Published Decision (SA and RA) s10

Huntingdon Gardens Aged Care Facility

RACS ID: 2590 Approved provider: Huntingdon Nursing Home Pty Ltd Home address: 1-11 Connemarra Street BEXLEY NSW 2207

Following an audit we decided that this home met 43 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 21 July 2020. We made our decision on 07 June 2017. The audit was conducted on 02 May 2017 to 04 May 2017. The assessment team’s report is attached. The Quality Agency came to a different view from that of the assessment team and finds the home does not comply with expected outcome 2.4 Clinical Care.

We will continue to monitor the performance of the home including through unannounced visits. ACTIONS FOLLOWING DECISION Since the accreditation decision, we have undertaken an assessment contact to monitor the home’s progress and found the home has rectified the failure to meet the Accreditation Standards identified earlier. This is shown in the ‘Most recent decision concerning performance against the Accreditation Standards’ listed below. Most recent decision concerning performance against the Accreditation Standards Since the accreditation decision we have conducted an assessment contact. Our latest decision on 21 July 2017 concerning the home’s performance against the Accreditation Standards is listed below. Standard 1: Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met Standard 2: Health and personal care 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. 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

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 2 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 Standard 3: Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community. 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional Support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and responsibilities Met Standard 4: Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors 4.1 Continuous improvement Met 4.2 Regulatory compliance Met 4.3 Education and staff development Met 4.4 Living environment Met 4.5 Occupational health and safety Met 4.6 Fire, security and other emergencies Met 4.7 Infection control Met 4.8 Catering, cleaning and laundry services Met

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 3 Audit Report

Name of home: Huntingdon Gardens Aged Care Facility RACS ID: 2590 Approved provider: Huntingdon Nursing Home Pty Ltd Introduction This is the report of a Re-accreditation Audit from 02 May 2017 to 04 May 2017 submitted to the Quality Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards. To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards. There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment. Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home. During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards. Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets:  44 expected outcomes

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 4 Scope of this document An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 02 May 2017 to 04 May 2017. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014. Details of home Total number of allocated places: 184 Number of care recipients during audit: 171 Number of care recipients receiving high care during audit: 128 Special needs catered for: Dementia specific unit

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 5 Audit trail The assessment team spent three days on site and gathered information from the following: Interviews

Position title Number

Director of nursing/executive director of care 1 services

Chief executive officer 1

Assistant facility manager 1

Deputy director of nursing 1

Assistant director of nursing/senior educator/ 1 infection control coordinator/fire safety officer

Registered nurses 6

Care staff 7

Lifestyle coordinator/recreational activity 5 officers

Counselling consultant 1

Physiotherapist 1

Physiotherapy assistant 1

Care recipients 20

Representatives 10

Administration assistant 1

Catering staff 3

Laundry staff 2

Contract cleaning service representative/ 2 cleaning staff

Maintenance/fire safety officer 1

Chemical service representative 1

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 6 Sampled documents

Document type Number

Care recipients’ files 22

Summary/quick reference care plans 19

Medication charts 40

Wound charts 6

Oxygen therapy administration directives 5

Personnel files 10

Other documents reviewed The team also reviewed:  Activity and lifestyle documentation: monthly and daily activity programs, personal profiles, diversional therapy care plans, activity attendance records, activity evaluations, consent record checklist  Care recipient information pack, handbook, resident and accommodation agreement including extra services schedule  Care recipient room listing  Cleaning and maintenance schedules  Clinical care: bowel charts, blood glucose level monitoring, continence management, meals and drinks, weight monitoring, wound management/dressings, pain charts, incident reports, medical officers directives of care, case conferences, electronic care documentation  Comments and complaints register, compliments  Continuous improvement: continuous improvement action work plan, audit schedule and results, monthly incident and infection control reports - trend analysis, staff satisfaction survey, care recipient/relative satisfaction survey, food satisfaction survey  External contractors: contracts and service agreements, contractor insurance details, preferred contractor/service supplier list, equipment service reports  Fire security and other emergencies: fire safety equipment and sprinkler system service records, fire safety audits, fire officer monthly checklists, evacuation plans, emergency procedures manual, disaster management plan  Food safety program: daily record sheets - food and equipment temperatures, NSW food authority audit results  Human resource management: induction checklist, staff handbook, statutory declarations, visa status, confidentially agreements, position descriptions, duty statements, rosters, staff allocation sheets, performance appraisals and schedule  Infection control information: manual, monthly summary of infection rates, infection register reports, care recipient and staff vaccination programs, audits, refrigeration temperature monitoring, pest control service reports, Legionella testing reports

