The Churchill Retreat

RACS ID 6507 470 Churchill Road KILBURN SA 5084

Approved provider: Hahndorf Holdings 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 02 April 2020.

We made our decision on 08 February 2017.

The audit was conducted on 17 January 2017 to 18 January 2017. The assessment team’s report is attached.

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

Standard 1: Management systems, staffing and organisational development

Principle:

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

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

Home name: The Churchill Retreat RACS ID: 6507 2 Dates of audit: 17 January 2017 to 18 January 2017 Standard 2: Health and personal care

Principles:

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

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

Home name: The Churchill Retreat RACS ID: 6507 3 Dates of audit: 17 January 2017 to 18 January 2017 Standard 3: Care recipient lifestyle

Principle:

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

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

Standard 4: Physical

Principle:

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

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

Home name: The Churchill Retreat RACS ID: 6507 4 Dates of audit: 17 January 2017 to 18 January 2017 Audit Report

The Churchill Retreat 6507

Approved provider: Hahndorf Holdings Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 17 January 2017 to 18 January 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: The Churchill Retreat RACS ID: 6507 1 Dates of audit: 17 January 2017 to 18 January 2017 Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 17 January 2017 to 18 January 2017.

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

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

Details of home

Total number of allocated places: 60

Number of care recipients during audit: 46

Number of care recipients receiving high care during audit: 45

Special needs catered for: Care recipients living with dementia and related disorders.

Home name: The Churchill Retreat RACS ID: 6507 2 Dates of audit: 17 January 2017 to 18 January 2017 Audit trail

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

Interviews Position title Number Site Manager/Director of Nursing 1 Corporate management and staff 4 Clinical and care staff 9 Care recipients/representatives 7 Administration staff 2 Lifestyle staff 1 Catering staff 1 Laundry staff 1 Cleaning staff 2 Maintenance staff 1

Sampled documents Document type Number Care recipients’ care files 6 Lifestyle care plans 5 Summary/Respite care plans 1 Medication charts 5

Other documents reviewed

The team also reviewed:

 Audit schedule and various audit reports

 Call bell response time audits and analyses

 Care recipient personal activity plans

 Cleaning schedules

 Clinical data, analysis and reporting

 Clinical handover documentation

 Comments, compliments and complaints data

Home name: The Churchill Retreat RACS ID: 6507 3 Dates of audit: 17 January 2017 to 18 January 2017  Compliance folder

 Continuous improvement action plan and associated data

 Contractor and visitor sign in/out register

 Critical incidents register

 Dietary needs profiles

 Disaster management plan

 Discretionary reporting log

 Drugs of dependence licence and register

 Duty statements

 External contracts

 Fire system monitoring records

 Food Safety Plan and audits

 Hazard log and hazard reports

 Information handbooks for staff, care recipients and contractors

 Menus

 Ministers Specification SA 76 log book

 Monthly and weekly activity calendars

 Newsletters

 Preventative and corrective maintenance records

 Refurbishment plan and manual

 Resident and Accommodation agreement

 Safety Data Sheets

 Staff performance monitoring data, training certificates, records, evaluations and registration records

 Staff recruitment and orientation materials

 Staff roster

 Temperature monitoring records

 Training calendar 2017

Home name: The Churchill Retreat RACS ID: 6507 4 Dates of audit: 17 January 2017 to 18 January 2017  Triennial fire certificate

 Various meeting minutes, memoranda and emails

 Various policies, procedures, guidelines and flowcharts

Observations

The team observed the following:

 Accreditation notice displayed

 Activities in progress

 Charter of rights and responsibilities on display

 Cleaning in progress

 Comments and complaints information on display

 Equipment and supply storage areas, including chemical storage and signage

 Fire Board and fire suppression equipment

 First aid kits

 Hand washing and hand gel stations

 Interactions between staff and care recipients

 Internal and external living environment

 Locked suggestion box

 Meal service

 Medication round in progress

 Noticeboards

 Outbreak kit

 Personal protective equipment in use

 Refurbishment plans on display

 Secure document storage and disposal systems

 Short observation in Wallace memory support unit

 Storage of medications

 Vision, mission and values statements on display

Home name: The Churchill Retreat RACS ID: 6507 5 Dates of audit: 17 January 2017 to 18 January 2017 Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The Churchill Retreat is one of five homes in the Bonney Health Care group of aged care facilities. The home has systems and processes to monitor compliance with the Accreditation Standards and is provided with ongoing support from corporate office. Opportunities for improvement are identified by a variety of processes including audits, surveys and staff and care recipient feedback. Issues identified are added to the continuous improvement action plan and addressed according to allocated timeframes. Progress is monitored at a site level by the Director of Nursing and a corporate level by the Regional manager. Improvement initiatives are discussed at all meetings, including Resident meetings. Care recipient representation on the Quality Assurance and Work Health and Safety committee provides for direct care recipient input into the development of the annual quality plan. Results across the four Accreditation standards show the home identifies improvement opportunities, and improvements are monitored and evaluated. Care recipients, representatives and staff interviewed state they are aware of the home’s feedback system and how they can make suggestions for change.

