Palm Lake Care Bargara

RACS ID 5409 55 Wearing Road BARGARA QLD 4670

Approved provider: Palm Lake Care Operations 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 15 March 2020.

We made our decision on 16 January 2017.

The audit was conducted on 13 December 2016 to 14 December 2016. The assessment team’s report is attached.

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

Standard 1: Management systems, staffing and organisational development

Principle:

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

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

Home name: Palm Lake Care Bargara RACS ID: 5409 2 Dates of audit: 13 December 2016 to 14 December 2016 Standard 2: Health and personal care

Principles:

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

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

Home name: Palm Lake Care Bargara RACS ID: 5409 3 Dates of audit: 13 December 2016 to 14 December 2016 Standard 3: Care recipient lifestyle

Principle:

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

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

Standard 4: Physical

Principle:

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

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

Home name: Palm Lake Care Bargara RACS ID: 5409 4 Dates of audit: 13 December 2016 to 14 December 2016 Audit Report

Palm Lake Care Bargara 5409

Approved provider: Palm Lake Care Operations Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 13 December 2016 to 14 December 2016 submitted to the Quality Agency.

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

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

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

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

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: Palm Lake Care Bargara RACS ID: 5409 1 Dates of audit: 13 December 2016 to 14 December 2016 Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 13 December 2016 to 14 December 2016.

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

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

Details of home

Total number of allocated places: 160

Number of care recipients during audit: 65

Number of care recipients receiving high care during audit: 31

Special needs catered for: Secured living environment

Home name: Palm Lake Care Bargara RACS ID: 5409 2 Dates of audit: 13 December 2016 to 14 December 2016 Audit trail

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

Interviews Category Number Management 4 Registered nurses 2 Care staff 5 Care recipients/representatives 9 Lifestyle staff 2 Laundry, cleaning and catering staff 6

Sampled documents Category Number Care recipients’ files 9 Additional care recipient files (focused assessment and care plan 5 review) Medication charts 17 Personnel files 4

Other documents reviewed

The team also reviewed:

 Activities calendar

 Asset register

 Audit tools and results

 Care recipient agreement and handbook

 Care recipient diet performance summary sheets

 Cleaning schedules

 Clinical incident forms and data reports/summaries

 Clinical observation charts

 Comments, complaints and suggestion folder and associated documentation

 Communication diaries

Home name: Palm Lake Care Bargara RACS ID: 5409 3 Dates of audit: 13 December 2016 to 14 December 2016  Continuous improvement plan and associated documentation

 Controlled drug registers

 Daily in-charge reports

 Dining room seating plan

 Education folder and associated documentation

 Emergency procedures

 Fire and evacuation procedures

 Food safety plan and associated documentation

 Handover sheets

 Hazard alert documentation

 Infection control data sheets

 Job descriptions

 Lifestyle documentation

 Maintenance inspection and service reports

 Maintenance schedule and preventive maintenance program

 Mandatory reporting folder and associated documentation

 Medication fridge temperature records

 Memoranda

 Menu (four weekly rotational)

 Newsletter

 Nutrition and hydration summary charts

 Policies and procedures

 Recruitment documentation

 Restraint authorisations and register

 Risk assessments

 Roster

 Safety data sheets

Home name: Palm Lake Care Bargara RACS ID: 5409 4 Dates of audit: 13 December 2016 to 14 December 2016  Self-assessment

 Staff handbook

 Wound management documentation

Observations

The team observed the following:

 Activities in progress

 Cleaning in progress

 Directional signage

 Equipment and supply storage areas

 Fire and emergency equipment, evacuation diagrams, emergency lighting, paths of egress and assembly area

 Fire panel

 Gas emergency stop button

 Hand washing facilities and hand sanitiser

 Interactions between staff and care recipients/representatives

 Internal and external living environment

 Meal and beverage service and delivery

 Medication administration and storage

 Menu on display

 Noticeboards and information displayed

 Personal protective equipment in use

 Secure suggestion box and feedback forms

 Sharps containers

 Short group observation

 Sign in/out visitor and contractor registers

 Spills and outbreak kits

 Staff work practices

Home name: Palm Lake Care Bargara RACS ID: 5409 5 Dates of audit: 13 December 2016 to 14 December 2016 Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

Palm Lake Care Bargara (the home) has developed policies and procedures which guide management and staff in the pursuit of continuous improvement across the Accreditation Standards. Care recipients/representatives and stakeholders are encouraged to contribute to the home’s continuous improvement system through the completion of improvement forms, comments, complaints and suggestion forms, verbal consultation and via monthly meetings. In addition, opportunities for improvement are identified through audits and clinical incident analysis with results discussed at various meetings and a copy of the monthly analysis data placed in a communication folder for staff to access and read. Information and feedback of quality activities occurs through various means and forums such as meetings and meeting minutes, one-on-one consultation, emails and memorandum. Care recipients/representatives and staff are satisfied they are able to raise suggestions for improvements and management is responsive to improvement ideas and suggestions.

