Published Decision (SA and RA) s2

Feros Village Wommin Bay

RACS ID: 0278 Approved provider: Wommin Bay Hostels Ltd Home address: McKissock Drive KINGSCLIFF NSW 2487

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 18 August 2020. We made our decision on 19 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: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 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: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 3 Audit Report

Name of home: Feros Village Wommin Bay RACS ID: 0278 Approved provider: Wommin Bay Hostels Ltd 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: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 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 three registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014. Details of home Total number of allocated places: 70 Number of care recipients during audit: 66 Number of care recipients receiving high care during audit: 58 Special needs catered for: Secure living environment

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 5 Audit trail The assessment team spent two days on site and gathered information from the following: Interviews

Position title Number

Administration assistant 1

Care manager 1

Care recipients/representatives 19

Care staff 6

Catering, cleaning and laundry staff 5

Director of residential and clinical services 1

General manager residential services 1

Hospitality services manager 1

Maintenance staff 1

Operations supervisor 1

Positive Living assistant 1

Positive living coordinator 1

Registered nurses 2

Resident support liaison 1

Volunteers 4

Sampled documents

Document type Number

Care recipients’ files 8

Medication charts 10

Personnel files 5

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 6 Other documents reviewed The team also reviewed:  Activities program  All about me and key to me assessments  Animal admission form and pet care plans  Assessment of resident’s ability to self-medicate  Audit documentation  Call bell response time records  Care manager monthly reports  Care recipient agreement  Care recipients’ admission packs and information handbook  Chemical inventory  Cleaning schedules  Clinical assessment and monitoring charts  Criminal record reports  Diabetic management care plan and blood glucose monitoring  Dietary folders including daily supplement list and dietary preferences  Dietitian’s review  Discharge notes  Duty guidelines and position descriptions  External contractors documentation  Feedback forms  Fire equipment service records  Fire resource folder  Food authority licence  Food safety program  Four week menu  Handover sheets – registered nurse and carer  Hazard logs  Improvement report  Incident accident reports and incident analysis  Infection control surveillance form  Letters, electronic mail and facsimiles  Mandatory reporting register  Meal choice option request forms and meal service records

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 7  Meeting minutes  Memoranda and notices  Nurse initiated medication medical consent  Performance appraisals  Plan for continuous improvement  Policies and procedures  Positive living activity records  Professional registration reports  Reactive and preventative maintenance documentation  Restraint authorisation form  Risk assessments  Roster  Safety data sheets  Self-assessment  Specialised nursing care folder  Staff and care recipient satisfaction surveys  Staff handbook  Staff orientation resource folder  Temperature monitoring records – equipment  Training/education records and learning packages  Ward register of drugs of addiction  Wound assessment and management charts and progress notes Observations The team observed the following:  Activities in progress and activity calendar displayed  Administration and storage of medications  Archive records  Care recipients’ rights and responsibilities on display  Cleaners trolley and colour coded cleaning equipment  Equipment and supply storage areas  Fire equipment and evacuation signage and routes  Hand hygiene stations  Interactions between care recipients, representatives and staff  Internal and external complaints information on display  Internal and external living environment  Kitchen and laundry operations

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 8  Kitchenette areas  Meal and beverage service  Menu on display  Noticeboards and whiteboards  Outbreak kits  Personal protective equipment in use  Shift handover and team handover meetings in progress  Short group observation  Spill kits  Supplies for use in emergency