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 7  Information and communication systems: policies and procedures, newsletters, memoranda, communication diaries, shift handover report forms, organisational chart, committee meeting agendas and minutes - workplace health and safety/infection control/food/safety/ continuous quality improvement, management, registered/enrolled nurses, staff, residents/relatives  Inventory and equipment: equipment register and lists, maintenance requests, internal and external preventative maintenance schedule, equipment service records; thermostatic mixing valve testing records, electrical test tagging  Medication management: drugs of addiction register, medication care plans, medication refrigerator temperature records, incident reports  Nutrition and hydration: food preference lists, specialised dietary requirements, seasonal menus, dietician review  Physiotherapy documentation: assessments and care plans, exercise schedule, walking program, falls’ prevention program  Regulatory compliance: consolidated incident reporting register, unexplained care recipient absences, staff and contractors police certificate checks, professional registrations - registered nurses, general practitioners, allied health  Self-assessment report for re-accreditation and associated documentation  Staff education: orientation program, monthly education calendar, mandatory and non- mandatory attendance record, staff qualifications, competency assessments Observations The team observed the following:  Activities and entertainment in progress, activities programs on display  Aged Care Complaints Commissioner and advocacy information on display  Archive room  Cleaning in progress, trolleys and supplies, wet floor signage in use  Daily exercise group in progress  Dining environments during midday meal services, morning and afternoon tea, staff serving/supervising  Displayed notices: Quality Agency re-accreditation audit notices, Charter of care recipients’ rights and responsibilities, mission statement  Electronic and hardcopy documentation systems  Equipment and supply storage areas including linen, continence and medical supplies  Feedback forms - ‘quick fix’ and comments/complaints, locked suggestion boxes  Firefighting equipment checked and tagged, fire indicator panel, sprinkler system, evacuation diagrams, evacuation resources  Hairdressing salon, café, gift shop, gymnasium  Huntingdon Gardens bus for care recipient outings  Infection control resources: hand washing facilities, hand sanitisers, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, locked clinical medication bins, infectious laundry handling, waste management

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 8  Information noticeboards, electronic boards  Interactions between staff and care recipients/relatives/visitors during: meal service and lifestyle activities  Kitchen and serveries, NSW food authority licence on display  Laundry, personal laundry, heat seal labelling machine  Living environment internal and external  Medication administration and storage  Menu on display  Mobility and manual handling equipment in use and in storage  Nurse call system and timely response by staff  Pressure relieving mattresses, bed rail protectors  Safe chemical and oxygen storage, safety data sheets (SDS) at point of use  Secure storage of care recipients’ clinical information and staff information  Short group observation in dementia secure unit  Sign in/out registers, keypad access, closed circuit television (CCTV) security cameras  Staff handover  Staff work practices and work areas

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 9 Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Management at Huntingdon Gardens Aged Care Facility actively pursues continuous improvement across the four Accreditation Standards. The home’s quality management system identifies improvement opportunities from a range of sources that include scheduled audit results; surveys; incident and clinical indicator trend analysis reporting; meetings and feedback mechanisms. Management develops a continuous improvement action work plan to enable identified areas for improvement to be prioritised, actioned and evaluated. Continuous improvement is discussed at the home’s combined workplace health and safety/infection control/food/safety/continuous quality improvement meetings. Care recipients/representatives and staff are encouraged to make suggestions and stated they are aware of improvements undertaken in the home. Examples of recent improvements implemented in relation to Accreditation Standard One include:  An extension to Huntingdon Gardens was undertaken in 2016 resulting in an increase in care recipient capacity to 171 beds, (Refer also to Standard Four continuous improvement.) As a result, a management restructure and recruitment of new staff across all designations of the home was undertaken. This included a roster review and an increase in staffing hours on a variety of shifts. New roles created include an assistant director of nursing; and exercise therapists. Care recipients/representatives commented on the dedication and caring attitude of staff across all designations at the home.  Management identified the audit tools in use at the home did not meet their needs. A new audit tool was purchased and implemented in 2015. As a result some issues were identified and rectified through the new audit tool. Examples include gaps in staff education; the need for additional questions in surveys; and the need for more staff training in complaints management. Feedback from staff utilising the audits is that the format is user friendly. 1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome The home’s management has systems in operation to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home monitors the regulatory environment through updates from government and industry

