Regis Port Stephens

RACS ID 0611 40 Bagnalls Beach Road CORLETTE NSW 2315

Approved provider: Regis Aged Care Pty Ltd - NSW

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 11 March 2020.

We made our decision on 18 January 2017.

The audit was conducted on 13 December 2016 to 15 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: Regis Port Stephens RACS ID: 0611 2 Dates of audit: 13 December 2016 to 15 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: Regis Port Stephens RACS ID: 0611 3 Dates of audit: 13 December 2016 to 15 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: Regis Port Stephens RACS ID: 0611 4 Dates of audit: 13 December 2016 to 15 December 2016 Audit Report

Regis Port Stephens 0611

Approved provider: Regis Aged Care Pty Ltd - NSW

Introduction

This is the report of a Re-accreditation Audit from 13 December 2016 to 15 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: Regis Port Stephens RACS ID: 0611 1 Dates of audit: 13 December 2016 to 15 December 2016 Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 13 December 2016 to 15 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: 150

Number of care recipients during audit: 144

Number of care recipients receiving high care during audit: 140

Special needs catered for: 45 dementia specific

Home name: Regis Port Stephens RACS ID: 0611 2 Dates of audit: 13 December 2016 to 15 December 2016 Audit trail

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

Interviews Category Number Facility manager 1 Regional manager 1 Compliance manager 1 Assistant manager 1 Customer service manager 1 Office coordinator 1 Clinical support team leader 1 Clinical team leaders 2 Registered nurses 4 Registered nurse medical surgery liaison 1 Endorsed enrolled nurses 2 Care staff 11 Physiotherapist 1 Occupational therapist 1 Care recipients 12 Representatives 17 Volunteers 4 Pharmacist 1 National volunteer/Lifestyle support 1 Lifestyle coordinator 1 Recreational activity staff 4 Cleaning staff 2 Laundry staff 2 Regional maintenance officer Qld & NSW 1 Maintenance officers 2 Regional catering manager 1 Chef/manager 1

Home name: Regis Port Stephens RACS ID: 0611 3 Dates of audit: 13 December 2016 to 15 December 2016 Category Number Catering staff 4

Sampled documents Category Number Care recipient files 14 Wound management files 5 Medication charts 14 Staff files 9 Resident agreements 9

Other documents reviewed

The team also reviewed:

 Allied health: physiotherapy pain management treatment and exercise, podiatry treatments, dietician reviews, audiology and dental reviews and treatments

 Audits and surveys

 Care recipient room listing

 Catering documentation including cleaning schedules/logs, temperature logs food/fridges, food safety manual, calibration records, care recipient preferences, theme day menus, task lists, nutrition manual, memorandum, kitchen maintenance

 Cleaning documentation including policies, processes, signing sheets, schedules, training, infection control, task lists

 Clinical care: assessments and care plans, medical consults, care recipients advanced care directives and palliative care team reviews, case conference records, clinical monitoring charts including blood pressure, blood glucose levels, fluid intake, pain, weight, specialist consultations reviews, pathology

 Comments, compliments and complaints

 Continuous improvement documentation including logs, action plans, evaluations

 Education documentation including calendar, training needs analysis and surveys, consolidated register, online education schedules, evaluations, attendances, toolbox talks, competencies, and mandatory education

 Emergency disaster folder, emergency evacuation resident list including important information about care recipients

 External services documentation including policies, insurances, approved supplier lists, contracts and agreements

Home name: Regis Port Stephens RACS ID: 0611 4 Dates of audit: 13 December 2016 to 15 December 2016  Handbooks including staff and residents

 Human resource documentation including rosters, allocation lists, performance appraisals, induction checklists, qualifications, professional registrations, competencies, position descriptions, confidentiality statements, statutory declarations, police checks

 Infection control information including manual, trend data, outbreak management program, care recipients/staff vaccination records, infection incidence and antibiotic utilisation chart, pest control records

 Infection control information: care recipient/staff vaccination program, audits, infection control clinical indicator reports, pest control service reports, refrigeration temperature monitoring,