The home demonstrated results of improvements relating to Standard 1 Management systems, staffing and organisational development including:

 Provision of information on comments and complaints has been improved following audit results. It was identified that not all care recipients and representatives were aware of external avenues available to them in the event they are dissatisfied with the outcomes of issues raised with the home. Folders containing information on internal and external complaints processes have been developed and placed in the room of each care recipient. Information in a variety of languages is provided where required. Feedback from care recipients and representatives is that they appreciate the home’s response to their feedback and that they are now aware of internal and external complaints processes available to them. The folders have been placed on the home’s audit schedule to ensure information remains current.

 Monitoring of legislative requirements in relation to statutory declarations has been strengthened following the introduction of a system linking performance appraisals to annual statutory declarations. Management identified the need to monitor staff criminal clearance status between triennial police clearance checks. A question relating to criminal clearance status has been added to the performance appraisal tool and all

Home name: The Churchill Retreat RACS ID: 6507 6 Dates of audit: 17 January 2017 to 18 January 2017 staff are required to complete a statutory declaration at their annual performance appraisal. Staff interviews and a review of documentation confirmed the process.

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 organisation has systems and processes to manage and monitor regulatory compliance at a corporate and site level. Management receives legislative updates and notifications through a variety of different sources, including Commonwealth and State legislative updates, industry networking and membership of professional bodies and committees. Information about changes to regulatory compliance is communicated to the Director of nursing who informs staff via electronic and printed formats, meetings and other communication mechanisms. Care recipients are advised of legislative changes at meetings and in newsletters. Compliance is monitored through the audit system, review of controlled information, review of incidents and monitoring of staff knowledge and skills. Results show the home uses systems to identify and monitor compliance with relevant legislation, regulations and guidelines, and staff understand and use the system. Staff confirm they are required to have a current satisfactory police clearance certificate prior to commencing work and to complete a statutory declaration every year. Care recipients and representatives interviewed state they are kept informed of relevant changes.

The home provided examples of compliance with legislative requirements in relation to Standard 1 Management systems, staffing and organisational development, including:

 Police clearance certificates for all staff and volunteers

 Planned review of policy and procedure documents

 Advising care recipients and representatives of the Re-accreditation site audit within the legislated timeframes

 Maintaining an updated asset register.

Home name: The Churchill Retreat RACS ID: 6507 7 Dates of audit: 17 January 2017 to 18 January 2017 1.3 Education and staff development

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

Team’s findings

Staff feedback, surveys and annual performance reviews are combined with care recipient feedback and changing needs to plan the annual training program. Annual competency programs support skills maintenance and skills development. The training calendar is a living document and sessions are added throughout the year. Corporate office provides ongoing support to the home and staff have ready access to the aged care channel for ongoing education. A program of orientation ensures new staff are provided with relevant education prior to commencing on the floor. Staff knowledge and skills are monitored and specialised education is accessed as required. Management is aware of the benefit of up-skilling and there are currently four personal care staff being supported to complete enrolled nurse training and one enrolled nurse being supported to complete registered nurse training. Results show staff receive appropriate induction and training prior to commencing at the home and have access to a range of training opportunities. Staff interviewed state they are supported to attend training and education relevant to their role. Care recipients and representatives interviewed are satisfied staff have the required training for their roles.

Education and staff development relevant to Standard 1 Management systems, staffing and organisational development has been provided to staff over the last 12 months. Topics include:

 Aged Care Funding Instrument

 iCare

 My Aged Care Portal

 Workplace conflict.

Home name: The Churchill Retreat RACS ID: 6507 8 Dates of audit: 17 January 2017 to 18 January 2017 1.4 Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings

Care recipients are provided with information about their rights and the internal and external complaints mechanisms available to them by a variety of methods, including the Resident and Accommodation agreement and rights and responsibilities posters displayed in the home. A variety of processes are used to identify areas of concern. These include surveys, meetings, informal discussions and feedback forms. Major complaints are reported to the Regional manager who in turn reports to the home’s corporate office. Complaints are trended and discussed at all meetings. Results show the home monitors care recipient and representative feedback and responds to issues in a timely manner. Staff interviewed said they assist care recipients to use the system when required. Care recipients and representatives said they are aware of the home’s complaint mechanisms and are satisfied with the response to issues raised.

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 organisation has documented its mission, vision, values, philosophy of care and commitment to quality. These are included in the care recipient information pack and handbook and staff handbook. Staff interviewed state they are aware of the organisation’s philosophy and their responsibility in embodying these principles.

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 Director of nursing uses a formula based on environmental factors, care recipient needs and care recipient and staff feedback to determine the number of appropriately qualified and skilled staff required to provide appropriate care. There is a dedicated dementia care team assigned to the memory support unit and members of the team are available to assist staff across the home as required. Surveys, audits and reporting activities across the four Accreditation Standards monitor that there are sufficient skilled staff available to deliver the care and services required. Competency assessments and performance reviews are conducted annually. Recruitment processes, including student placements and links with the community identify prospective staff who have the necessary skills and approach to provide

Home name: The Churchill Retreat RACS ID: 6507 9 Dates of audit: 17 January 2017 to 18 January 2017 care and services. New staff complete buddy shifts prior to commencing on the roster. Management is responsive to staff and care recipient feedback and care recipients’ changing needs and additional hours are accessed as required. Results of surveys and audits and data gathered through monitoring activities across the four Accreditation Standards show there are sufficient skilled staff available to deliver the care and services required by care recipients. Staff interviewed are satisfied with the assistance they receive to maintain their competencies and state they have sufficient time for their duties. Care recipients and representatives are satisfied with staff responses to care recipients’ needs and that staff have the required skills and knowledge to perform their duties.

