstrate there is a system to ensure care recipients’ medication is managed safely and correctly. Nursing and care staff administer medications from multi-dose packs. All medications have secure storage according to required regulations and legislation. Policies and procedures provide staff with additional guidelines alongside annual medication competencies to support their practice. Medication charts reflect current photographs, allergies and special instructions for administration. Staff report medication incidents as they occur and management follow up and analyse all incidents for resolution. The medication advisory committee meets regularly to discuss adverse events, pharmacy anomalies, medication errors and audit results. Care recipients and representatives said medications are administered regularly and within a timely manner.

Home name: Riddell Gardens Hostel RACS ID: 3674 13 Dates of audit: 06 December 2016 to 07 December 2016 2.8 Pain management

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

Team’s findings

Management and staff ensure all care recipients are as free as possible from pain. Staff gather past history information and on entry record and monitor individual pain experiences. Once assessment occurs, information on strategies to assist with providing pain relief is detailed on care plans including heat therapy, massage, skin stimulation therapy, exercise and repositioning. Evaluation of care recipients’ pain management occurs when pain medications are altered or ceased and when new pain is reported. Medical practitioners are consulted regularly regarding pain relief measures. Care recipients and representatives are satisfied staff respond to pain management matters effectively.

2.9 Palliative care

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

Team’s findings

Management and staff ensure the comfort and dignity of terminally ill care recipients is maintained. On entry to the home there are opportunities to discuss advanced care directives to assist with identifying specific end of life wishes. As care recipients enter the palliative phase a palliative care plan provides details to ensure staff maintain and provide all comfort measures. Consultation with the medical practitioner and an external palliative care team occurs for further advice as required. Staff respect individual cultural and spiritual aspects of care and provide emotional support to care recipients and representatives. Palliative care equipment and resources are used for minimising pain, to maintain comfort and to reflect care recipients’ end of life preferences.

2.10 Nutrition and hydration

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

Team’s findings

The home has a system to ensure care recipients receive adequate nourishment and hydration. Staff document information on individual dietary requirements, menu choices and personal preferences and complete an assessment using a risk management approach. Additional information informs staff regarding care recipient preferences on location for meals and any assistance required. Meal and refreshment services are available throughout the day and a varied menu offers choices and options. Monitoring of weight occurs monthly to assist with identifying unplanned weight loss or gain. A visiting dietitian and speech pathologist provide advice on modified food and fluids, supplements and instructions regarding meal management. Care recipients and representatives are satisfied with the meals and refreshments provided on a daily basis.

Home name: Riddell Gardens Hostel RACS ID: 3674 14 Dates of audit: 06 December 2016 to 07 December 2016 2.11 Skin care

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

Team’s findings

Care recipients’ skin integrity is consistent with their general health. Information is gathered using a risk management approach with details entered on to a care plan to assist staff in their approach to care delivery. A visiting podiatrist provides routine foot care services at the home. Nursing staff complete wound management information and record treatment plans and photographs to monitor, support and maintain skin integrity. A visiting wound care consultant provides further advice on chronic wounds if necessary. The incident reporting system monitors skin tears, pressure areas and wounds with information analysed and discussed at quality and staff meetings. Care recipients and representatives are satisfied with the skin care provided.

2.12 Continence management

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

Team’s findings

Management demonstrates there is a system to ensure care recipients’ continence is managed effectively. Staff complete charts and an assessment to assist in identifying individual toileting patterns, necessary support and types of continence aids and devices required. Equipment and resources are available for additional care needs and continence and technical care plans reflect individualised programs. Staff report on infections as they occur with information forwarded to management for recording on a register with results discussed at quality and staff meetings. Care recipients and representatives are satisfied staff attend to continence requirements in a timely manner.

2.13 Behavioural management

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

Team’s findings

Management and staff ensure the needs of care recipients with challenging behaviours are managed effectively. Care recipients with a diagnosis of cognitive impairment and presenting with responsive behaviours live within the community of the home. Prior history information and a range of assessments identify behaviours of concern. Care plans include possible causes of behaviours and provide staff with individualised strategies to assist in meeting care needs. Consultation with the medical practitioner and dementia advisory services occurs when necessary for further advice. Care recipients and representatives said staff attend to matters as they arise in a respectful and timely manner.