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 10 bodies, industry conferences, internet access and various other mechanisms. Staff are advised of regulatory requirements and any relevant changes to them through various means including memoranda, updates to policies, meetings and education. Compliance with regulatory requirements and other standards is monitored through a comprehensive audit program as well as day-to-day supervisory arrangements. We sighted relevant legislation and/or legal documentation displayed in various locations in the home. Examples of regulatory compliance related to Standard One Management systems, staffing and organisational development include:  ensuring care recipients/representatives were informed of the Quality Agency re- accreditation audit in keeping with legislative requirements  ensuring care recipients and other stakeholders have access to complaints mechanisms  ensuring police certificate checks are undertaken for staff, and applicable volunteers and contractors  ensuring relevant staff meet statutory declaration and visa requirements  monitoring external service providers for applicable insurances, registrations, licences and other necessary regulatory requirements. 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome It was evident from our observations, document review and interviews that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has an education program which is based on educational needs identified through a wide range of mechanisms. These include a training needs analysis process, feedback from various meetings, the staff appraisal process, and the quality improvement system. The education program is comprehensive and covers a range of functional areas encompassing all four Accreditation Standards. The program is reinforced by competency assessments in relevant areas. Staff also have access to relevant external educational opportunities and where appropriate are supported to obtain formal qualifications. Examples of recent education sessions related to Accreditation Standard One Management systems, staffing and organisational development include:  Assessing the Accreditation Standards; clinical documentation and aged care funding instrument (ACFI); managing complaints; use of a range of equipment. In addition, the home’s orientation program incorporates a range of topics relating to management systems, staffing and organisational development. Refer expected outcome 1.6 Human resource management for other mechanisms designed to ensure appropriate staff performance. 1.4 Comments and complaints This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome The home has a policy and procedures for feedback management. All stakeholders are encouraged to provide feedback on the services provided through meetings; newsletters;

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 11 surveys; brochures and notices. Care recipients/representatives are informed of the internal and external complaints mechanisms on entry to the home. This is documented in the information pack provided and residential agreement. Management has an ‘open door’ policy for feedback from all stakeholders. Feedback forms are readily accessible and locked suggestion boxes are available for confidential issues. Information on the external Aged Care Complaints Commissioner and advocacy services is on display. Feedback received including compliments, comments and complaints are logged by management. Any complaints received are responded to and actioned in a timely manner. Feedback received is discussed at the home’s meetings. Care recipients/representatives and staff stated management is very approachable to discuss any issues that arise. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome Huntingdon Gardens has a mission statement documented in publications and on display in the home. The Charter of care recipients’ rights and responsibilities is documented in the residential agreement and is also on display in the home. The home’s commitment to quality is demonstrated in the pursuit of continuous improvement activities. The home’s vision, values, objectives and philosophy of care are promoted through staff orientation and ongoing education. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome The home has policies and procedures to facilitate recruitment to ensure selected staff meet the requirements of their roles. Human resource management is implemented through position descriptions; provision of a handbook; an orientation program; ‘buddy’ shifts; and duty lists. Management ensures sufficient skilled and qualified staff are rostered to meet the needs of care recipients. This includes 24 hour registered nurse cover. There is a casual pool of staff available to fill shifts if required and agency staff are not utilised. Staff personnel files are stored securely at the home and contain a signed privacy and confidentiality of information agreement. Human resource management is monitored through probationary and annual performance appraisal; meeting and personal feedback; surveys; audits; and results of clinical indicator reports. Staff stated they can complete their duties on shift and management is very supportive. Care recipients/representatives stated staff are very caring and polite. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome There are policies and procedures for ensuring there are stocks of appropriate goods and equipment available for quality service delivery. The home has an overall purchasing system of preferred suppliers designed to ensure desired standards are met. A stock control and