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

There are systems and processes to monitor and maintain adequate supplies of goods and equipment required for care and service delivery. Ordering responsibilities are defined and goods are delivered on a regular or as needs basis. A system of stock rotation is in place to manage stock control. Staff and care recipients have input into the purchasing of goods and equipment where appropriate and have the opportunity to comment on new supplies and equipment. Preventative and breakdown maintenance systems are used to maintain the safety of equipment. Staff have access to after-hours maintenance services in the event of an emergency. Planned audits are combined with staff and care recipient feedback to ensure an adequate supply of goods and equipment. Results of these processes show inventory and equipment is effectively monitored. Care recipients, representatives and staff state they are satisfied with the level of stock and equipment available in the home.

1.8 Information systems

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

Team’s findings

The home has effective information management processes to provide management and staff with access to information supporting them in meeting the requirements of their roles. Management communicates relevant information to staff, care recipients and representatives through meetings, noticeboards, newsletters, emails and memoranda. Shift handover, communication books, policies, procedures and education sessions further support staff communication processes. Monitoring processes include feedback from care recipients, representatives and staff, staff meetings, audits, surveys, incident and hazard reporting. Results show the home uses audit tools which record follow-up actions from audits and has processes for the effective storage, archiving, disposal and management of information. Staff interviewed are satisfied they have access to information to guide them in the delivery of care and services. Care recipients interviewed said they have access to appropriate information to assist them to make decisions about care and lifestyle preferences.

Home name: The Churchill Retreat RACS ID: 6507 10 Dates of audit: 17 January 2017 to 18 January 2017 1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings

There are systems and processes to ensure external services are provided in a way that meets the needs of the home and care recipients. The home has a preferred supplier list. External contracts are managed centrally by corporate office and monitored for quality and effectiveness at a corporate and site level. Contractors are required to sign in on arrival and report to appropriate personnel at the home for induction prior to commencing any work. Staff and care recipients provide feedback on external suppliers through the use of feedback forms and surveys. Results show external contractors and services are monitored and non- conformance reports generated when services do not meet contractual obligations. Staff, care recipients and representatives interviewed state they are satisfied with the majority of the current external services.

Home name: The Churchill Retreat RACS ID: 6507 11 Dates of audit: 17 January 2017 to 18 January 2017 Standard 2 – Health and personal care

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

Team’s findings

Refer to Expected outcome 1.1 Continuous improvement for information on the home’s continuous improvement systems and processes.

Care recipient incident data is analysed and combined with clinical key performance indicators to identify opportunities for improvement in health and personal care. The home is using a variety of methods to evaluate continuous improvement activities and demonstrated results of improvements relating to Standard 2 Health and personal care including:

 Care recipients’ clinical care has been improved following introduction of care plan tags in the electronic progress notes to readily identify changes in care recipient clinical needs. A template has been developed to guide staff in the use of the system that enables ready access to key information without having to search all progress note entries. Feedback is that the system is easy to use. Staff report that care recipient clinical information can be readily tracked enabling medical officers to assist in making any changes to care needs in a timely manner.

 Medication management has been improved following the introduction of electronic medication charts. Management liaised with their IT provider and the pharmacy in introducing the system. Laptops have been purchased and relevant staff provided with education in use of the system. Evaluation results show the system enables staff to readily track dose omissions and reduces the risk of accidental medication discontinuities. Feedback from staff is that the system is efficient and enables them to have more time to provide clinical care.

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 additional information relating to the home’s systems and processes for monitoring regulatory compliance.

Home name: The Churchill Retreat RACS ID: 6507 12 Dates of audit: 17 January 2017 to 18 January 2017 Processes are in place to monitor regulatory compliance relating to care recipients’ health and personal care. Results show these processes are effective in monitoring regulatory compliance in this Standard. Staff at the home said they understand and use the system.

The home provided examples of compliance with ongoing legislative requirements in relation to Standard 2 Health and personal care including:

 Registration of nurses

 Supervision of care staff

 Effective medication management

2.3 Education and staff development

Team’s findings

Refer to expected outcome 1.3 Education and staff development for additional information relating to systems and processes for education and staff development.

Staff interviewed said they have ready access to a range of training and are satisfied this assists them in their role. Education and staff development in relation to Standard 2 Health and personal care has been provided to nursing and personal care staff over the last 12 months in a range of topics. These include:

 Skin care

 Falls prevention

 Medication management

 Dementia care

2.4 Clinical care

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

Team’s findings

Care recipients receive clinical care appropriate to their needs and preferences. Nursing staff complete clinical assessments in consultation with medical and allied health professionals, the care recipient, representatives and staff attending care recipients’ needs. Care plans are reviewed regularly, and handover processes and progress notes inform staff of changes in care. Clinical staff advise medical officers of changes in care recipient health status. Clinical care is monitored through audits, care recipient surveys, observations during regular care, medical review and incident analysis. Results show care needs are assessed and reviewed on a regular basis and changes in health status are referred to appropriate medical professionals for review. Staff interviewed provided examples of individual care needs

Home name: The Churchill Retreat RACS ID: 6507 13 Dates of audit: 17 January 2017 to 18 January 2017 consistent with planned care. Care recipients and representatives interviewed said they are consulted about care recipients’ care needs and care is provided in an appropriate manner.