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 9 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 Feros Village Wommin Bay (the home) actively pursues continuous improvement by seeking feedback from staff, care recipients and representatives through consumer feedback forms, meetings, surveys and an open-door policy with management. The home reviews its processes across the four Standards through audits and surveys and results are monitored by management. Opportunities for improvement and solutions are discussed at management, staff and care recipient meetings and improvement opportunities and objectives are captured on a plan for continuous improvement. Care recipient, staff and clinical data is collected and reviewed on a regular basis through the clinical incident management system and results are communicated either to individuals or via relevant meetings or memoranda to staff. Care recipients/representatives and staff indicated that management are responsive to suggestions for improvement. Improvement initiatives implemented by the home over the last 12 months in relation to Standard 1 Management systems, staff and organisational development include:  Recently, it was identified that the home’s response to care recipients’ requests for housekeeping assistance was often delayed until the hospitality manager was available on site to attend to their concerns. In response, the home increased housekeeping staff and appointed a housekeeping team leader to be responsible for managing cleaning and laundry staff operations, paper work and record keeping. A cleaning schedule template and duty guidelines were developed to assist staff to know how and when to clean care recipients’ rooms, community areas and the laundry. Management stated the team leader effectively manages any staff or care recipients’ concerns and assists the hospitality manager in day to day operations. We observed all areas of the home to be clean and tidy and care recipients interviewed expressed satisfaction with the timeliness of staff response to their requests for assistance.  In response to an identified need for guidance for bereaved family members the home has developed an information sheet to provide information about the steps following the death of a family member including the first few hours after passing, issuing of the death certificate, collection of belongings, donation of clothing/equipment/furniture, a memorial notice, funeral arrangements, celebration of life, final accounts and trust funds. Management stated the information sheet has been well received by family members.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 10 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 meets this expected outcome The organisation’s management has systems to identify and ensure compliance with regulatory requirements. Management has established links with industry groups and government departments to obtain advice about relevant regulatory requirements. When advised of new requirements, the home’s policies and procedures are reviewed and amended as necessary. There is a system to inform staff about mandatory registrations and certificates and a system to monitor that these are current. Training mandated by legislation or regulation is provided and there is a system to monitor staff attendance. Maintenance, inspections and testing mandated by legislation or regulation is incorporated into the home’s maintenance program and there is a system to monitor completion. Mandatory audits are incorporated into the audit program. The home’s systems ensure all staff and volunteers have a current police certificate, registered nurses maintain national registration and medications are managed in accordance with relevant protocols. Care recipients/representatives are notified in advance of Australian Aged Care Quality Agency Re-accreditation audits. 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 Management ensure staff have the required knowledge and skills to perform their roles effectively through recruitment procedures, job specific orientation, and position descriptions. The skills and knowledge needs of staff are monitored through competency based assessments, observation, audits and staff/care recipient feedback. The home supports ongoing education for all staff and structured training and development activities include face-to-face sessions, on-line learning and videos, or training conducted by other agencies. Staff attend annual mandatory training including manual handling, fire safety, infection control and mandatory reporting. Management coordinates in-house education sessions including sessions relevant to the four Aged Care Accreditation Standards. In relation to Standard 1, Management systems, staffing and organisational development, staff have recently attended a leadership conference and education sessions on ‘direction and delegation’, computer education and team building. 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome The home has systems and processes to ensure each care recipient/representative has access to complaints mechanisms. Internal and external complaints avenues are communicated in entry information provided to care recipients/representatives and further information is available in common areas of the home. Written complaints are logged electronically, investigated and acted on in a timely manner by the Care Manager, with