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 12 ordering system is in operation, with particular staff roles having specific responsibility for particular areas of inventory monitoring and ordering. The home also has clear procedures for purchasing necessary equipment for use in various functional areas and in response to care recipients’ needs. We observed storerooms, staff areas, clinical areas, the kitchen, laundry and other work areas to be well equipped, well stocked and well maintained. Staff advised there were adequate supplies of inventory and equipment for them to perform their job roles effectively. A routine and preventive maintenance program is in operation which, among other things, ensures equipment is maintained and ready for use. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome Huntingdon Gardens has effective information management systems. Care recipients/ representatives are provided with information prior to entry; in a residential agreement; a handbook; by newsletters and notices. Case conferences and ongoing consultation with care recipients/representatives are offered by clinical staff to ensure care needs are met. The home’s information systems, documentation and publications ensure all staff have access to current policies, procedures and information relevant to their roles in the home. Induction of new staff; a handbook; handover; memoranda; education and meetings are also mechanisms to ensure current information is available for staff. Electronic information is backed up daily and password protected with access appropriate to position. There are systems for archiving and document destruction to ensure confidentiality of care recipient information. Management monitors the effectiveness of the information systems through meetings; audits; surveys and verbal feedback. Care recipients/representatives and staff stated they are well informed of matters of importance to them. 1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome The home has a system to ensure externally sourced services are provided in a way that meets the home’s needs and service quality goals. A range of contractors and external service providers operate within contracts and agreements covering care recipient and care related services, fire systems and various building maintenance and services. Service agreements encompass the home’s requirements/expectations for quality service provision, relevant insurances and police checks (where appropriate). The home’s management and staff monitor the performance of external service providers and take appropriate action in order to ensure that services are provided at the desired level of quality. The home also relies on feedback from care recipients/representatives to assess the quality of service providers such as dental, optometry, podiatry, hairdressing, beautician and other similar care recipient-related services. It was reported there are good working relationships with the range of external service providers and services are being provided at desired levels.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 13 Standard 2 – Health and personal care Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Two include:  Management received negative feedback from a relative regarding the oral and dental care of a care recipient. A NSW state funded oral health project was approached to assess care recipients, undertake dental work and provide staff education at the home. Approximately 50 care recipients consented to utilise the service. Staff attended compulsory education sessions on oral and dental care. The lead dental officer reported a 37 per cent improvement in the oral hygiene of care recipients on follow up. Changes to dental practice introduced as a result of the project include improved storage of dentures and seasonal colour coded change of toothbrushes. The program is of benefit for care recipients who would have difficulty in accessing dental services in the community.  Huntingdon Gardens implemented a quarterly site-based medication advisory committee (MAC) in March 2017. The committee reviews and guides the home’s medication management policies and procedures and reviews any medication incidents. Previously clinical staff attended a regional MAC meeting. A medical officer, pharmacist and key personnel from the home attend. To date the committee has reviewed the home’s nurse initiated medication list and introduced a new anti-coagulant therapy chart. As a result, care recipient medication management specific to the home is better managed. 2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about health and personal care”. Team’s findings The home meets this expected outcome The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard Two Health and personal care. Examples of regulatory requirements in relation to Accreditation Standard Two include:  having appropriate arrangements in operation to ensure the correct management and administration of medications  monitoring relevant registrations of nursing and allied health professionals  having policies and procedures to manage unexplained care recipient absence in accordance with regulatory requirements.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 14 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard Two Health and personal care. Examples of recent education sessions related to Standard Two include:  Managing the acute aged care patient; dementia care; managing challenging behaviours; nutrition and dementia; oral and dental health; managing inflammatory arthritic conditions; enteral nutrition; continence aids and management; palliative care; pressure injury management; motor neurone disease; reporting processes for unexplained care recipient absence. The education program is reinforced by competency assessments in appropriate areas. In addition, care staff have or are obtaining relevant certificate level qualifications. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome Huntingdon Gardens provides care recipients with appropriate clinical care through initial and ongoing assessments, care planning and evaluation processes. The home has systems that enable care recipients/representatives to exercise control over the care they receive and to provide input into care recipients' care planning. The registered nurses review and evaluate care recipients’ individual plans of care every three months or when required. Relevant staff are informed of any alterations/exceptions to the usual care required by the care recipient through handovers, progress notes, meetings, communication diaries and verbally. On most occasions care recipients’ weights, vital signs and urinalysis results are recorded monthly or as ordered by the medical officer. An accident and incident reporting system is in place for the reporting of incidents such as falls, skin tears and behaviours of concern. Staff demonstrate knowledge of care recipients’ care needs ensuring that care recipients’ clinical care is being met. All care recipients/representatives interviewed are satisfied with the timely and appropriate assistance given to care recipients by care staff. 2.5 Specialised nursing care needs This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome Care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff, with medical officer input when required. This includes registered nurse input into assessment, management and care planning for care recipients. The home currently provides specialised nursing care for care recipients requiring dementia care, diabetic management, catheter care, oxygen therapy, wound care and pain management. Staff are provided with education in specialised nursing procedures. Staff confirmed they have access to adequate supplies of equipment for the provision of care recipients’ specialised nursing care needs. Care recipients/representatives are satisfied with the level of