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 staff. Registered nursing staff identify, plan, implement and evaluate specialised care needs. Specialised care documentation includes specific needs and preferences, equipment required and relevant instructions for use. Registered Nurses are appointed to specialised care portfolios to enable consistency of care. Specialised care provided includes, pain management, diabetes management, complex wound and catheter care. Specialised nursing care is monitored through scheduled care review, care recipient surveys, clinical audits and consultation with relevant specialist services. Results show medical and specialist services are accessed as required and treatment orders updated. Staff interviewed said specialised care is delivered by registered nursing staff, in consultation with medical and health professionals. Care recipients and representatives interviewed are satisfied with the specialised nursing care provided.

2.6 Other health and related services

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

Team’s findings

Care recipients are referred to appropriate health specialists in accordance with their needs and preferences. Physiotherapy services are provided at the home and podiatry services, speech pathology, ophthalmological, mental health specialists and other allied health services visit the home when required. Specialist treatment orders are recorded in progress notes and care plans and changes in treatment orders are reported in the handover report. External appointments are recorded in handover documents and diaries. Referral processes are monitored through regular consultation with relevant services, feedback, audits and care review. Results show staff make appropriate referrals to specialist services and care documentation is updated as required. Staff interviewed said they are notified of changes in treatment orders and gave examples of instructions consistent with planned care. Care recipients and representatives interviewed said they are satisfied care recipients are referred to specialist services when appropriate.

Home name: The Churchill Retreat RACS ID: 6507 14 Dates of audit: 17 January 2017 to 18 January 2017 2.7 Medication management

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

Team’s findings

The home has systems to manage care recipients’ medication safely and correctly. Nursing staff assess and record medication administration. There are procedures for medical officer approved nurse initiated medications and ‘as required’ medications are recorded on care recipient medication orders and in the electronic medication management system. Evaluation of effectiveness of nurse initiated and ‘as required’ medications is recorded in progress notes and pharmacists and medical officers review medication orders on a regular basis. Medication management is monitored through audits, care recipient surveys, observation of staff practices, clinical meetings and analysis of medication incidents. Results show care recipients wishing to self-medicate are assessed for suitability by clinical staff and medical officers. Nursing staff interviewed described their practice for safe administration of medication and said they undertake medication competency assessment. Care recipients and representatives interviewed are satisfied care recipients’ medications are managed safely and correctly.

2.8 Pain management

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

Team’s findings

The home has an approach to pain management which assists care recipients to remain as free as possible from pain. Nursing staff document specific and individual verbal and non- verbal indicators of pain and strategies to manage pain are included in the care plan. Physiotherapy services provide ongoing assessment and pain management treatments for care recipients with pain. Nursing staff utilise alternatives to medication when possible, including massage, positioning and reassurance. The effectiveness of pain management is monitored through review of ‘as required’ medication, observation of care recipients, care recipient surveys and formal pain assessment during regular care plan reviews. Results show care recipients’ level of comfort is regularly assessed and interventions implemented are monitored for effectiveness. Staff said pain assessments occur on a regular and as needed basis and gave examples of how individual care recipients indicate they may have pain. Care recipients and representatives interviewed are satisfied care recipients’ pain is managed.

Home name: The Churchill Retreat RACS ID: 6507 15 Dates of audit: 17 January 2017 to 18 January 2017 2.9 Palliative care

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

Team’s findings

There are processes to maintain the comfort and dignity of terminally ill care recipients and to support staff and representatives. In consultation with representatives, where possible, nursing staff identify and document individual end-of-life needs and preferences. End-of-life care and comfort is managed in consultation with the medical officer and documented in care plans with consideration for maintaining dignity and comfort. The home provides on-site memorial services for families, friends, staff, volunteers and other care recipients who may wish to attend. The provision of appropriate end-of-life care is monitored through ongoing observation of care recipients’ comfort, monitoring staff practices, and feedback from family and friends. Results show care recipients’ individual needs are assessed and documented and medical officer support is accessed should care needs change. Staff interviewed provided examples of care interventions such as, skin care, pain management and oral care to maintain comfort and dignity. The home provided examples of feedback from representatives complimenting the home on the comfort and dignity provided during end-of- life care.

2.10 Nutrition and hydration

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

Team’s findings

Care recipients receive adequate nourishment and hydration. Nursing staff assess individual nutritional needs and assistive care requirements in consultation with care staff and allied health professionals. Referrals are made to the speech pathologist as required and specific orders are communicated to relevant staff via the handover process, progress notes and care plans. Meals and drinks are modified according to specialist advice. Nutrition and hydration is monitored through regular weighing of care recipients, care recipient surveys, scheduled care review and ongoing consultations with the medical officers. Results show there is ongoing assessment and monitoring of nutrition and hydration needs for care recipients at risk of nutrition and hydration deficiencies. Staff interviewed gave examples of individual nutritional requirements, such as, modified consistency of foods, consistent with planned care. Care recipients and representatives interviewed said they are satisfied care recipients receive adequate nutrition and hydration.