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 11 escalation to organisational management as appropriate. Communication is provided to the complainant during the resolution process. Complaints are kept confidential as appropriate. Care recipients/representatives are satisfied they have access to complaints mechanisms, feel able to discuss concerns with staff and/or management and are satisfied with the response received when they raise a concern or make a suggestion. 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 has documented their vision, mission, service principles and commitment to quality. This information is communicated to care recipients, representatives, staff and others through a range of documents. 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 The home has a system and processes to ensure that there are appropriately skilled and qualified staff sufficient for the delivery of services. Recruitment is conducted within the organisation’s guidelines and using role specific position descriptions. Staffing is determined according to care recipient needs and in consultation with care recipients/representatives and staff, through one to one discussion and feedback processes. Performance appraisals of staff are conducted on a regular basis. Rostering ensures appropriately skilled and qualified staff are available to meet the identified care needs of care recipients. Care recipients/representatives are satisfied that there are sufficient staff to provide care and deliver services to meet care recipients’ needs. 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 processes to ensure the adequate supply and quality of goods and equipment used in care and service provision. Key personnel are responsible for the regular ordering of goods including food, continence aids, chemicals, medical supplies, medications and other general goods from preferred suppliers. Standard processes ensure goods are checked on delivery, returned if not correct or of satisfactory quality and that stock is rotated. Storage areas are appropriate for the type of goods. Feedback from staff, assessment of clinical needs and assessment of suitability of current equipment are used to identify equipment needs. New equipment is trialled with staff education provided. Servicing of equipment is tracked and provided by maintenance staff and/or external contractors as appropriate. Care recipients/representatives and staff are satisfied they have access to appropriate and adequate goods and equipment to meet their needs.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 12 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The home has effective information management systems, and staff have access to information to guide them in the delivery of care and services. Information about care recipients’ needs and preferences is communicated between clinical staff, care staff and support services. Management have access to information to enable them to monitor the home’s performance and pursue continuous improvement activities. There are processes to inform care recipients about the operation of the home and day-to-day events. Representatives are informed about incidents when they occur, informed about changes in care recipients’ care needs and are regularly consulted about care and services. There are systems to secure hardcopy and electronic information, to manage obsolete records and ensure confidential information is protected. Care recipients and/or their representatives are satisfied with information management. 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 Systems and processes are in place to ensure externally sourced services meet the home's service needs and quality goals. Preferred contractors provide services such as fire equipment maintenance, specialist maintenance, pharmacy, allied health services, pest control, waste management and food supplies. Contracts are managed at head office with input from the home regarding performance or changes in requirements. Issues of non- performance are managed in a timely manner during the term of the contract. Contractors are provided with an information pack to ensure appropriate conduct while on site, are orientated to the site and supervised as required. Staff and care recipients/representatives are satisfied with externally sourced services provided by the home.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 13 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 system and processes. In relation to Standard 2 Health and personal care, the home collects and analyses information about care recipient incidents and other clinical data to identify opportunities for improvement. Examples of recent improvements related to Standard 2 Health and personal care include:  In 2015 the home joined a clinical research trial examining the use of strength and balance exercises to reduce falls. The trial was led by a physiotherapist in collaboration with university researchers and involved 50 hours of exercise for a group of care recipients over three months in progressive gymnasium based training. Prior to participation in the exercise program, 50% of participants experienced at least one fall in the previous 12 months, whereas after participation in the exercise program, only one of the participants experienced a fall during the 12 month follow-up period. The home has continued offering regular resistance and balance training in a newly established ‘wellness centre’ gymnasium and management stated falls have continued to decrease for participants.  As the nearest medical specialist centre for care recipients is located more than 40 kilometres from the home, it was identified that some care recipients did not receive the benefit of specialist care as they were unable, or chose not, to travel to that location. In response, the home has developed a system whereby staff facilitate connection with both specialists and general practitioners via video technology using hand-held computer ‘tablets’. The video technology provides improved access to general practitioners and specialist services, improves case collaboration and reduces waiting times. Staff now have ‘virtual’ access to a vascular surgeon for advice on dressing techniques and wound management for example, and there has been a reduction in avoidable hospital admissions. Management stated that use of the new technology has been accepted favourably by both care recipients and the general practitioners/specialists concerned and has improved care recipient health outcomes. 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 Refer to Expected outcome 1.2 Regulatory compliance, for information about the systems to ensure compliance with all relevant legislation, professional standards and guidelines.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 14 In relation to Standard 2 Health and personal care, compliance with legislation includes a system to ensure specialised care and services are provided to care recipients, registered staff are available to provide care as required and medications are stored and provided in- line with regulations and guidelines. 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 Refer to expected outcome 1.3 Education and staff development for information about management and staff knowledge and skills. In relation to Standard 2 Health and personal care, staff have recently attended education sessions on assessment and care planning, high blood pressure medication, continence management, syringe driver management and the prevention and management of skin tears. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome The clinical care needs of care recipients are assessed on entry through interviews with care recipients/representatives, review of medical history, past assessment and through completion of focus assessments. The information gathered is used to create individualised plans of care to guide staff. Regular clinical reviews are completed to ensure care provided is relevant, appropriate and meets the changing needs of care recipients. Changes to care needs are communicated to staff through a variety of methods including via the handover sheet, shift and team handover meetings, changes to care plans and progress notes. Care recipients are attended by a medical officer of their choice with referrals to appropriate health professionals as required. Clinical incidents are reported, assessed by a registered nurse and addressed as necessary; strategies are implemented to reduce the risk of incident recurrence. Effectiveness of clinical care is monitored through auditing processes, review of clinical indicators, feedback, observation of practice and regular clinical review by registered nurses and visiting medical officers. Care recipients/representatives are satisfied care recipients receive appropriate clinical care. 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 Care recipients’ specialised nursing care needs are identified and assessed by registered nurses. Care is planned in consultation with care recipients/representatives, the medical officer, medical specialists, and other health professionals. Care plans and treatment sheets provide details of care to be provided and direct individual specialised nursing care requirements. A registered nurse is onsite 24 hours a day and senior clinical staff can be accessed after hours. The home consults with external services should care recipients’ needs exceed the current knowledge and skill of staff and external education is sourced. Videoconferencing to specialist advisors can be arranged to enable expert review and advice. Care recipients/representatives are satisfied care recipients’ specialised nursing care needs are met by appropriately qualified staff.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 15 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 The home has referral processes for care recipients, if and when the need arises, to a range of medical and allied health professionals. On identification of the need for referral, registered nurses coordinate access to appropriate health services in consultation with care recipients/representatives and their medical officer. Appointments are facilitated in the home where possible; care recipients who require or request external appointments are assisted with transport and escort as necessary. The outcome of referrals including instructions for ongoing care are documented, actioned and appropriate changes made to care plans and treatment directives. Implementation of recommended care strategies is monitored and the effectiveness of care is evaluated by nursing staff and allied health professionals. Care recipients/representatives are satisfied with the range and access to appropriate health specialists and the follow up care provided to care recipients. 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 Registered nurses, pharmacists and medical officers oversee the medication system to ensure care recipients medication is managed safely and correctly. Medications are managed using a packaged system and are administered by registered and care staff who complete education and assessment of competency. Medications are stored securely including drugs of addiction; appropriate records are maintained. Care recipients wishing to self-medicate discuss this with their medical officer; on approval they are assessed for ability, the outcome is documented and appropriate storage is provided. A pharmacy provides a medication imprest system for commonly used medications such as antibiotics and pain relieving medications. An approved nurse initiated medication list is utilised when necessary. Medication incidents are reported, analysed and discussed with staff involved to minimise risk of recurrence. Effectiveness of medication management is monitored through audits, incident reporting, medical officer and pharmacy review. Care recipients/representatives are satisfied with the management of care recipients’ medications and the assistance provided by staff. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome Care recipients’ pain is assessed on entry to the home and on an ongoing basis by nursing staff and the physiotherapist. Assessments are reviewed and evaluated; information gathered is used to formulate individual pain management strategies for care recipients who experience pain. Staff monitor effectiveness of pain relieving strategies and report concerns regarding pain and discomfort to registered nurses. If pain is not effectively managed, further assessment and monitoring is completed and the treating medical officer is contacted and notified to enable further investigation, review and alternative approaches. Strategies used to manage pain include both pharmacologic and alternative therapies such as massage, exercise and heat application. Strategies are aimed at keeping care recipients as free as