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 15 specialised nursing care offered to care recipients by nursing, medical and/or other health professionals and related service teams. 2.6 Other health and related services This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”. Team’s findings The home meets this expected outcome Staff interviews, progress notes, medical notes, pathology, allied health and hospital discharge information demonstrates timely referrals for care recipients are arranged with appropriate health specialists as required. The registered nurse has regular access to a physiotherapist, podiatrist, speech pathologist, optometrist and community clinical nurse consultants. Regular review and evaluation of care recipients’ health and well-being and referrals are carried out by the registered nurse in collaboration with care staff and medical officers. Effective monitoring is achieved through the handover of key care recipient information to relevant staff. When required, care recipients’ medical officers are alerted and consulted. Care recipients/representatives stated referrals are made to the appropriate health specialists in accordance with care recipients’ needs and preferences. 2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Huntingdon Gardens has processes to ensure care recipients’ medication is managed safely and correctly. These include policies and procedures, regular pharmacy deliveries, the secure storage of medications and internal/external audits. Staff administer medication using a prepacked system and the registered nurse oversees the home’s medication management system and processes. Review of care recipients’ medication profiles show current medical officers’ orders are recorded and information includes medication identification sheets, care recipients’ photographic identification and medication allergy status. All staff who administer medications are assessed according to the home’s medication policy through annual skills based assessments or as required. Care recipients/representatives said they are satisfied with the home’s management of care recipients’ medication. 2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome All care recipients are assessed to identify their pain history on entry to the home with medical officer input in determining the effectiveness of interventions. A multidisciplinary approach involving the care recipient’s medical officer, nursing staff, physiotherapist and recreational activity officers supports the care recipient’s pain management program. Staff are knowledgeable about the many ways of identifying care recipients who are experiencing pain. Pain management strategies include pharmacological reviews, various non- pharmacological interventions and treatment in liaison with care recipients’ medical officers. Care recipients are repositioned, assisted with movement and exercise, given gentle heat therapy, massage and are involved in distraction therapy. Care recipients said the care provided at the home relieves their pain or it is managed so they are comfortable.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 16 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome The home has a suitable environment and culture to ensure the comfort and dignity of terminally ill care recipients is maintained. Where possible, care recipients' end of life wishes are identified and documented on entry to the home or at an appropriate time thereafter, through the assessment process. The home has specialised clinical and comfort devices to ensure and maintain care recipient palliation needs and preferences. The local clergy visit and are available to provide emotional and spiritual support. The home has a variety of resources and equipment that families, friends and staff can use for the benefit of the care recipient. Staff receive ongoing education and describe practices appropriate to the effective provision of palliative care. Care recipients/representatives said the home’s practices maintain the comfort of terminally-ill care recipients. 2.10 Nutrition and hydration This expected outcome requires that “care recipients receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome The home has processes to provide care recipients with adequate nourishment and hydration. Care recipients are assessed for swallowing deficits and other medical disorders, allergies, intolerances, food likes and dislikes, as well as cultural or religious aspects relating to diet. Provision is made for care recipients who require special diets, supplements, pureed meals and thickened fluids or extra meals and snacks throughout the day. The information is recorded on a care recipient’s nutrition and hydration form and sent to the kitchen. Care recipients are provided with assistance at meal times and assistive cutlery and crockery are available. The home monitors nutrition and hydration status through staff observations and recording of care recipients’ weights with variations assessed, actioned and monitored. Care recipients are referred to a dietician and/or speech pathologist when problems arise with nutrition. Care recipients/representatives are satisfied they are able to have input into menus and care recipients’ meals. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The home has a system to ensure care recipients’ skin integrity is consistent with their general health. Initial assessment of the care recipient’s skin condition is carried out along with other assessments relating to and influencing skin integrity. Care recipients have access to nutritional support, podiatry, hairdressing and nail care according to their individual needs and choices. Maintenance of skin tears, skin breakdown and required treatments are documented, reviewed and noted on wound care charts. The home’s reporting system for accidents and incidents affecting skin integrity is monitored monthly and is included in clinical indicator data collection. The home has a range of equipment in use to maintain care recipients’ skin integrity. Care staff help to maintain care recipients’ skin integrity by providing regular pressure care, by applying skin guards and by using correct manual handling practices. Care recipients/representatives are satisfied with the skin care provided to care

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 17 recipients and report that staff are careful when assisting them with their personal care activities. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome The home has a system for identifying, assessing, monitoring and evaluating care recipients’ continence needs to ensure their continence is managed effectively. Processes are in place for the distribution of care recipients’ continence aids and informing staff of care recipients’ continence aid needs. Care recipients are assisted and encouraged to maintain or improve their continence level in a dignified and supportive manner. Care staff have access to adequate supplies of continence aids to meet care recipients’ needs and they provide care recipients with individualised toileting programs as indicated. Bowel management programs include daily monitoring and various bowel management strategies. For example: regular drinks, aperient medications if necessary and a menu that contains high fibre foods such as fresh fruit and vegetables and a variety of fruit juices. Infection data, including urinary tract infections, is regularly collected, collated and analysed. The home’s continence supplier provides ongoing advice and education for staff and care recipients. Feedback from care recipients/representatives shows satisfaction with the continence care provided to care recipients. 2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The needs of care recipients with challenging behaviours are managed through consultation between the care recipient and representative, staff, medical officers and allied health professionals. Care staff and recreational activity officers implement a range of strategies to effectively manage care recipients with challenging behaviours. The care recipients’ challenging behaviours are monitored and recorded with referrals made to their medical officer and/or external health specialists as appropriate. Staff are able to recognise the triggers and early warning signs exhibited by some care recipients and put in place appropriate strategies to manage behaviours. The team observed the environment to be calm and care recipients well groomed. Care recipients/representatives said staff manage care recipients’ challenging behaviours well. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”. Team’s findings The home meets this expected outcome Care recipients are assisted to maintain their mobility, dexterity and independence for as long as possible. Clinical assessments on entry identify the assistance required by care recipients for transferring and mobility. A care recipient’s mobility status and falls risk are assessed by a registered nurse when the care recipient moves into the home and as their needs change. This is followed by a physiotherapy review if necessary. Individual treatments include massage, heat treatments and exercises. Falls prevention strategies include the completion of risk assessments. Interventions noted include group exercises and the provision of specialised equipment such as mobility aids, ramps and handrails. Staff are able