Home name: The Churchill Retreat RACS ID: 6507 16 Dates of audit: 17 January 2017 to 18 January 2017 2.11 Skin care

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

Team’s findings

The home provides effective care strategies to maintain care recipients’ skin integrity consistent with their general health. Registered Nursing staff assess skin care needs and record care interventions to maintain skin health in the care plan. Strategies to maintain skin integrity include the use of moisturising creams, nutrition and hydration management, regular positioning, protective bandages, protective clothing and pressure relieving equipment. Nursing staff assess and monitor skin incidents and provide wound care, in consultation with wound care specialists and the medical officer when required. Skin care is monitored through care evaluation, care recipient surveys, review of wound care results and observation of staff practices. Results show nursing staff assess and monitor skin care and document required interventions in the care plan. Staff interviewed described strategies and interventions to maintain and improve skin care. Care recipients and representatives interviewed are satisfied care recipients’ skin integrity is managed effectively.

2.12 Continence management

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

Team’s findings

The home has a continence management program that is effective in managing care recipients’ continence needs, comfort and dignity. Nursing and care staff assess, plan and monitor continence and comfort needs in consultation with relevant health professionals. Care plans include individual strategies to manage continence requirements and interventions to assist with personal care and, where required, appropriate aids are provided. An appropriately qualified staff member has portfolio responsibility for continence management and strategies are documented to manage and monitor urinary infections, skin condition and fluid intake. Monitoring processes include feedback, care recipient surveys, audits and care review. Results show individual continence requirements are assessed and evaluated on a regular basis and staff report and document changes in care needs. Staff interviewed gave examples of continence management consistent with planned care. Care recipients and representatives interviewed said they are satisfied the care provided maintains care recipients’ comfort and dignity.

Home name: The Churchill Retreat RACS ID: 6507 17 Dates of audit: 17 January 2017 to 18 January 2017 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 has systems to support and manage care recipients with challenging behaviours. Nursing staff assess, plan and evaluate behavioural management needs in consultation with medical officers, relevant specialist services and staff providing daily care. Care documentation includes information regarding triggers that cause care recipients’ anxiety and discomfort, and interventions to manage individual’s needs. Behaviour incidents are documented and reviewed by senior clinical staff. Medical officers and specialist services are accessed as required and treatment orders are recorded in care documentation. Monitoring processes include scheduled care review, incident analysis, observation, care recipient surveys and feedback. Results show individual needs are assessed and monitored and medical officers are consulted when care needs change. Staff interviewed gave examples of strategies used in response to challenging behaviours. Care recipients and representatives interviewed are satisfied care recipients with challenging behaviours are managed effectively.

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 maintains care recipients’ mobility and dexterity at a level consistent with their general health status. Nursing staff and the physiotherapist assess individual mobility and dexterity needs and document detailed strategies for support in care plans. The physiotherapist is on site regularly to review care and provide treatments and exercise programs and clinical and care staff provide ongoing mobility support. The physiotherapist assesses the suitability of mobility aids for individual care recipient needs and provides staff training regarding individual manual handling and equipment needs. Falls prevention strategies include sensor mats, and protective equipment. Regular monitoring and lifestyle activities encourage mobility and dexterity. Nursing staff monitor mobility and dexterity needs through scheduled care review, analysis of fall incidents, observation, care recipient surveys and audits. Results show staff implement strategies to support mobility and dexterity consistent with planned care needs. Staff gave examples of strategies to maintain care recipients’ dexterity such as exercise and therapeutic massage. Care recipients and representatives said they are satisfied care recipients have access to suitable equipment and specialist care to assist in optimising their mobility.

Home name: The Churchill Retreat RACS ID: 6507 18 Dates of audit: 17 January 2017 to 18 January 2017 2.15 Oral and dental care

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

Team’s findings

There are processes to assist care recipients to maintain their oral and dental health. Nursing staff assess individual oral and dental care needs and include this information in care plans. Care recipients are assisted to access local dental services, when required. Toothbrushes are replaced seasonally, tooth and denture care products are replaced as required and staff assist care recipients with their daily oral and dental care needs where necessary. Management monitors the oral and dental care program through care reviews, observation of staff practice, care recipient surveys and feedback from care recipients. Results show regular care review and ongoing consultation processes enable effective management of care recipients’ oral and dental care needs. Staff said they monitor oral and dental hygiene during daily care and report signs of discomfort. Care recipients and representatives interviewed said they are satisfied with the care and services.

2.16 Sensory loss

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

Team’s findings

The home has processes that identify and manage the impact of sensory loss in relation to the five senses. Nursing staff assess sensory loss for hearing, vision, taste, touch and smell and record relevant information in the care plan. There are assistive aids to support vision and hearing loss and optometrists and audiologists visits the home when required. The physiotherapist regularly reviews sensory loss in relation to heat sensitivity. Nursing staff monitor the impact of sensory loss through observation, care recipient surveys and feedback and staff provide appropriate support to assist care recipients in their daily activities. Results show appropriate aids are available and are maintained by staff to assist care recipients to participate in daily activities. Staff interviewed gave examples of how they manage the impact of sensory loss for individual care recipients. Care recipients and representatives interviewed said staff assist them with changing batteries in their hearing aids on a regular basis.