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 16 possible from pain. Care recipients/representatives are satisfied that care recipients are as free as possible from pain. 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 End of life requirements and preferences are discussed as part of the entry process or at a time convenient to care recipients/representatives. Outcomes of these discussions are documented in the care recipient’s file which also records information such as enduring power of attorney, authorised decision maker and advance health directives. Relatives and significant others are supported to be involved in end of life care; overnight stays and meals are provided to visitors as necessary. Palliative care specialists can be accessed to provide additional advice and support. The Resident Support Liaison can provide care recipients and their representatives with counselling and emotional support; religious representatives can be organised according to preferences. Care recipients’ pain and comfort needs are managed in consultation with the care recipient/representative, medical officers, nursing and care staff. Appropriate care and comfort is provided for care recipients at the end stage of their life and through the palliative phase. 2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Care recipients’ nutritional and hydration needs are assessed on entry with relevant information specific to needs and preferences communicated to the catering department. Care recipients’ weights are monitored to identify unintended weight variations. Unplanned weight changes are analysed by registered nurses for causative factors; management strategies include special diets, texture modified meals, nutritional supplements and additional snacks, milkshakes and smoothies between meals. Referral to a medical officer, dietitian and/or speech pathologist is completed where the need is identified. Strategies from health professionals are incorporated into plans of care with changes communicated to relevant staff. Staff provide assistance during meal times for care recipients who are frail, unwell or require encouragement. Care recipients/representatives are satisfied with the provision of food and fluids and the support of staff to meet 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, condition and potential for compromise are assessed on entry to the home. Management strategies to maintain and promote skin integrity are identified and communicated to staff. Staff observe skin integrity and condition during care delivery; changes are reported to registered nurses to enable treatment and intervention strategies to be implemented. Preventative strategies utilised by the home include pressure relieving devices, use of barrier creams, regular positional changes, limb protectors and nutritional