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 18 to discuss an individual care recipient’s needs and were seen assisting care recipients to mobilise within the home. Care recipients said they are satisfied with the program and assistance they receive from staff. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome The home has systems to ensure care recipients’ oral and dental health is maintained. Care recipients’ dental needs are identified through assessment and consultation with the care recipient and representative on a care recipient’s entry to the home and as their needs change. Appropriate dental health is planned and staff are informed of the care recipients’ needs. The care recipient’s medical officer is consulted if there are any needs and a referral may be made to a specialist and/or a dentist for further assessment or treatment. Ongoing care needs are identified through care recipients’ feedback, staff observation of any discomfort, or reluctance to eat and weight variances. Care recipients are encouraged to maintain their oral and dental health with staff providing physical assistance and prompts where necessary. Care recipients/representatives said they are satisfied with the oral and dental care provided to them. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome The home assesses care recipients’ vision and hearing initially on entry and on an ongoing basis. Other sensory assessments for touch, smell and taste are undertaken when assessing care recipients’ nutritional needs, dexterity and interest in activities. These are documented on care recipients’ care plans to prompt and instruct staff on how to care for and engage care recipients appropriately. The home’s activity program features activities to stimulate care recipients’ sensory functions. Staff described types of group and individual activities which encourage active participation from care recipients with sensory deficits. Staff said they employ various strategies to assist care recipients with sensory deficits. These include positioning, utilising and adapting materials and equipment to enhance care recipients’ participation, adapting the environment to ensure it is conducive to maximising care recipients’ enjoyment and participation in the chosen activity. Care recipients/ representatives said they are satisfied with the home’s approach to managing care recipients’ sensory losses. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome The home assists care recipients to achieve natural sleep patterns through a sleep assessment, care planning, choice of time for going to bed and rising, and staff support at night. Staff are able to explain the various strategies used to support care recipients’ sleep. For example: offering warm drinks or snacks, appropriate pain and continence management, comfortable bed, repositioning and night sedation if ordered by the medical officer. Care recipients can use the nurse call system to alert the night staff if they have difficulties in