2.17 Sleep

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

Team’s findings

The home supports care recipients to achieve natural sleep patterns. Nursing staff identify and document individual preferences to support natural sleep, including preferred settling routines, warm drinks and reduction of environmental stimuli. Staff document sleep disturbances and comfort strategies provided are documented in progress notes. This

Home name: The Churchill Retreat RACS ID: 6507 19 Dates of audit: 17 January 2017 to 18 January 2017 information is reviewed by nursing staff, who consult medical officers when strategies are not effective. Nursing staff monitor sleep patterns and ‘as required’ medications on a regular basis through the regular care review process. Results show sleep disturbances are identified, reported and interventions are regularly reviewed. Staff described strategies to support individual preferences consistent with documented care plans. Care recipients and representatives interviewed said they are satisfied with individual sleep strategies implemented by the home.

Home name: The Churchill Retreat RACS ID: 6507 20 Dates of audit: 17 January 2017 to 18 January 2017 Standard 3 – Care recipient lifestyle

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

Team’s findings

Formal and informal feedback processes assist care recipients and staff to contribute to continuous improvement in care recipient lifestyle. Management and key staff encourage suggestions for improvement.

Examples of recent improvements relating to Standard 3 Care recipient lifestyle include, but are not limited to:

 Choice and decision making has been enhanced following the introduction of folders that are placed on each dining room table. The folders are in the form of a menu that contain the menu for the day on one side and activities to be held that day on the other side. This provides prompts for care recipients on the meal for the day and of activities to be held for each day. Feedback is that care recipients appreciate the folder being available at breakfast as it is a timely reminder of activities. In addition they state this enables them to change their meal preference in time for the kitchen to make adjustments.

 Information on activities for care recipients with sensory loss or cognitive impairment has been improved following staff feedback. It was identified that care recipients with sensory loss or cognitive impairment were having difficulty following the monthly activities planner. Staff responded by breaking the monthly planner down into a weekly planner and producing the planner in large print with pictorial enhancement. The planner is placed in the rooms of selected care recipients. Feedback from care recipients is that they appreciate the change in format and find it easier to follow. Staff feedback is that they have noticed an increase in activity attendance in care recipients who have the planner.

Home name: The Churchill Retreat RACS ID: 6507 21 Dates of audit: 17 January 2017 to 18 January 2017 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

Refer to expected outcome 1.2 Regulatory compliance for additional information relating to systems and processes for monitoring regulatory compliance.

There are systems and processes to monitor and maintain regulatory compliance relating to care recipient lifestyle. Staff interviewed said they understand and use the system.

The home provided examples of ongoing compliance with legislative requirements in relation to Standard 3 Care recipient lifestyle, including:

 Maintaining confidentiality of care recipient information

 Providing residential care service agreements to assist care recipients understand their rights and responsibilities

 Protecting care recipients’ privacy.

Team’s findings

Refer to expected outcome 1.3 Education and staff development for additional information relating to systems and processes for education and staff development.

Staff interviewed confirm they have access to a range of training and development opportunities and said they are satisfied the training and education provided assists them in their roles.

Education and staff development in relation to Standard 3 Care recipient lifestyle has been provided to all staff groups in the last twelve months in the following:

 Privacy and dignity

 Elder abuse

 Choice and decision making

Home name: The Churchill Retreat RACS ID: 6507 22 Dates of audit: 17 January 2017 to 18 January 2017 Education and staff development has been provided to lifestyle staff in:

 Mindfulness, compassion and presence

 Dementia specific activities

Education and staff development has been provided to senior management and lifestyle staff in:

 Achieving real culture change in residential aged care.

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 support in adjusting to life in the new environment and on an ongoing basis. The home has processes to identify, assess and monitor each care recipient’s emotional needs. On entry, staff provide individual support to care recipients to assist them settle into their new environment. Lifestyle staff and volunteers provide one-to-one companionship for care recipients when required. General practitioners, allied health and pastoral care services are able to be accessed as required. Monitoring of care recipients’ ongoing needs is conducted through the lifestyle and care review processes, audits, care recipient surveys, observation and feedback. Results show care recipients are referred to medical officers or allied health services where further support is required. Staff interviewed gave examples of emotional support provided to care recipients. Care recipients and representatives interviewed said they receive emotional support from staff provided in a sensitive and caring manner.

3.5 Independence

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

Team’s findings

Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Each care recipient’s lifestyle preferences, interests and abilities are assessed on entry and regularly reviewed. Care plans include strategies to encourage independence, including civic, cultural, physical, emotional and social aspects. The home is able to assist care recipients to attend appointments outside the home if required and family members assist care recipients maintain links with family, friends and the community. The home monitors strategies to support independence through care and lifestyle review processes, audits, care recipient surveys, observation and feedback. Staff interviewed described strategies to support care recipients’ independence consistent with documented plans of care. Care recipients and representatives interviewed said the home assists care recipients to maintain their independence, according to their needs and preferences.