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 17 supplements. Manual handling equipment is provided to support safe positioning, transfer and mobility of care recipients. Wounds and skin tears are reported to registered nurses who assess and direct wound management; wound charts, progress notes and photographs are utilised to monitor and evaluate wound healing progress. Complex wounds and ongoing skin issues are referred to medical officers and/or wound specialists for additional advice and assistance. Care recipients/representatives 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 Care recipients’ continence needs are assessed on entry to the home to inform toileting and bowel management programs. Individual continence programs are developed in consultation with care recipients to assist in maintenance of continence levels. Staff interventions and strategies utilised to promote and manage care recipients’ continence levels include scheduled toileting, use of continence aids, ensuring sufficient fluid intake, and screening for infection. Staff monitor the effectiveness of continence and bowel management programs and report changes to a registered nurse for follow-up and appropriate intervention strategies where necessary. Continence aids are provided to care recipients in a manner that ensures their privacy is maintained and respected. Bowel management strategies may include dietary intervention, encouragement of fluids, exercise and, following medical officers’ directive, regular and as required medication. Care recipients/representatives are satisfied care recipients’ continence needs are met and staff support privacy and dignity. 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 are identified on entry to the home through review of medical history, previous assessments and discussion with representatives. Ongoing monitoring of challenging behaviours is completed to assist in the identification of possible triggers and effective management strategies. Information gathered is translated into behaviour management plans to guide staff. External specialists can be accessed to assist in advice and management of complex behaviours. Regular medical officer review occurs and staff are aware of their reporting responsibilities in the event of a behavioural incident. The home has a dedicated secure unit to accommodate care recipients who may have wandering or challenging behaviours and require close staff observation and intervention. Care and positive living staff support care recipients in maintaining their abilities and interests as well as providing distraction and one-on-one support. Restraint use is minimal and only used as necessary to facilitate safety and in discussion with representatives and the medical officer; authorisation and review of restraint is completed. Care recipients/representatives are satisfied the home manages challenging behaviours in an effective manner. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 18 Care recipients’ mobility and dexterity needs and falls risk are assessed by registered nurses and the physiotherapist on entry with consideration to their medical history and personal preferences. Strategies are developed in consultation with care recipients to maintain optimum levels of mobility and dexterity. A care plan is formulated which includes mobility, transfer and exercise needs and any equipment required. Care recipients are encouraged with their functional mobility and dexterity during activities of daily living. Falls prevention and mobility programs are coordinated by the physiotherapist and a gymnasium is available with individual programs and rehabilitation opportunities provided for care recipients. A number of walking and exercise programs are delivered throughout the week. Care recipients’ falls are monitored and a registered nurse, physiotherapist and/or medical officer review falls; interventions are implemented to prevent recurrence. Staff are provided with training in manual handling techniques. Care recipients/representatives are satisfied with care recipients’ ability to maintain optimum levels of mobility and dexterity and the assistance provided by staff. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Care recipients are assessed on entry to the home to determine their needs and preferences for oral and dental care; information gathered is included in plans of care. Staff encourage care recipients to attend to their mouth care needs as independently as possible and assist as necessary. Staff monitor the condition of care recipients’ mouths, teeth and dentures during care provision and report changes to the registered nurse for follow-up. Registered nurses assist with referral and access to external services such as dentist, denture technician or speech pathologist where required. Mouth care equipment and products are supplied and replaced regularly. Increased frequency of oral care and specialised equipment is available for palliating and frail care recipients. Care recipients/representatives are satisfied with the assistance provided by staff to maintain care recipients’ oral and dental health. 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 Care recipients’ sensory needs and deficits are identified on entry and as changes occur through assessment, review of past history and discussion with care recipients/representatives. Management strategies and interventions reflect care recipients’ individual needs and preferences. Staff assist care recipients to manage assistive devices such as spectacles and hearing aids. Activities and aids are provided to manage sensory loss and maximise participation in activities of daily living. Referral systems are in place for health professionals to assess sensory loss and provide appropriate assistive devices. Care recipients/representatives are satisfied with management strategies and assistance provided by staff to support care recipients with identified 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