Examples of improvement initiatives implemented by the home related to Standard 1 Management systems, staffing and organisational development include:

 In response to a staff suggestion to improve information systems relating to the documentation and recording of information following falls by care recipients, management purchased a ‘post falls’ stamp for each nurse station. The stamps are used in the diary by staff to alert and prompt staff to complete daily information over a three day post fall observation period. Management reported since the implementation of the stamp, the occurrence of post fall observations, days one to three is being completed in a timely manner. Documentation reviewed demonstrated the stamp being used by staff over the post fall observation period.

 In response to a suggestion in relation to the ‘Resident Agreement’ being updated to include increased information pertaining to the fee structure in line with the Aged Care Act, management reviewed the content of the agreement. This resulted in an additional section being added by the Quality Manager to enhance information contained within the document. Management advised the revised agreement has improved compliance with the Aged Care Act and enhances care recipients/representatives understanding of the home’s fee structure. Care recipients/representatives provided positive feedback relating to the information they received prior to and on entry to the home.

Home name: Palm Lake Care Bargara RACS ID: 5409 6 Dates of audit: 13 December 2016 to 14 December 2016 1.2 Regulatory compliance

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

Team’s findings

The home has systems to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines through subscription with industry peak bodies and government websites. Legislative updates are monitored and communicated electronically to the Facility Manager. Changes are disseminated to relevant staff and stakeholders through emails, memorandum, verbal and written handover processes, a communication folder, discussed at relevant meetings and through education sessions. Where changes to legislation directly affect the day to day lives of the care recipients this is discussed at the care recipient meeting and letters are mailed out to representatives. Compliance with legislation is monitored through the audit process, staff and care recipient feedback and observation of staff work practices.

In relation to Standard 1 Management systems, staffing and organisational development, systems ensure: all staff and contractors with unsupervised access to care recipients have a current police certificate which is monitored for three yearly updates, registered staff have appropriate qualifications and registration and all care recipients and/or representatives and staff are advised of 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 has an education and staff development process for management and staff based on the Accreditation Standards, mandatory topics, identified needs and legislative requirements. On commencement of employment all staff are required to undertake orientation; this includes mandatory education topics and competencies such as but not limited to, manual handling, infection control, fire and safety, chemical safety and compulsory reporting of assaults and elder abuse. In addition, all staff must attend annual mandatory training; their attendance is monitored with measures in place for non-attendance. The education calendar outlines the annual scheduled education program for staff. The calendar is compiled following the completion of a staff training needs analysis, gap analysis, staff appraisals and audit results. The Facility Manager has the capacity to add specific education sessions throughout the year in response to care recipients’ health and care needs, clinical indicators and the purchase and use of new equipment. Management and staff are satisfied they have access to ongoing learning opportunities and are kept informed of their training obligations.

In relation to Standard 1 Management systems, staffing and organisational development, education has been provided in relation to: increase in staffing hours across all departments - consultation and roster procedures, use of new equipment, general principles of good documentation and how to use and navigate the electronic clinical system.

Home name: Palm Lake Care Bargara RACS ID: 5409 7 Dates of audit: 13 December 2016 to 14 December 2016 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 has documented policies and procedures in relation to comments and complaints process that summarises processes for verbal and written complaints, compliments and suggestions from care recipients, representatives, staff and other interested parties. On entry to the home all care recipients and/or their representatives are provided with a care recipient handbook which contains information pertaining to comments and complaints. Information about the internal and external complaints mechanisms are displayed in the main foyer. A secure suggestion box is box located in the main foyer adjacent to feedback forms. Compliments and complaints are recorded, analysed by management, actioned and resolved with feedback provided to the complainant as required. Comments, complaints and suggestions are discussed at relevant meetings. Care recipients/representatives and staff are aware of the various forums to initiate a suggestion or raise a concern and advised management is responsive 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’s documented residential care service’s vision, philosophy, objectives and commitment to quality is displayed in the main foyer area of the home. The care recipient and staff handbook contains a copy of the vision statement. Staff are initially informed of the organisation’s residential care service’s vision, philosophy, objectives and commitment to quality through the recruitment process, on commencement of employment, orientation and work instructions.