Home name: The Churchill Retreat RACS ID: 6507 23 Dates of audit: 17 January 2017 to 18 January 2017 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

Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. The home identifies each care recipient’s privacy and dignity preferences during assessment processes. Strategies, including preferences for preferred name, activities of daily living and lifestyle are documented in care plans. The home maintains processes to protect care recipients’ privacy and confidentiality, including consent to collect and disclose personal information. Care recipients have access to lounge and outdoor areas to meet with family and friends. Monitoring processes include care and lifestyle reviews, audits, care recipient surveys, observation and feedback. Results show care plans include individualised strategies to support care recipients’ privacy, dignity and confidentiality needs and preferences. Staff interviewed described practices to support care recipients’ privacy and dignity. Care recipients and representatives interviewed said privacy, dignity and right to confidentiality is respected.

3.7 Leisure interests and activities

This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".

Team’s findings

Care recipients are encouraged and supported to participate in a wide range of activities of interest to them. The home has processes to identify and document each care recipient’s lifestyle needs and preferences, social history, leisure interests and preferred activities. Monthly activity calendars provide varied and responsive programs of activities and special events enabling staff to respond to care recipient preferences. Care recipients are assisted to participate in activities of their choice and their attendance is monitored. The ongoing suitability of activities is monitored through lifestyle reviews, audits, surveys, observation, evaluation and feedback. Results show care recipients are encouraged to participate in activities and individual activity programs are in place. Staff interviewed said they have access to information relating to each care recipient’s lifestyle and leisure interests and assist care recipients to attend activities. Care recipients and representatives interviewed said care recipients are supported to participate in activities of interest to them and can make suggestions regarding activities they would like to introduce.

Home name: The Churchill Retreat RACS ID: 6507 24 Dates of audit: 17 January 2017 to 18 January 2017 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

Care recipients’ individual interests, customs, beliefs and cultural and ethnic background are recognised, valued and fostered. The home has processes to identify, assess, monitor and communicate each care recipient’s cultural and spiritual needs and preferences. Spiritual preferences, social history and cultural background are recorded in care plans. Care recipients are encouraged to participate in cultural and spiritual events of significance to them. Multidenominational religious services are held on-site and representatives from various denominations visit the home to provide spiritual support to individual care recipients. Significant cultural days are celebrated including Australia day, St Patrick’s Day, Christmas, and Easter. Monitoring processes include lifestyle reviews, audits, care recipient surveys, observation and feedback. Results show care recipients’ individual spiritual and cultural needs are documented and supported. Staff interviewed provided examples of spiritual support strategies for individual care recipients consistent with documented care plans. Care recipients interviewed said they are satisfied the home fosters and supports their cultural and spiritual needs and preferences.

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

Care recipients and representatives are encouraged to make decisions and exercise choice and control over care recipients’ care and lifestyle. Each care recipient’s needs and preferences are assessed on entry to the home. Care plans identify care recipients’ preferences for activities of daily living, meals and drinks, sleep and lifestyle. Care recipients are provided with information on their rights and responsibilities on entry, in residential accommodation agreements, Resident handbooks and noticeboards throughout the home. Care recipients and representatives are encouraged to raise concerns through feedback forms and verbally to staff. Monitoring processes include audits, surveys and through care recipient, representative and staff feedback. Results show care recipients are assisted and encouraged to make choices and participate in decisions about their care and lifestyle. Staff interviewed described their responsibilities in supporting care recipients’ choices regarding services they receive. Care recipients and representatives interviewed said they are supported to make choices and decisions about the services offered and their lifestyle needs and preferences.

Home name: The Churchill Retreat RACS ID: 6507 25 Dates of audit: 17 January 2017 to 18 January 2017 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 organisation’s policy and procedure documents support care recipients’ right to safe and secure tenure and staff responsibilities to protect these rights. The Business administration manager meets with each care recipient and/or their representative prior to entry to assist in understanding the Resident and Accommodation agreement. This includes information on rights and responsibilities, fees and charges, security of tenure and decision making forums. Care recipients and representatives said they are satisfied that the information provided assists them to understand care recipients’ rights and responsibilities and security of tenure.

Home name: The Churchill Retreat RACS ID: 6507 26 Dates of audit: 17 January 2017 to 18 January 2017 Standard 4 – Physical environment and safe systems

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

Team’s findings

Internal and external audits are combined with key performance indicators and staff and care recipient feedback to demonstrate measurable results for all stakeholders in physical environment and safe systems.

The home demonstrated results of improvements relating to Standard 4 Physical environment and safe systems including:

 The location of the hairdresser has been changed to improve care recipient living environment. It was identified that the location of the hairdresser was too small with care recipients waiting in the corridor for their appointment. A purpose built hairdressing salon has been created that resembles community hairdressing salons. The new salon provides sufficient space for care recipients to wait in comfort. Care recipient feedback is that they enjoy the new salon and they state it is just like when they used to visit the hairdresser in the past.

 Living environment in the memory support unit has been improved following upgrade of the area. It was identified that the furniture and layout of the lounge and outdoor area were not conducive to care recipient interaction. Lounge chairs, recliners and a coffee table have been purchased and arranged in a typical living room layout indoors. Outdoor furniture has been purchased and placed in the garden area adjacent to the unit. Evaluation results show care recipients are sitting in the areas in a more relaxed and friendly manner and that challenging behaviours have reduced significantly in the unit. Representative feedback is that the new furniture and layout is comfortable and homely and promotes positive interaction.

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 additional information relating to systems and processes in monitoring regulatory compliance.