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 19 Assessment processes identify care recipients’ preferred routines for rest and sleep. Care plans outline settling routines, preferred rest, sleep and wake times. Provision is made for care recipients who need or prefer to have a rest during the day. Night routines maintain an environment conducive to sleep. Factors that may interfere with natural sleep patterns are identified and interventions are implemented to assist in regaining natural sleep patterns. Night staff monitor care recipients and provide comfort measures such as repositioning, continence care and pain management. Staff have access to catering supplies if care recipients require or request drinks or snacks to settle. Medical officers are consulted if ongoing sleep issues are identified and pharmacological strategies are utilised as prescribed. Care recipients/representatives are satisfied with interventions to manage care recipients’ sleep.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 20 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 information about the home’s continuous improvement system and processes. In relation to Standard 3 Care recipient lifestyle, care recipient surveys, meetings, suggestions and feedback are used to identify opportunities for improvement. Care recipients and their representatives are supported and encouraged to provide feedback. Examples of recent improvements related to Standard 3 Care recipient lifestyle include:  The home has recently implemented a horticultural therapy program through a holistic approach to organic and sustainable gardening. Staff attended special training sessions to understand and facilitate plant and garden related activities to promote physical, social and cognitive well-being for care recipients. Staff and volunteers have assisted care recipients to participate in the establishment of colourful flower/vegetable/herb gardens in raised garden beds as well as cultivating fruit trees. Management stated the psychological benefits of the program include improvements to emotional well-being through more frequent socialisation, problem-solving skills, a reduction in anxiety and stress, improved self-esteem, a feeling of ‘belonging’ and of being helpful. Care recipients reported they enjoy the gardening activities and the added colour and beauty of flowers in their environment.  Following a staff suggestion, the home developed an assessment tool called the ‘All About Me Flower’ which is a one-page story teller accessible to staff and volunteers located in the care recipient’s folder and on the inside of their bedroom and/or bathroom doors. The ‘flower’ has colour-coded petals that provide information to staff/volunteers about each care recipient’s favourite music, hobbies, people, places and fond memories. Management, and positive living staff, stated the tool is completed with the help of care recipients/representatives and serves as a ‘conversation starter’ for personalising care of individual care recipients. 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 Refer to Expected outcome 1.2 Regulatory compliance, for information about the systems used by the organisation to identify and ensure compliance with relevant regulatory requirements. In relation to Standard 3 Care recipient lifestyle, compliance with legislation includes a system to ensure compulsory reports of assaults and missing care recipients are made,