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 has processes for the recruitment and selection of appropriately skilled and qualified staff in line with the organisations’ policies and procedures and relevant industrial legislation. This includes key selection criteria such as a valid police certificate, professional registrations specific to individual roles, and a minimum of Certificate III in Aged Care. All new employees participate in the orientation program which includes mandatory education, and on commencing shifts are ‘buddied’ with an experienced staff member. Staff roles and

Home name: Palm Lake Care Bargara RACS ID: 5409 8 Dates of audit: 13 December 2016 to 14 December 2016 responsibilities are outlined in their job descriptions and are accessible to staff. Staff appraisal forms are scheduled six monthly after commencement of employment and annually thereafter or as required with action plans initiated as required. Rosters are planned in advance, which includes access to registered staff 24 hours a day seven days a week. Planned and unplanned leave is filled by permanent part-time staff and/or permanent part- time casual staff as the need arises. Staff are multi-skilled and provide shift coverage within the existing roster as required. Staff are generally satisfied they have sufficient time and appropriate skills to carry out their duties effectively. Care recipients/representatives are generally satisfied with the responsiveness of staff in meeting care recipients’ care 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

All equipment is new and still under warranty. Management have established stock control processes to ensure adequate and appropriate stocks of goods and equipment for quality service delivery are available. Equipment needs are determined by care recipient need, staff feedback, and monitoring the safety of the environment. A preventative and corrective maintenance program is in place, and all relevant equipment documented on an asset register to identify, maintain, repair or replace broken and/or unsuitable equipment as required. The supply and maintenance and purchasing of goods and equipment is managed by key personnel in conjunction with management. Processes are in place to ensure stock rotation occurs and that goods are checked on delivery to ensure quality, condition and that temperatures are within range where applicable. Care recipients/representatives and staff are satisfied with the availability and appropriateness of the goods and equipment provided.

1.8 Information systems

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

Team’s findings

Policies and procedures guide management and staff in the identification, collection, use, storage, destruction and communication of information and data relevant to the home, management, staff, care recipients/representatives and other stakeholders. Electronic information management systems are secured by individual password protection, role specific access authorisation and automatically backed-up on the organisation’s server. There are processes for archiving and destruction of documentation. Staff reported information necessary to enable them to perform their allocated duties is available and accessible. Information regarding changes to care recipients’ care needs is communicated via handover, care plans, progress note entries, communication diaries and scheduled staff meetings. Care recipients/representatives are provided with information when moving into the home, via meetings, on notice boards, mail-outs, and verbal reminders from staff.

Home name: Palm Lake Care Bargara RACS ID: 5409 9 Dates of audit: 13 December 2016 to 14 December 2016 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 General Manager in consultation with the Maintenance Manager oversees the management of services provided by external providers. This includes the establishment of a service agreement that outlines relevant legislation, guidelines and the organisation’s quality requirements, a performance measure and review process if non-compliance is unable to be addressed. Processes are in place for an on-call system to address repairs to equipment after hours or over the weekend. External service contractors providing service at the home are required to sign in/out prior to commencing work at the home. Performance is monitored and reviewed annually through observation and visual inspection of works carried out. Care recipients/representatives and staff are satisfied with the quality of services provided by external service providers.

Home name: Palm Lake Care Bargara RACS ID: 5409 10 Dates of audit: 13 December 2016 to 14 December 2016 Standard 2 – Health and personal care

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

Team’s findings

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

Examples of improvements implemented by the home related to Standard 2 Health and personal care include:

 Following a staff suggestion in relation to a quick and easy reference for care recipients requiring ‘two person’ assistance and repositioning, the implementation of an alert sticker was introduced and is placed above the bed of the care recipients. A sticker has been implemented for care recipients that require the use of a hoist and are strictly two person assist. Management and staff report the use of the sticker system ensures discretion and privacy is maintained while providing a quick reference and alert for staff.

 Following a suggestion on ways to improve the storage of oxygen equipment and accessories, management purchased oxygen accessory bags for each oxygen storage area. The bags are clear and allow for quick and safe checking of equipment. The bags have separate pockets to hold various items used with the oxygen equipment. Management and staff reported the new process is working well.

2.2 Regulatory compliance

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

Team’s findings

Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes.