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 19 sleeping. Care recipients stated they sleep well at night. Care recipients/representatives said they are satisfied with the home’s approach to care recipients’ sleep management.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 20 Standard 3 – Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Three include:  A counselling consultant specialising in dementia care was engaged by the home in April 2015. This was in response to feedback from care recipients/representatives on the need for additional emotional support when transitioning from their own home to residential care. The counsellor attends the home weekly to provide individual support to care recipients/representatives and group meetings. Staff education and training is also provided. Evening workshops on ‘Being Dementia Aware’ are also held quarterly. Feedback from care recipients/representatives and staff is very positive regarding the support and assistance the counsellor provides to them.  Recreational activity officers identified a number of care recipients were having difficulty in reading the monthly activity program due to the amount of information recorded. The activity program could not always reflect last minute changes necessary to meet the changing needs and requests of care recipients. This caused difficulty for some representatives. As a result, the diversional therapy and physiotherapy teams now provide a simple daily integrated program for each of the four main areas of the home. Copies of the daily program are readily available for all care recipients/representatives. Feedback was positive from care recipients on this improvement in that the program is current, easy to read and keeps them well informed of the day’s events. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”. Team’s findings The home meets this expected outcome The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards including Standard Three Care recipient lifestyle. Examples in relation to regulatory requirements for Standard Three include:  having various arrangements in operation to meet obligations regarding staff and care recipients’ confidentiality and privacy provisions  ensuring care recipients’ security of tenure and informing care recipients of their rights and responsibilities  having mechanisms to ensure the appropriate reporting of suspected or alleged incidents of elder abuse.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 21 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard Three Care recipient lifestyle. Examples of recent education sessions related to Standard Three include:  Compulsory reporting and elder abuse; lesbian, gay, bisexual, transgender and intersex (LGBTI) awareness and inclusion; loss and grief – responding to grieving people; cultural considerations in palliative care; sexuality and ageing; sexuality and dementia; anxiety and depression – supportive management for the older person; advance care planning; music therapy; chair tai chi; aged care and cultural diversity; depression in the elderly. Moreover, various care recipient lifestyle issues such as privacy and dignity are covered indirectly in the staff education program in the treatment of issues relating to care recipients’ health and personal 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 The home meets this expected outcome There are effective systems to ensure each care recipient receives initial and ongoing emotional support. New care recipients are supported by management and staff through orientation to the home; introductions to other care recipients and to activities of interest in the home as they occur. Emotional needs are identified through the lifestyle assessments including one-to-one support and family involvement in planning of care. Emotional support for care recipients/representatives is also offered by a counselling consultant in both a group and on an individual basis. Staff encourage care recipients to engage in life at the home while also respecting their independence, choices and privacy. Care recipients/ representatives stated they are satisfied with the way they are assisted to adjust to life at the home and the ongoing support they receive. 3.5 Independence This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome The home has processes which encourage care recipients’ independence and participation in community life. There is a range of individual and general strategies implemented to promote independence including exercise and lifestyle engagement programs. Each care recipient’s level of independence and their need for assistance is assessed on entry to the home and reviewed as needed. The home promotes care recipients’ links with the community through for example bus trips; visits from community groups; and voting in government elections is facilitated on-site. Staff gave examples of how they assist an individual care recipient to remain as independent as possible as part of daily interactions.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 22 Care recipients/representatives said they are satisfied with the home’s processes to maximise care recipients’ community involvement and independence. 3.6 Privacy and dignity This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome There are systems to ensure care recipients’ privacy and dignity is respected in accordance with individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs with respect to their privacy. Permission is sought to protect privacy for example in the use of photographs. All personal information is collected and stored securely with access only by authorised staff. Staff sign a confidentiality agreement to protect care recipients’ personal information. We observed staff respecting care recipients’ privacy by knocking on their doors prior to entering and interacting with care recipients in a dignified and respectful manner. Care recipients/representatives stated care recipients’ privacy and dignity is well respected. 3.7 Leisure interests and activities This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome Care recipients are encouraged and supported to participate in an extensive range of interests and activities of interest to them. Care recipients’ specific needs, interests and preferences are assessed through completion of a personal profile on entry to the home and monitored on an ongoing basis. A care plan that reflects the care recipients’ social, spiritual and culture preferences and needs is developed to ensure all staff have an understanding of the individual care recipient. The physiotherapy and diversional therapy teams at the home provide an integrated program and promote exercise as a means to maintain an active life within the individual’s capability. The range of activities is designed to meet care recipients’ sensory, intellectual, physical, social and spiritual needs. Programs based on their individual choices and interests are offered in all areas of the home seven days a week. One-to-one visits are offered for care recipients unable or who prefer not to participate in group activities. Attendance records are maintained to assist recreational activity officers with program planning. Care recipients stated they are very satisfied with the activities program in the home. They stated they especially enjoy bus trips; ‘fast’ bingo; art and music therapy; and the daily exercise programs. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome The home has processes to promote care recipients’ interests, customs, beliefs and cultural backgrounds that are identified during the assessment process. Multi-lingual information is available for care recipients from a culturally and linguistically diverse background if required. Care recipients are actively encouraged to maintain cultural and spiritual links in the community. Care recipients are encouraged and supported to maintain affiliation with their own place of worship. Pastoral visitors of various denominations regularly attend and religious services are also held at the home. The home recognises and celebrates days of

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 23 cultural significance and anniversaries of importance to the care recipients. Care recipients/ representatives said they are satisfied with the support provided for care recipients’ cultural and spiritual needs. 3.9 Choice and decision-making This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home has processes to ensure each care recipient (or their representative) participates in decisions about the services received by the care recipient. These processes uphold the care recipient’s right to exercise choice and control over his or her lifestyle. Care recipients are informed and given opportunities to provide input into the home through systems such as assessment and care planning processes, surveys and at meetings. Where care recipients are unable to make choices for themselves, an authorised decision maker is identified. Care recipients gave examples of how they are able to exercise choice and decision making. These included their personal care regimes; waking and sleeping times; choice of general practitioner; choice of meal; and attendance at activities. Care recipients/representatives said staff support care recipients in making their own lifestyle choices and decisions. 3.10 Care recipient security of tenure and responsibilities This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome The home has processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. An information pack and a residential agreement are provided to all care recipients. A schedule for extra services is provided as appropriate. The agreement sets out the standard requirements under the relevant legislation including security of tenure; information about care recipients’ rights and responsibilities; fee payment options; cooling-off periods and rules of occupancy. Details are discussed with care recipients and/or their representative prior to entry to the home. Care recipients/ representatives are advised to obtain independent financial and legal advice. The Charter of care recipients’ rights and responsibilities is also displayed in the home. Care recipients/ representatives stated they feel secure in their tenure in the home and they have an understanding of their rights and responsibilities.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 24 Standard 4 – Physical environment and safe systems Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer to Expected Outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system. Examples of recent improvements implemented in relation to Accreditation Standard Four include:  Huntingdon Gardens underwent the building of a new extension with 75 extra services rooms and refurbishment of the original building in 2016. The home’s capacity has increased to 171 beds for care recipients. The completed home also includes additional amenities such as a new hairdressing salon; a cafe; a care recipient gymnasium; an auditorium; and a cinema. Care recipients feedback was very complimentary on the design and style of the completed home. They said there are a number of areas they can entertain visitors in comfort.  An issue was identified that some care recipients inclined to wander were entering other care recipient rooms. As a result, electronic access control locks have been installed on most care recipient room doors. The locks can be freely opened from the room’s interior and are unlocked from the outside by an electronic key worn on a wrist band. This has proved preferable to a key lock. As a security improvement, care recipients able to wear the wrist band can readily enter their own room with no risk of intrusion from others.  Due to the home’s increased size, management decided to outsource cleaning to a contract service provider. Feedback from care recipients/representatives is the change provides improved quality of services and enhances the home’s environment. 4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome The home’s systems for ensuring regulatory compliance, outlined in expected outcome 1.2 Regulatory compliance, encompass all four Accreditation Standards, including Standard Four Physical environment and safe systems. Examples of regulatory requirements in relation to Standard Four include:  displaying relevant regulatory information concerning work health and safety legislation  appropriate testing for items such as Legionella, thermostatic mixing values, electrical tagging  certification of relevant plant and equipment such as lifts  the installation of fire safety systems including sprinklers, displaying the annual fire safety statement in accordance with legislative requirements, and staff undertaking mandatory fire safety training