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 21 maintaining consolidated records of reports, offering care recipient agreements and providing care recipients with security of tenure. 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 Refer to expected outcome 1.3 Education and staff development for information about management and staff knowledge and skills. In relation to Standard 3 Care recipient lifestyle, staff have recently attended sessions on elder abuse, horticulture therapy and dance and movement therapy. 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/representatives receive information about the home prior to and upon entry. On the day of entry, staff meet with care recipients, orientate them to the home and introduce them to other staff and care recipients. Assistance is given in settling into their room and the environment by care staff and the positive living team who visit daily during the settling in period. Care recipients are encouraged to have personal items in their rooms and family members are encouraged to visit and be involved in daily life at the home. Information regarding care recipients’ emotional needs is communicated to staff via handover processes and referrals are made to the home’s resident support liaison when additional support and/or counselling is required. Care recipients/representatives are satisfied with the support care recipients receive during their settling in period and with the ongoing emotional support provided by management and staff 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 On entry to the home, care recipients’ preferences in relation to maintaining independence for lifestyle, care and clinical decisions is identified. Care recipients are encouraged to maintain as much independence as possible, including in relation to activities of daily living, relationships, activities external to the home and personal care. All care recipients are assessed by a physiotherapist who contributes to care plans to promote physical independence. Individual and group exercise programs assist care recipients to maintain and improve strength and balance. Equipment such as mobility aids are provided to support independence. Care recipients receive assistance when required to promote independence in all areas of their life in the home. Assistance and encouragement is also provided to attend functions and outings external to the home. Care recipients/representatives are satisfied with assistance provided to maintain care recipients’ independence and to participate in life within and outside the village.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 22 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/representatives receive written and verbal information in relation to privacy and confidentiality during the entry process. Consent is obtained to allow staff to provide care and services and prior to release of information. Staff receive education on their responsibility to respect care recipients’ privacy and dignity and to maintain confidentiality. Care recipients are accommodated in single rooms, with ensuite and external terrace. Private and communal areas are available inside the home and in the gardens. Staff knock on doors before entering rooms and personal cares and procedures are conducted in private areas. Staff practices are monitored via observation and auditing processes. Care recipients’ personal information is kept secure at all times. Verbal handover and discussion regarding care recipients’ needs is conducted in private. Care recipients/representatives are satisfied privacy and dignity is maintained and care recipients are treated in a respectful manner. 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 The positive living team collect leisure interests and life history information from care recipients during the entry process. This information is communicated to staff via care plans and summary information is available in care recipients’ rooms for quick reference by staff. This information is reviewed three monthly with each care recipient. The activities program is created by the positive living team to meet group and individual needs of care recipients. A range of activities are included in the activity program including regular bus outings, exercise groups, care recipient run events, monthly special events and one to one visits. Staff encourage, support and assist care recipients to participate in activities of their choice. Monthly activity planners are displayed throughout the home; a copy is available for care recipients/representatives if requested. Activities are monitored and evaluated through attendance records, individual feedback, care recipient meetings and surveys. Care recipients/representatives are satisfied care recipients are able to choose from a range of individual and group activities and that staff assist them to be involved in activities of their choice. 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’ specific cultural and spiritual needs, including information regarding their religious beliefs, customs and cultural requirements are identified through initial and ongoing assessment processes. Information collected is included in care plans for reference by staff. Church services are conducted in the home and care recipients are assisted to attend religious observances according to their preference. Religious representatives visit care recipients at their request. The home facilitates and assists care recipients to maintain culturally important customs and beliefs. Special events and culturally significant days are celebrated with appropriate catering services provided on these occasions. Resources are

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 23 available to assist staff with information relating to cultural diversity; interpreter services can be accessed and information in languages other than English is provided as necessary. Care recipients/representatives are satisfied that care recipients’ cultural and spiritual needs are respected and supported. 3.9 Choice and decision-making This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home has processes to assess the choice and decision-making needs and capabilities of care recipients. Where applicable, information regarding appropriate decision makers such as enduring power of attorney or adult guardian is identified and documented. Care recipients/representatives are involved in the development of care plans through a consultative process which enables them to identify their choices and preferences. Further input into care and the environment is available via meetings, surveys, feedback processes and one to one discussions with staff and management. Information regarding care recipients’ rights and responsibilities, feedback mechanisms and advocacy services is provided and regularly discussed with care recipients. Care recipients retain the right to refuse attendance at activities, treatment and intervention and personal risk is explained to allow informed decision making. Care recipients/representatives are satisfied that they are able to exercise choice in relation to care recipients’ care and lifestyle. 3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Care recipients have secure tenure within the home and understand their rights and responsibilities. Information is provided to care recipients/representatives during the entry process regarding security of tenure and care recipients’ rights and responsibilities. The residential care agreement and handbook contains information about rights and responsibilities, the terms and conditions of their tenure, fees and charges and information about dispute resolution. Care recipients/representatives are consulted should any changes in needs require a room transfer and refusal of a room change is respected. Care recipients/representatives are satisfied care recipients have security of tenure and understand their rights and responsibilities.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 24 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 In relation to Standard 4 Physical environment and safe systems, audit and survey results, corrective and scheduled maintenance and reporting systems are used to identify opportunities for improvement. Examples of recent improvements related to Standard 4 Physical environment and safe systems include:  Following a review of the home’s performance during a recent cyclonic weather event, management has developed a set of residential evacuation decision-making guidelines, including maps of the local area detailing alternative routes to the home during floods and a checklist for staff/management to complete as soon as the initial weather warning is released. Other recommendations from the review that the home has implemented include setting up a telephone text messaging system to provide communication bulletins to all care recipients’ representatives and setting up an ‘emergency’ box containing a range of products to aid survival if the home becomes isolated.  Subsequent to care recipient feedback in 2016 about the quality of meals provided at the home, management introduced the role of head chef with specialist training to ensure effective delivery of the menu and provision of variety, spontaneity and creativity with meals. Management stated the head chef has improved the ability to control food costs, trains existing and new staff, can make dietary preference changes ‘on the fly’, fixes rostering issues without delay and acts as a point of contact for care recipients. Care recipients interviewed expressed satisfaction with meals provided at the home. 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 Refer to Expected outcome 2.2 Regulatory compliance, for information about the systems used by the organisation to identify and ensure compliance with relevant regulatory requirements. In relation to Standard 4 Physical environment and safe systems, compliance to legislation includes food safety, work health and safety and the inspection and management of fire systems and equipment. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 25 Team’s findings The home meets this expected outcome Refer to expected outcome 1.3 Education and staff development for information about management and staff knowledge and skills. In relation to Standard 4 Physical environment and safe systems, staff attend compulsory annual fire safety training and complete an orientation ‘refresher’ including manual handling and infection control each year. Recent education sessions for staff include laundry practice and basic food safety (eggs). 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 The home has systems and processes to ensure they are actively working to provide a safe and comfortable environment consistent with care recipients' care needs. Care recipients are accommodated in individual rooms with ensuite and outside terrace. Care recipients are encouraged to have their own furnishings in their room. Internal and external communal areas are available for use by care recipients and their visitors. Preventative maintenance and cleaning schedules are in place and are adhered to by staff and contractors. Any additional maintenance requirements are reported and attended to in a timely manner. Evening lock up procedures and security checks ensure overnight security in the home. Processes are in place to minimise the use of restraint. The comfort and safety of care recipients is monitored through feedback, review of incidents and audits, with safety issues identified and actions taken as required. Care recipients/representatives are satisfied with the comfort and safety of the home. 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 The home has systems to provide a safe working environment which meets regulatory requirements. The Operations Supervisor and the Care Manager oversee safe systems at the home with support from head office. Processes include meetings, identification of hazards, the reporting, investigation and risk assessment of staff incidents, safety audits and staff education in workplace health and safety. New and existing staff are provided with relevant education including manual handling, use of equipment, safe chemical handling, infection control and fire safety. Staff are aware of hazard identification and incident reporting processes and how to perform their roles in a safe manner. 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 in place to ensure fire, security and emergency risks are minimised. External providers ensure maintenance of fire safety systems and equipment is carried out in