In relation to Standard 2 Health and personal care, systems ensure: the reporting of unexplained absences, specified care and services are provided to care recipients and medications policy and procedure are accessible to guide registered staff in line with relevant regulatory protocols.

Home name: Palm Lake Care Bargara RACS ID: 5409 11 Dates of audit: 13 December 2016 to 14 December 2016 2.3 Education and staff development

Team’s findings

Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes.

In relation to Standard 2 Health and personal care, education has been provided in relation to: stoma therapy, continence management, mobility and falls prevention, nail care and development of a check list, drug calculations and first response.

2.4 Clinical care

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

Team’s findings

Care recipients residing at the home receive appropriate clinical care. The home has assessment, care planning and review processes to identify the initial and ongoing clinical care needs of care recipients and these are generally followed by staff. Clinical care is overseen by the Facility Manager and General Manager with the support of registered nursing staff. Medical officers and other health professionals attend the home to support a collaborative model of care. Mechanisms are in place to keep staff informed of care recipients’ current clinical care needs. Care recipients and/or their representatives have input into the care provided through consultation with clinical staff and other health professionals. Staff are aware of care recipients’ individual clinical care needs. Monitoring mechanisms include the conducting of audits, observation of staff practices and the collation, trending and analysis of clinical incident data. Care recipients/representatives are satisfied care recipients’ clinical care needs are met.

2.5 Specialised nursing care needs

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

Team’s findings

Care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. Registered staff, with the support of other health professionals, are meeting the specialised nursing care needs of care recipients who require diabetes management, catheter care, stoma management, complex wound care and oxygen therapy. Complex health care planning and treatment regimens are in place and educational resources available to guide staff practices. Specialised equipment can be accessed to meet the complex care needs of care recipients and processes ensure staff competency in its use. Care recipients/representatives are satisfied care recipients’ specialised nursing care needs are met and attended to by appropriately qualified staff.

Home name: Palm Lake Care Bargara RACS ID: 5409 12 Dates of audit: 13 December 2016 to 14 December 2016 2.6 Other health and related services

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

Team’s findings

Care recipients are referred to appropriate health specialists in accordance with the care recipients’ needs and preferences. The home has established a group of health and allied services which visit on a regular basis. These services include mental health professionals, specialised health clinics, podiatrist, speech pathologist, dietician, optometrist, audiologist and dental services. Health professional recommendations are documented, care plans updated and relevant staff notified. Care recipients are assisted to attend external appointments and health specialists attend the home. Care recipients/representatives stated care recipients are referred to other health specialists if a need is identified.

2.7 Medication management

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

Team’s findings

Care recipients’ medication is managed safely and correctly. Care recipients’ medication needs are assessed on entry to the home, recorded in care planning and reviewed on an ongoing basis. Registered staff administer care recipients’ medications and liaise with pharmacy and medical officers. Medication stock is securely and safely stored and urgent after hours medications can be accessed when required. Processes to monitor the use of ‘as required’ (PRN) medication are in place and followed by staff. Safe staff practice is monitored through medication chart audits and incident reporting and skills maintained through education and competency assessment. Care recipients’ medication regimens are reviewed by their medical officer. Care recipients/representatives are satisfied care recipients receive their medication 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

Care recipients are supported to be as free as possible from pain. Medical officers and staff manage and monitor care recipients’ pain. Care plans reflect strategies to manage care recipients’ pain including non-pharmacological strategies such as exercise, hot and cold packs and massage. Staff are aware of non-verbal cues to assist in identifying care recipients’ pain or discomfort and interventions to support care recipients’ comfort needs. Care recipients/representatives are satisfied with care recipients’ current pain management strategies and the provision of alternative interventions if and when pain persists.

Home name: Palm Lake Care Bargara RACS ID: 5409 13 Dates of audit: 13 December 2016 to 14 December 2016 2.9 Palliative care

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

Team’s findings

Care recipients’ end of life wishes and care needs are identified, documented and communicated to guide staff practice. As a care recipient’s needs change regular consultation with the care recipient and/or their representative occurs to ensure the care recipient’s physical, spiritual, cultural and emotional needs are respected and provided for. The home has access to specialised equipment and external palliative care services if this is required. Consultation with the care recipient’s medical officer and palliative care professionals ensures the care recipient’s comfort is managed and their dignity is maintained. Staff are aware of end of life care interventions to ensure the comfort and dignity of care recipients.