Home name: The Churchill Retreat RACS ID: 6507 27 Dates of audit: 17 January 2017 to 18 January 2017 Staff interviewed said they understand and use the system. The home has processes to monitor and maintain regulatory compliance relating to Standard 4 Physical environment and safe systems. These include:

 Implementing work health and safety regulations

 Monitoring and maintaining fire safety systems.

Team’s findings

Refer to expected outcome 1.3 Education and staff development for information relating to systems and processes for education and staff development.

Mandatory training provides staff with education and staff development relevant to their roles. Training attendance is monitored and staff are required to attend mandatory training each year. Staff interviewed said they are required to attend mandatory training and state the training and education provided assists them in their roles.

Education and staff development in relation to Standard 4 Physical environment and safe systems has been provided to all work groups over the last twelve months in a range of areas. These include:

 Fire safety, including unannounced fire drills

 Infection control

 Manual handling

 Food handlers responsibility and food safety training

 Chemical safety

4.4 Living environment

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

Team’s findings

Care recipients have their own room with ensuite bathroom and are encouraged to personalise their rooms with decorations as appropriate. Preventative and corrective maintenance is combined with environmental audits, surveys and ongoing reporting processes to monitor and maintain the safety and comfort of the living environment that includes well maintained external areas. Hazards are identified and corrective measures actioned. The home has a policy of minimal restraint. Assessment, consultation, monitoring

Home name: The Churchill Retreat RACS ID: 6507 28 Dates of audit: 17 January 2017 to 18 January 2017 and review processes support the safe application of restraint when required for care recipient safety. Results show the home is using its monitoring processes to identify issues in the living environment and to implement corrective action. Care recipients and representatives interviewed state they are satisfied with the safety, comfort and amenities available in the home, including care recipients’ rooms and communal areas.

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

Responsibility for the site work health and safety program is vested in the Director of nursing with oversight by the corporate Regional manager. The Quality Assurance and Work Health and Safety committee monitors the home’s compliance with the organisation’s work health and safety program. Processes, including a preventative maintenance program and hazard and incident reporting are used to monitor and maintain the safety of equipment and staff work environment. The home has a designated work health and safety officer and staff receive regular training in manual handling, work health and safety, and hazardous substances. Information systems and feedback processes assist staff to identify hazards and report accidents and incidents. Results show that staff work environment is monitored at a site level by the Quality Assurance and Work Health and Safety committee and a corporate level by the Regional Manager. Staff interviewed state they are aware of their rights and responsibilities in relation to safe work and are satisfied that management is supportive and proactive in providing equipment and resources to maintain a safe working environment.

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 has systems and procedures that minimise the risk of fire, security and other emergencies. Staff receive regular training in fire and emergency procedures and have appropriate equipment for use in the event of an emergency. Evacuation plans and emergency procedures are strategically placed in all areas of the home. An accredited external contractor monitors and maintains the safety and function of fire alarm and fire suppression equipment. Electrical testing and tagging monitors the safety of electrical equipment. Automatic after-hours lock down procedures are in place. Results show management and staff are working to provide a safe environment that minimises fire, security and other emergencies. Staff and care recipients interviewed state they are aware of their responsibilities in an emergency. Staff interviewed confirm they are required to attend mandatory fire drills each year.

Home name: The Churchill Retreat RACS ID: 6507 29 Dates of audit: 17 January 2017 to 18 January 2017 4.7 Infection control

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

Team’s findings

The home maintains an infection control program that meets Australian Government infection control guidelines. There are processes for outbreak management, including care recipient and staff vaccination, pest control and cleaning programs. Care recipient infections are identified by clinical staff and appropriate interventions implemented. Licensed external service providers and internal maintenance staff manage waste and pest control. The home has an audited food safety plan and processes to manage infectious outbreaks. The infection control program is monitored through internal and external audits, incident reporting and workplace inspections. Results show care recipients’ infections are managed effectively. Staff interviewed said they attend training in infection control and food safety and have access to appropriate personal protective equipment. Care recipients and representatives interviewed are satisfied with staff practice to minimise the incidence of 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

Care recipients’ needs and preferences are identified on entry to the home and reviewed on a regular basis. Catering staff are advised in writing of any assessed changes as a result of care recipients’ changing needs. The menu is varied to reflect the seasons and reviewed by a dietitian each year. Snacks and drinks are available at all times, including evenings. Catering services are outsourced to an external provider and the home’s catering staff plate and serve meals delivered by the provider. Cleaning is provided by the home’s staff and cleaning schedules guide staff in their daily cleaning routine. Personal laundry is laundered on site and linen is outsourced to an external provider. Care recipients’ clothing is marked for identification and the home has processes to monitor and locate lost clothing. Care recipient satisfaction with catering, cleaning and laundry services is monitored by feedback mechanisms including comments and complaints, meetings, surveys and direct consultation. Staff interviewed confirm they have access to work schedules to guide them in their role. They state they are satisfied with their work environment and the equipment provided to assist them in their tasks. Care recipients and representatives said they are satisfied with cleaning and laundry services provided. The majority of care recipients said they are satisfied with catering; however, some were not satisfied with the quality of the food provided by the external provider.

Home name: The Churchill Retreat RACS ID: 6507 30 Dates of audit: 17 January 2017 to 18 January 2017