Home name: Riddell Gardens Hostel RACS ID: 3674 15 Dates of audit: 06 December 2016 to 07 December 2016 2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings

Management demonstrates optimum levels of mobility and dexterity are achieved for all care recipients. On entry a physiotherapist assesses individual mobility and transfer needs incorporating a risk management approach. A care plan provides staff with detailed information on a range of strategies, equipment and aids used to maximise functional ability. Monitoring of individuals experiencing multiple falls occurs and a physiotherapist conducts a reassessment post falls. Staff report falls regularly with all incidents forwarded to management for follow up and reviews. Discussion and analysis of incidents occurs at quality and staff meetings. Care recipients and representatives are satisfied with the range of programs offered by the home to maintain mobility.

2.15 Oral and dental care

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

Team’s findings

Management and staff demonstrate care recipients’ oral and dental health is maintained. Staff document prior history information and complete an assessment to identify any gum, teeth and mouth anomalies. A care plan contains details on the frequency of oral care and any staff assistance required. A mobile dentist provides services at the home and staff assist with dental mechanic appointments when necessary. Treatments are provided for mouth and gum problems in consultation with the medical practitioner. Mouth care products are routinely replaced. Care recipients and representatives are satisfied oral hygiene is provided on a regular basis.

2.16 Sensory loss

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

Team’s findings

Care recipients’ sensory losses are identified and managed effectively. A range of assessments identify any concerns with communication, vision, hearing, taste, touch and smell. Care plans inform staff of communication strategies and assistance necessary for the care, application, cleaning and storage of vision and hearing aids. A variety of sensory items are provided including large print books, large television screens, large sized puzzles and large lettered notices. Staff conduct regular audits to ensure the environment is uncluttered. Care recipients and representatives are satisfied they are supported by staff regarding the use of any sensory aids.

Home name: Riddell Gardens Hostel RACS ID: 3674 16 Dates of audit: 06 December 2016 to 07 December 2016 2.17 Sleep

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

Team’s findings

Management and staff assist care recipients to achieve natural sleep patterns. Staff document prior history information and use an assessment to identify contributing factors that add to individuals not achieving restful sleep. A care plan contains details on preferences for rising and retiring times, room temperature, lighting and comfort measures. Staff offer a combination of sedatives, warm drinks, snacks, heat therapy and massage to assist with sleep. Care recipients said the home is quiet at night and they generally sleep well.

Home name: Riddell Gardens Hostel RACS ID: 3674 17 Dates of audit: 06 December 2016 to 07 December 2016 Standard 3 – Care recipient lifestyle

Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.

Team’s findings

The home has a continuous improvement system that demonstrates ongoing improvement in care recipient lifestyle. For a description of the system refer to Expected outcome 1.1 Continuous improvement.

Examples of recent improvements relating to Standard 3 - Care recipient lifestyle include:

 The home supports a small group of care recipients to take a holiday each year. The overnight trips are to the care recipients’ preferred destinations, including Philip Island and Echuca. Further to recent care recipients’ feedback, the home is starting to run ‘women only’ and ‘men only’ trips. Management has also purchased a new trailer to ensure staff can bring any additional equipment and mobility aids without taking away from space in the bus for care recipients.

 Lifestyle staff said care recipients are very keen on craft and art activities. A number of volunteers run sewing, scrap booking, beading and drawing classes each week. The classes became so busy; a separate activity was introduced for art lovers on a different day. Staff subsequently organised an ‘Art cocktail party’ inviting the local community to visit and purchase art works. Care recipients said it was a great event.

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

Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines in relation to care recipient lifestyle.

Examples of regulatory compliance relating to Standard 3 - Care recipient lifestyle include:

 Management maintains a register for incidents of alleged elder abuse and compulsory reporting.

Home name: Riddell Gardens Hostel RACS ID: 3674 18 Dates of audit: 06 December 2016 to 07 December 2016  Care recipients’ agreements include information regarding privacy and confidentiality, specified care and services, rights and responsibilities and security of tenure.

 The ‘Charter of care recipients’ rights and responsibilities’ are on display and included in the care recipients’ handbook.

Team’s findings

Refer to expected outcome 1.3 Education and staff development for a description of the system. Management and staff have the skills and knowledge to provide appropriate lifestyle support to care recipients.

Recent education and staff development relating to Standard 3 - Care recipient lifestyle includes:

 dementia - care recipients and representatives

 lifestyle certificate course

 lifestyle seminar attendance

 mandatory reporting.