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. Care recipients’ dietary needs, preferences and allergies are identified on entry to the home and reviewed on an ongoing basis. Care recipients’ nutrition and hydration requirements, special diets and preferences are reflected on dietary assessments and care plans to guide staff. Care recipients are weighed monthly (or more frequently as required) and changes in weight are monitored. In the event of care recipients experiencing weight loss, interventions include the provision of dietary supplements and fortified meals and/or referral to allied health professionals. Care recipients/representatives stated care recipients are satisfied they receive adequate nutrition and hydration.

2.11 Skin care

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

Team’s findings

Care recipients’ skin integrity is consistent with their general health. Care plans are developed to guide staff practice and staff are aware of interventions to optimise care recipients’ skin integrity such as the use of moisturisers, pressure relieving devices, diet and hygiene. The home has sufficient supplies of skin care products to meet the skin and wound care needs of care recipients. A wound care specialist is available for consultation if this is required. Monitoring processes include the reporting of breaks in care recipients’ skin integrity and this information is collated and analysed monthly by the management. Care

Home name: Palm Lake Care Bargara RACS ID: 5409 14 Dates of audit: 13 December 2016 to 14 December 2016 recipients/representatives are satisfied the skin care provided by staff meets care recipients’ needs.

2.12 Continence management

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

Team’s findings

Care recipients’ continence requirements are identified through assessment and care planning processes. Staff have an understanding of continence promotion strategies such as the use of aids and toileting programs. Care recipients’ continence is monitored daily and care plans are reviewed every three months or as required. Bowel management interventions may include dietary intervention and, following medical officer referral, regular and PRN medication. A staff member has been appointed the responsibility of overseeing the correct use of continence aids and is involved in assessment processes in consultation with registered staff. The home is supported by an external continence advisor who is able to provide staff education if requested. Changes to continence regimens are communicated to staff through shift handovers and progress note entries. Care recipients/representatives are satisfied care recipients’ continence needs and preferences are being managed effectively.

2.13 Behavioural management

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

Team’s findings

The needs of care recipients with challenging behaviours are managed effectively. Management processes include behavioural assessment and care planning, monitoring, development of wanderer’s profiles and lifestyle activities. External health professionals can be accessed to assist in the management of complex behaviours if this is required. Consideration is given to factors which may contribute to a care recipient exhibiting a challenging behaviour and goals of care are documented. Care recipients are encouraged to participate in lifestyle activities implemented by designated lifestyle staff. Regular medical officer review occurs and staff are aware of their reporting responsibilities in the event of a behavioural incident. The individual needs of care recipients with challenging behaviours are known and implemented by staff. Care recipients/representatives are satisfied the activities of other care recipients do not infringe on care recipients’ life at the home.

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

Processes are in place to assist care recipients to achieve optimum levels of mobility and dexterity. A physiotherapist undertakes assessments in liaison with registered staff and care

Home name: Palm Lake Care Bargara RACS ID: 5409 15 Dates of audit: 13 December 2016 to 14 December 2016 plans are developed which reflect interventions and programs to meet care recipients’ individual mobility and dexterity needs. The home’s lifestyle program incorporates group exercise activities and care recipients are assisted with individual walking programs. Falls incidents are reported and actioned, and the data collected is analysed and trended on a monthly basis. Aids to maintain and improve mobility and dexterity such as walking aids, dietary assistive aids and specific manual handling equipment are available. Care recipients/representatives are satisfied with the assistance care recipients receive in achieving optimum levels of mobility and dexterity.

2.15 Oral and dental care

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

Team’s findings

Care recipients are assisted to maintain their oral and dental health. Care recipients’ dental history and preferences relating to the management of their oral and dental health are identified on entry to the home through interview and assessment of their oral health status. Care staff monitor care recipients’ ability to self-manage their oral care and assist when required. Registered staff co-ordinate dental referrals when the need is identified. Sufficient stocks of equipment and products to meet care recipients’ oral hygiene needs are maintained. 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

Care recipients’ sensory losses are identified and managed effectively. Sensory assessment processes identify care recipients’ sensory needs in relation to hearing, vision, taste, touch and smell. Interventions are developed with consideration of care recipients’ care and lifestyle requirements and preferences to optimise their participation in activities of daily living and social interaction. Care recipients have access to audiology, optometry and speech pathology services as a need is identified. Staff assist care recipients to manage assistive devices such as spectacles and hearing aids to maximise sensory function and are aware of care recipients individual requirements. Care recipients/representatives are satisfied with management strategies and the assistance provided by staff to meet the needs of care recipients with sensory loss.