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 26 accordance with legislative requirements. Evacuation plans are displayed; emergency exits are marked, free from obstruction and are suitable for the mobility level of the care recipients. Mandatory fire safety training is provided to all staff at orientation, yearly and as required. Emergency information guides staff in emergency situations and evacuation lists are updated and accurate. Evening lock up procedures ensure overnight security for staff and care recipients in the home. Care recipients who choose to smoke are risk assessed to ensure their safety and the safety of others. Monitoring of fire safety systems and security occurs through the home’s preventative maintenance program, audits and inspection by external contractors; issues identified are resolved in a timely manner. Staff demonstrate knowledge of fire, security and other emergency procedures, including their role in the event of an alarm, emergency or evacuation. 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 infection control program which includes policies, procedures, staff education, competency assessment, supply of appropriate equipment and ongoing monitoring. Care recipients and staff are encouraged and assisted with vaccination programmes. Care recipient infections are identified, treated and the incidence collated to identify trends and inform preventative strategies and/or education. The home has a food safety program in place and safe food practices are followed by catering staff. The home provides hand washing facilities, sharps containers, spill kits, outbreak kits and personal protective equipment for staff; there are processes to manage waste and pest control. The effectiveness of infection control measures are monitored through review of infection statistics, regular audits and observation of staff practices. Staff are aware of effective infection control practices, the use of personal protective equipment, colour coded equipment and the principles used to prevent cross infection. 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 Care recipients’ dietary needs and preferences are identified through assessments and this information is effectively communicated to catering staff. The home has a rotating menu that is based on input from care recipients and a dietitian; care recipients are offered choices in their meals and drinks. Rooms and communal areas are regularly cleaned. Cleaning staff follow a schedule and use specialised cleaning equipment and cleaning products which they have been trained to use safely. Care recipients’ clothing is collected, laundered on-site and returned to their rooms. Catering, cleaning, laundry and care staff are aware of their role in ensuring effective standards of infection control practice. Care recipients/representatives are satisfied with catering, cleaning and laundry services provided by the home.

Home name: Feros Village Wommin Bay Date/s of audit: 23 May 2017 to 24 May 2017 RACS ID: 0278 27