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

Care recipients receive initial and ongoing emotional support during their transition to living in the home. Prior to entry care recipients and representatives tour the home and are provided with information outlining key aspects of living in residential care. On entry, staff assist them to orientate to the home and facilitate introductions to other care recipients and staff. In consultation with the care recipient or representative, staff identify specific emotional needs and outline how to meet these needs in care plans. Staff consider other opportunities to provide emotional support as needs change, during care plan reviews and at times of grief, loss or emotional distress. Visiting ministers provide additional emotional support as required. Care recipients and representatives are satisfied with the emotional support care recipients receive.

Home name: Riddell Gardens Hostel RACS ID: 3674 19 Dates of audit: 06 December 2016 to 07 December 2016 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

Management and staff assist care recipients to optimise their independence, maintain friendships and participate in life within the home and in the wider community. In consultation with the care recipient or representative, staff identify strategies to support each person’s physical and social independence and develop care plans outlining identified needs. Staff consider care recipient independence as needs change, during care plan reviews and when care recipients change their preferences. Referrals to allied health practitioners occur and staff provide assistive aids to enable care recipients to optimise their independence in mobility, during meals and communicating and participating in leisure activities. Care recipients and representatives are satisfied with the way staff assist 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

Management and staff ensure each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Information packs and agreements outline rights to privacy, dignity and confidentiality. In consultation with the care recipient or representative staff identify each person’s wishes for privacy in respect to personal space, the delivery of care and ways staff can support their wishes. Care recipients are encouraged to personalise their rooms and are free to welcome guests at any time. Staff provided examples of upholding privacy and dignity and care recipients and representatives said staff respect wishes for privacy and provide care in a way that supports 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

Care recipients are encouraged and supported to participate in a wide range of activities and provide input into the development of the activity program. In consultation with the care recipient or representative, staff identify each person’s interests and activity goals and develop care plans outlining their choices. Staff consider the suitability of each care recipient’s activity program, as care needs change, during scheduled reviews and when care recipient’s preferences change. Staff and volunteers deliver group and individual activities using a person centred care model. We observed staff supporting care recipients to engage

Home name: Riddell Gardens Hostel RACS ID: 3674 20 Dates of audit: 06 December 2016 to 07 December 2016 in activities. Care recipients said they particularly enjoy art and craft classes and learning how to use the computer.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings

Management and staff value and foster each care recipient’s interests, customs, beliefs and backgrounds. In consultation with the care recipient or representative staff identify cultural and spiritual practices and outline these in care plans. Staff review and update care plans in response to care recipients’ changing wishes and at scheduled reviews. Visiting religious leaders provide spiritual support and guidance to care recipients as requested and regular religious services occur. The organisation celebrates cultural events and days of significance throughout the year. Care recipients and representatives said staff support each person’s cultural and spiritual beliefs and assist them to practice their faith.

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

Staff actively support care recipients to make informed choices about the services they receive. Care recipients are free to exercise control over all aspects of their lifestyle in line with their preferences, unless the rights of others are infringed. Care plans reflect choices in relation to their care delivery and life more broadly within the home. Staff update care plans in response to changes in care recipients’ wishes and at scheduled reviews. Care recipients are free to nominate an advocate or representative to act on their behalf if they choose to do so. Staff are aware of individual preferences and care recipients and representatives are satisfied staff respect choices and decisions.

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

Care recipients have secure tenure within the residential care service, and understand their rights and responsibilities. Prior to and on entry, information brochures, a handbook and agreements provide care recipients and representatives with details regarding tenure, fees and services, accommodation and rights and responsibilities. Consultation occurs regarding proposed room or home relocation when required. Meetings and newsletters provide further

Home name: Riddell Gardens Hostel RACS ID: 3674 21 Dates of audit: 06 December 2016 to 07 December 2016 communication. Care recipients and representatives said they receive information as changes occur.

Home name: Riddell Gardens Hostel RACS ID: 3674 22 Dates of audit: 06 December 2016 to 07 December 2016 Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

Team’s findings

The home has a continuous improvement system that demonstrates ongoing improvement in physical environment and safe systems. For a description of the system refer to Expected outcome 1.1 Continuous improvement.

Examples of recent improvements to Standard 4 - Physical environment and safe systems include:

 The home’s catering staff have taken a customer focussed approach to ensuring all care recipients are satisfied with meal selection and quality. Meals are prepared fresh each day, avoiding the need to reheat meals and ensuring a high quality, appetising meal is delivered each time. The chef personally takes meal orders each morning and where a care recipient does not like the meal, the chef will offer a substitute protein or vegetable selection or prepare an alternative meal. Care recipients said meals are very good.