Home name: Palm Lake Care Bargara RACS ID: 5409 16 Dates of audit: 13 December 2016 to 14 December 2016 2.17 Sleep

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

Team’s findings

The home has processes to assist care recipients achieve natural sleep patterns. Care recipients’ individual settling and rising preferences are captured and communicated to staff. The environment is monitored to provide adequate lighting and minimal noise levels are maintained. Staff provide assistance when care recipients have difficulty sleeping, which includes the provision of refreshment and snacks, re-positioning, and attending to hygiene cares. Staff are aware of the individual assistance care recipients require to support their requested sleep and settling routines. Care recipients/representatives indicated satisfaction with interventions to manage care recipients’ sleep patterns.

Home name: Palm Lake Care Bargara RACS ID: 5409 17 Dates of audit: 13 December 2016 to 14 December 2016 Standard 3 – Care recipient lifestyle

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

Team’s findings

Examples of improvements implemented by the home related to Standard 3 Care recipient lifestyle include:

 In response to a care recipient’s request to start a singing group as a way of expanding the lifestyle program, the activity program was adjusted to accommodate the care recipient’s wishes. Weekly practices were organised with a goal for care recipients to sing at the home’s Christmas party on 13 December 2016. The singing group achieved their goal and performed in front of care recipients, representatives, visitors and staff at the Christmas party. At the completion of their singing performance the group received a ‘large’ round of applause.

 To enhance and support care recipients’ choice and decision making, the home implemented a process whereby each Wednesday a different care recipient gets to order a meal of their choice for lunch. The lifestyle staff then assists with the coordination and consultation with the chef. A selection of alcoholic and non-alcoholic beverages is supplied to complement the care recipient’s choice. Photos are taken and recorded in a special folder with the name of the meal choice and the care recipient who chose the meal. Care recipients and representatives have provided management with positive feedback on the weekly menu choice and their ability to have input to meals.

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

In relation to Standard 3 Care recipient lifestyle, systems ensure: identification, reporting and monitoring of reportable assaults, care recipients are notified of their rights and

Home name: Palm Lake Care Bargara RACS ID: 5409 18 Dates of audit: 13 December 2016 to 14 December 2016 responsibilities as per The Charter of Care Recipients’ Rights and Responsibilities, care recipients are offered an accommodation agreement and care recipients have security of tenure.

Team’s findings

In relation to Standard 3 Care recipient lifestyle, education has been provided in relation to: elder abuse/mandatory reporting, care recipients’ choice, spiritual and cultural, the activity program and one-on-one activities.

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. Staff assist care recipients to become orientated to the home and establish new friendships. Care recipients are encouraged to furnish their rooms with their personal and familiar items and family visits are encouraged and supported. Management and staff and pastoral personnel provide additional emotional support to those care recipients identified as requiring this. Staff are aware of strategies to provide assistance and emotionally support care recipients residing at the home. Care recipients/representatives are satisfied with the emotional support provided to care recipients on entering the home and on an ongoing basis.

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 by management and staff to achieve maximum independence with their daily care and lifestyle activities. Assessment processes identify the support care recipients require to maximise their independence relating to mobility, civic duties, personal care and decision making. Care recipients’ ability to perform activities of daily living is reviewed three monthly or as required and any changes in staff assistance required by care recipients is documented in care planning. Care recipients’ family and other significant persons are informed of events at the home and encouraged to attend and participate. Staff

Home name: Palm Lake Care Bargara RACS ID: 5409 19 Dates of audit: 13 December 2016 to 14 December 2016 are aware of interventions to support care recipients to achieve maximum independence. Care recipients/representatives are satisfied with the support care recipients receive to achieve maximum independence.

3.6 Privacy and dignity

This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".

Team’s findings

Care recipients’ right to privacy, dignity and confidentiality is recognised and respected. Care recipients’ privacy and dignity needs are identified through consultation and assessment processes and communicated to staff. The home’s expectations for maintaining privacy, dignity and confidentiality are reinforced during observation and supervision of staff practice. Staff obtain consent for entry to care recipients’ rooms, close doors during cares and address care recipients by their preferred name. Care recipients’ confidential information is stored securely. Care recipients/representatives are satisfied care recipients’ privacy is respected and confidentiality and dignity maintained.