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 25  various arrangements to ensure the home meets food safety requirements such as those encompassed in the NSW food authority's vulnerable person's food safety scheme and its licensing and audit requirements. 4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome The home’s comprehensive approach to education and staff development, outlined in expected outcome 1.3 Education and staff development, encompasses all four Accreditation Standards including Standard Four Physical environment and safe systems. Examples of recent education sessions related to Standard Four include:  Fire safety and evacuation; manual handling (including use of lifters and other equipment); infection control (including hand washing); work health and safety (WHS); chemical awareness/handling; food safety and safe food handling; food service etiquette. In addition, staff have attended external training courses related to their specialist roles such as fire safety officer training. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs". Team’s findings The home meets this expected outcome The home’s management is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. This is achieved through such mechanisms as regular environmental safety inspections, cleaning, maintenance and other safety related checks, and incident and accident reporting. There are also care recipient feedback mechanisms, such as meetings, surveys, and direct discussions with management, in relation to the comfort and safety of the living environment. Care recipients/representatives stated the home is safe and comfortable. This view was also supported by various safety monitoring and reporting data we reviewed. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome There are effective mechanisms in operation to ensure management is actively working to provide a safe working environment that meets regulatory requirements. The safety system is monitored by the home’s work health and safety (WHS) committee. The system includes regular staff induction and regular training (including manual handling); regular safety related audits and inspections; hazard reporting; accident and incident reporting and risk assessments. A preventative and routine maintenance program is in operation in the home, which helps ensure the overall safety of the environment and equipment. There have been minimal incidents relating to staff safety, thereby indicating the effectiveness of the home’s approach to work health and safety.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 26 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome The home’s management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire safety systems in the home include fire detection and alarm systems; a sprinkler system; firefighting equipment; exit signs and evacuation plans. The home has formal, external contractual arrangements for the monitoring and maintenance of all its fire safety equipment and systems. We sighted the annual fire safety statement appropriately displayed. The home has accredited fire safety officers who monitor relevant fire safety issues and an evacuation kit is maintained. Staff training records confirm staff participate in regular mandatory fire safety training. Staff interviewed are aware of fire safety and emergency procedures. We observed the home provides a secure environment including secured doors; keypad locks, lock up procedures and appropriate overnight staffing arrangements. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has an infection control policy and program with infection control clinical indicators and antibiotic use collated monthly and analysed for trends. Preventative measures include infection control education and hand washing skills; hand washing facilities; hand sanitiser availability; a cleaning program throughout the home and a care recipient and staff vaccination program. There is a food safety program in the kitchen to monitor food and equipment temperatures. Outbreak management information and resources are available. The home maintains a waste management system and a pest control program. Results of infection control audits and clinical indicator reports are monitored by management and discussed at the home’s meetings. Staff have access to personal protective clothing and colour coded equipment and have understanding of infection control measures relevant to their work area. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome The home has implemented policies, procedures and appropriate arrangements to ensure hospitality services are provided in a way that enhances care recipients’ quality of life and the staff working environment. The hospitality services are subject to regular monitoring and audits to ensure they are operating at desired levels. The catering system ensures care recipients’ preferences are taken into account in the food planning process and appropriate choices and alternatives are offered. Care recipients/representatives have input into menus through meetings, surveys, regular feedback directly to staff and other communication. Cleaning services are provided by a contracted service. We noted the cleaning system is well organised and effective, with common areas and each care recipient’s room being cleaned regularly. Laundry services are provided effectively, with care recipients’ personal items being washed and returned to their owner within a reasonable turnaround time. Our

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 27 interviews indicate care recipients/representatives are satisfied with the way in which the home provides hospitality services.

Home name: Huntingdon Gardens Aged Care Facility Date/s of audit: 02 May 2017 to 04 May 2017 RACS ID: 2590 28