 The home provides staff with a flip chart style quick reference guide for the prevention and control of infections. The guide provides definitions of common infections, their cause and method of transmission, together with strategies to manage their occurrence. Management has also purchased hands free automatic antibacterial dispensers to encourage hand hygiene prior to entering dining rooms as an additional strategy for reducing the likelihood of any infection spreading within the home.

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

Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance system and processes. Policies, procedures and guidelines demonstrate compliance with legislation and regulatory requirements, professional standards and guidelines about physical environment and safe systems.

Home name: Riddell Gardens Hostel RACS ID: 3674 23 Dates of audit: 06 December 2016 to 07 December 2016 Examples of regulatory compliance relating to Standard 4 - Physical environment and safe systems include:

 The kitchen has a current food safety plan and certifications by external authorities.

 External contractors maintain essential services according to legislative requirements and provide appropriate records.

 Chemical storage is secure and current safety data sheets are accessible.

Team’s findings

Refer to expected outcome 1.3 Education and staff development for a description of the system. Management and staff have the knowledge and skills to perform their roles effectively in relation to the physical environment and safe systems.

Recent education and staff development relating to Standard 4 - Physical environment and safe systems includes:

 chemical training

 fire evacuation training

 manual handling

 slips and trips.

4.4 Living environment

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

Team’s findings

Management is actively working towards providing a safe and comfortable living environment, which meets the needs of care recipients. Living areas are spacious and appropriately furnished. There are several communal and private places for people to gather or spend some quiet time alone. A hairdresser is on site and the lifestyle team coordinate local shops to set up stalls so care recipients can purchase incidentals. Cleaning processes ensure a clean environment and maintenance staff address any repair needs. Environmental audits provide ongoing reviews of the living environment. Care recipients and representatives said it is a pleasant home to live in or visit.

Home name: Riddell Gardens Hostel RACS ID: 3674 24 Dates of audit: 06 December 2016 to 07 December 2016 4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings

Management is actively working to provide a safe working environment and meet its regulatory requirements. At orientation and on an ongoing basis staff receive information and training to promote a safe workplace and safe work practices. Processes for identifying risks to staff safety include, incident reports, audits and workplace safety alerts. Designated safety representatives discuss occupational health and safety at scheduled meetings and are actively engaged in promoting the safety of colleagues. Staff said they are satisfied with the level of occupational health and safety within the home.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".

Team’s findings

Management and staff are actively working to promote safety and provide a care and work environment that minimises the risk of fire, security breaches and other emergencies. Staff undertake emergency training and evacuation drills. The home is equipped with security and smoke detection systems, sprinklers and other fire-fighting and emergency equipment. Scheduled servicing of fire and emergency equipment occurs and flammable substances are stored safely and securely. Management and staff are trained in the actions to take in the event of an emergency and on hearing an alarm. Care recipients are reminded of what to do in the event of an alarm on an ongoing basis and participate in evacuation drills.

4.7 Infection control

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

Team’s findings

Management demonstrates the home has an effective infection control program. Staff complete infection control learning modules and hand washing competencies annually, and personal protective equipment is provided for all staff. Management monitors infections analyse data to identify trends, and determine suitable interventions. Management records on a register and surveillance form the treatment and resolution of infections. There are designated procedures in the event of an infectious outbreak, including notification to relevant authorities. Contractors conduct routine pest control management. Staff access hand washing stations and hand sanitising units throughout the home and management offer care recipients and staff participation in an annual influenza vaccination program.

Home name: Riddell Gardens Hostel RACS ID: 3674 25 Dates of audit: 06 December 2016 to 07 December 2016 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

Staff provide hospitality services in a way that enhances care recipients’ quality of life. A seasonal, rotating menu developed in consultation with care recipients and a dietitian incorporates care recipient preferences and dietary requirements. Laundry services ensure personal items are well cared for and a labelling process minimises lost clothing. Cleaning staff follow documented schedules and respond to unscheduled requests in a timely manner. Staff described procedures relevant to their role, complete appropriate training courses and are satisfied with their work environment. Care recipients and representatives were complimentary of the quality of the catering, cleaning and laundry services.

Home name: Riddell Gardens Hostel RACS ID: 3674 26 Dates of audit: 06 December 2016 to 07 December 2016