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’ leisure and social interests are identified on entry to the home and reviewed with the care recipient and/or their family. A monthly activities program is developed, displayed and provided to each care recipient. Care recipients have opportunity to provide feedback on activities and have input into the program through meetings and on a one to one basis with lifestyle staff. Significant days are celebrated with care recipients and their families or significant other persons. Monitoring mechanisms include care recipient feedback at meetings, monitoring care recipient attendance at activities and evaluation of the event. Care recipients/representatives are generally satisfied with the variety of leisure activities offered by the home.

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 has processes to meet care recipients’ individual interests, customs, beliefs and cultural and ethnic backgrounds. A church service is held at the home and individual pastoral visits arranged to meet care recipients’ spiritual, social and emotional needs. Care recipients are assisted by their family members to access church services in the community. Days of personal, cultural and spiritual significance are planned and celebrated with care recipient

Home name: Palm Lake Care Bargara RACS ID: 5409 20 Dates of audit: 13 December 2016 to 14 December 2016 family members encouraged to attend. The home is able to accommodate culturally appropriate diets should this be required. Care recipients/ representatives are satisfied care recipients’ cultural practices and spiritual beliefs are provided for and respected by staff.

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/or their representative are able to participate in decisions about the services the care recipient receives and is enabled to exercise choice and control over the services received. Information is provided to care recipients and/or their representatives on entry to the home regarding the care and services offered to meet their physical, intellectual, emotional, social and financial needs. Communication processes ensure care recipients and/or their representatives have an understanding of complaints and advocacy processes. Management are aware of processes to appoint alternative decision makers for care recipients when a need has been identified. Staff are aware of interventions to enable care recipients to exercise choice and make decisions relating to activities of their daily living. Care recipients/representatives are satisfied care recipients are enabled to exercise choice and make informed decisions over care recipients’ lifestyle at the home.

3.10 Care recipient security of tenure and responsibilities

This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".

Team’s findings

Care recipients and/or their representatives are provided with information regarding care recipients’ rights and responsibilities and security of tenure prior to and on entry to the home. Information provided includes fees and charges, the reasons and processes utilised for changes to tenure and goods and services to be provided by the home. Care recipients and/or their representatives are consulted about any changes to their security of tenure, rights or responsibilities through correspondence, newsletters and discussions at meetings as the need arises. Care recipients/representatives are satisfied care recipients have secure tenure within the home and are aware of their rights and responsibilities.

Home name: Palm Lake Care Bargara RACS ID: 5409 21 Dates of audit: 13 December 2016 to 14 December 2016 Standard 4 – Physical environment and safe systems

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

Team’s findings

Examples of improvements implemented by the home related to Standard 4 Physical environment and safe systems include:

 In response to staff feedback in relation to traffic congestion at a right angled corner in the corridor when care recipients are mobilising to and from the dining room with mobility aids, management purchased a convex mirror. The mirror was placed in the corner of the right angle corner to improve vision of others approaching. Management and staff report the mirror is working well and has reduced the potential risk of an incident and/or injury.

 In response to a suggestion made by a staff member to improve staff understanding and knowledge of work health and safety (WHS) within the working environment, management reviewed the education sessions. This resulted in management implementing an interactive training session for October 2016 WHS awareness month. The education sessions included the following:

– a word search containing words relating to ‘WHS’,

– staff members entering a mock scenario and identifying and recording potential hazards within the room,

– staff matching photos of work related injuries to the wording of the potential risks related to the incident.

Management reported staff provided positive feedback to the education session and participation levels were high.

Home name: Palm Lake Care Bargara RACS ID: 5409 22 Dates of audit: 13 December 2016 to 14 December 2016 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

In relation to Standard 4 Physical environment and safe systems, there are systems to ensure: compulsory fire training is provided for staff and a fire safety advisor is available as required, a maintenance program is in place, safety data sheets are available for chemicals used in the home, a current food safety program is in place and a food safety supervisor is accessible during the operation of the kitchen. Staff are provided with infection control training and have access to personal protective equipment. Processes are in place to monitor work health and safety requirements with training provided to promote safe work practices.

Team’s findings

In relation to Standard 4 Physical environment and safe systems, education has been provided in relation to: fire and emergency safety, chemical safety, manual handling, infection control, workplace health and safety and spill kits – content and use of.

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

As the home is a new purpose built facility which was opened in April 2016, management is continuing to work to maintain the current environment while providing a safe and comfortable environment consistent with care recipients’ care needs. The home provides single rooms with an en-suite and care recipients are provided with a 40 inch wall mounted television, a refrigerator and reverse cycle air conditioning. Care recipients and their representatives are invited to view the home prior to entry and are encouraged to bring in items that will assist in personalising the room and make it comfortable. The environment

Home name: Palm Lake Care Bargara RACS ID: 5409 23 Dates of audit: 13 December 2016 to 14 December 2016 provides access to hand rails, internal and external private seating areas and furniture appropriate to the needs of care recipients. Directional signage assists with navigation to the different areas of the home. The environment and equipment are maintained in accordance with the preventative maintenance schedule, cleaning checklists, and regular hazard and risk assessments. Where the need for protective assistive devices is identified, policies are available to guide staff in assessment, authorisation and review. Care recipients/representatives have input into the home’s living environment through meetings and feedback forms. Care recipients/representatives are satisfied management is working to provide a safe and comfortable environment.

4.5 Occupational health and safety

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

Team’s findings

Management, key personnel and staff are actively working to provide a safe and secure working environment that meets regulatory requirements. Work health and safety policies, procedures and mandatory education guide management and staff in the process of identification, notification and control of hazards; reporting and investigation of staff incidents, management of chemicals and environmental audits. All staff undertake training and education at orientation and annually thereafter in relation to work health and safety requirements, infection control, manual handling, safe handling of chemicals, and incident reporting and assessment. Chemicals are stored securely with access to safety data sheets. Staff accidents and incidents are investigated to determine causative factors, collated and analysed monthly with information discussed at relevant meetings and/or disseminated to staff via a communication folder to ensure effectiveness of interventions implemented. Staff reported satisfaction with the incident, hazard and maintenance reporting systems and management’s response to safety issues.

4.6 Fire, security and other emergencies

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

Team’s findings

Management and staff are actively working to minimise fire, security and emergency risks. The home’s fire systems, equipment and evacuation plans and emergency signage are maintained by organisation approved contractors. Evacuation plans and instructions are displayed in prominent areas of the home and explained to staff, care recipients and/or representatives upon orientation. Emergency exits are clearly marked, free from obstruction and are suitable for the mobility level of the care recipients. An emergency procedures folder, fire and evacuation procedures and the completion of mock fire drills guide management and staff in emergency situations. All staff are required to complete mandatory fire safety and evacuation training during orientation and annually thereafter. Care recipients are provided with information regarding sign in/out procedures and fire and evacuation procedures via information contained in their handbook. The home has internal lock-up procedures and security processes to ensure the safety of care recipients and staff at the home. Care

Home name: Palm Lake Care Bargara RACS ID: 5409 24 Dates of audit: 13 December 2016 to 14 December 2016 recipients/representatives are satisfied with staff knowledge and ability in the event of an emergency.

4.7 Infection control

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

Team’s findings

The home has an infection control program consisting of preventative procedures and practices, appropriate and sufficient equipment and staff training relevant to their role and responsibilities. A Food Safety Program guides staff in safe food handling processes which includes the use of colour coded equipment, correct storage and receipt of goods. The home has in place pest control measures and general and clinical waste management procedures. An immunisation program is available and offered to staff and care recipients. Staff have access to hand washing facilities and personal protective equipment located throughout the home. There is information to guide infection control processes, with outbreak information to guide staff practice should an outbreak occur. There is a monitoring program that oversees the incidence of infections to identify trends that may occur. Staff attend regular infection control training on, and are aware of infection control principles, during care and service delivery.

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

Hospitality services are provided in a way that enhances care recipients’ quality of life and staffs’ working environment. Catering services are provided to meet care recipients identified dietary needs and preferences through initial and ongoing assessments. Each care recipient’s meal summary form reflects their dietary information in relation to allergies, likes, dislikes and meal size to guide staff. Meals are provided following a four-week rotating menu which has been developed in conjunction with a dietitian. Cleaning services are provided five days per week in accordance with health and hygiene standards. Cleaning checklists ensure care recipient rooms, common areas, and service areas of the home are cleaned on a regular basis with the ability to complete ad hoc cleaning as required. All laundry services are completed on-site five days per week (Monday to Friday) by laundry staff using specialised equipment and practices that minimise risk of cross infection. Hospitality staff use colour coded equipment and personal protective equipment is readily available. Care recipients/representatives are satisfied with catering, cleaning and laundry services and have the opportunity to provide feedback through meetings and on a one to one basis. Staff are satisfied with their working environment.

Home name: Palm Lake Care Bargara RACS ID: 5409 25 Dates of audit: 13 December 2016 to 14 December 2016