 Laundry documentation including cleaning schedules, policies and procedures, laundry schedules

 Lifestyle: assessments, care plans, attendance records, activities calendar, residents’ meeting minutes, newsletters

 Mandatory reporting log, action plans, responses

 Medication management: medication charts, schedule eight medication records, medication reviews, medication audits and incident reporting

 Nutrition and hydration: diet analysis forms, diet allergy list, dietary needs matrix, menu, dietician review, drinks lists, thickened fluid requirements

 Policies and procedures

 Preventative and reactive maintenance documentation including calendars, schedules, logs, corrective actions, procedures

 Safety data sheets

 Self-assessment report for accreditation

 Spiritual care: assessments, care plans, activities records, spiritual/religious contacts

 Testing/tagging records and asset register

 Warm water testing

 Work, health and safety documentation including environmental audits and meetings

Observations

The team observed the following:

 Activity program on display, activities in progress and activity resources

 Annual fire and food safety authority certificates

Home name: Regis Port Stephens RACS ID: 0611 5 Dates of audit: 13 December 2016 to 15 December 2016  Archive storage and records

 Care recipients utilising pressure relieving mattresses, bed rail protectors, hip and limb protection equipment

 Charter of care recipients’ rights and responsibilities on display

 Cleaning in progress, equipment in use and safe staff practices

 Code of conduct for visitors to facility

 Coffee lounge

 Complaints, comments and compliments forms, aged care complaints scheme and advocacy brochures, suggestion boxes, aged care complaints scheme posters in various languages

 Dining environments during lunch and beverage services with staff assistance, morning and afternoon tea, including resident seating, staff serving/supervising, use of assistive devices for meals and care recipients being assisted with meals in their rooms

 Emergency equipment including extinguishers, blankets, sprinklers, hydrants, evacuation backpack, emergency lighting, and sensor lighting

 Equipment and supply storage rooms including clinical, medication, toiletry, chemical, paper goods, continence and linen stock in sufficient quantities

 Hairdressing salon

 Infection control resources: including hand washing facilities, spill kits, personal protective equipment, colour coded cleaning equipment, hand sanitiser dispensers throughout the home, waste disposal facilities, outbreak kits, instruction to staff and visitors, refrigerator temperature checking charts, outbreak manual available

 Infection control signage, personal protective equipment, spills kits, infectious waste bins, sharps disposal containers, hand-washing facilities, colour coded cleaning equipment, garbage storage areas, hand sanitiser dispensers, outbreak boxes

 Interactions between staff, visitors and care recipients

 Living environment internal and external, resident library/sitting room

 Medical and allied health professionals in attendance

 Medication administration

 Menu displayed

 Notice boards containing resident activity programs and notices, menus, memos, staff and resident information, comments and complaints information, notices informing residents/representatives of the re-accreditation site audit

 Nurse call system and response by staff

Home name: Regis Port Stephens RACS ID: 0611 6 Dates of audit: 13 December 2016 to 15 December 2016  Residents visitor, contractor sign in/out books

 Secure storage of care recipient and staff information

 Sensory interactive walls

 Short group observation

 Staff work practices and work areas

 Vision, mission and values statement – Regis way: Optimism, passion, integrity, respect

Home name: Regis Port Stephens RACS ID: 0611 7 Dates of audit: 13 December 2016 to 15 December 2016 Assessment information

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

Standard 1 – Management systems, staffing and organisational development

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

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

The organisation actively pursues continuous improvement through a system of quality management across the four Accreditation Standards. The home is part of a larger organisation that supports management in the implementation and development of continuous improvement systems and processes. This includes the monitoring of clinical indicators, audits and surveys, meetings, comments and complaints through use of feedback forms, or through management and staff observations. Strategies are developed and documented in the continuous improvement system. The management team evaluate improvements once completed, to ensure the actions taken have been effective. Staff are aware of systems for continuous improvement and confirm they are involved in continuous improvement activities such as audits and they contribute to suggestions for improvement through meetings and surveys. Examples of recent improvements relating to Accreditation Standard One, Management systems, staffing and organisational development, include the following:

 In response to staff feedback, the organisation implemented a new national initiative called Regis Spirit. This program provides support, acknowledgement and opportunities for valued staff. Each month management focuses on a particular initiative such as recognition of staff service, or the employee of the moment award, which recognises and celebrates good work and is nominated by work colleagues. There are also national awards with prizes for staff nominated by management or co- workers. Afternoon teas are organised for award recipients, and management has implemented a ‘Wall of Thanks’ where staff can write thank you notes for their colleagues. Similarly, a system of feedback to acknowledge good feedback from care recipients and their families on a compliment board has been setup in the staff room for all staff to view.

 In conjunction with a recognised training organisation (RTO), management has developed a program for attracting and interviewing new applicants for the certificate three in individual support (aging). Management along with the RTO staff interview prospective students and then choose appropriate students to train on the course. The students are orientated to the facility and a full time trainer is assigned to guide the students while training at the facility. This new initiative has enhanced training, recruitment opportunities, and provides a smooth transition from trainee to care worker. Feedback from students, staff, and management has been positive.

Home name: Regis Port Stephens RACS ID: 0611 8 Dates of audit: 13 December 2016 to 15 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 organisation has systems to identify and ensure compliance with changes in relevant legislation, professional standards and guidelines. The organisation subscribes to a number of government information services and is a member of an industry body which provides ongoing information about industry issues and regulatory changes. This is monitored by the organisation’s leadership team and any changes or policies affected are communicated to the management team in the home. The management team monitor the adherence to regulatory requirements through audit processes and observation of staff practice, and ensure resulting changes in policy and procedure are communicated to staff via meetings, memoranda, notice boards and staff education programs. Examples of regulatory compliance relating to Accreditation Standard One, Management systems, staffing and organisational development include:

 There is provision of information and access to internal and external complaints mechanisms for care recipients/representatives and stakeholders.

 The organisation monitors and ensures currency of police certificates for staff and other personnel.

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 organisation has systems to ensure that management and staff have appropriate knowledge and skills to perform their roles effectively. Staff have an induction program on commencement of employment and ongoing education in a range of subjects. Mandatory education is provided for staff and monitored to ensure all staff have attended. Education needs are identified through annual staff appraisals, training needs analysis, individual self- assessments, audits, observations and feedback. An education schedule is then prepared and a learning plan implemented. Throughout the year education sessions are added to the education calendar as needs and opportunities arise and are identified. Training and education is offered on-site in groups, one-on-one and through electronic and audio visual learning programs. At the conclusion of each session staff are encouraged to complete evaluation forms. All sessions are advertised internally to encourage participation and records of staff attendance are maintained. Staff are supported to attend external education, and encouraged to take responsibility for their development. Care recipients/representatives expressed satisfaction with the knowledge and skills of staff.

Home name: Regis Port Stephens RACS ID: 0611 9 Dates of audit: 13 December 2016 to 15 December 2016 Examples of education for staff and management in relation to Accreditation Standard One, Management systems, staffing and organisational development include:

 Leadership program

 Stand up against bullying

 Probation

 Regis way – organisation vision, mission and philosophy

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 organisation has systems to ensure all care recipients, their representatives and other interested parties have access to internal and external complaints mechanisms. Posters and brochures are displayed on how to access external advocacy services. Care recipients are encouraged to use the various complaints mechanisms available at meetings and feedback forms are accessible. Management have an open door policy to encourage care recipients and representatives to raise issues. Management maintain a record of issues raised through the continuous improvement process and feedback is offered individually. Management and staff monitor trends in complaints and discuss outcomes at relevant meetings. Care recipients/representatives can speak directly with managers or staff as they find them approachable and report they respond in a timely manner to any concerns.

1.5 Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings

The home has documented the mission, vision, and philosophy at an organisational level via the Regis Way statement, and consistently communicates these to care recipients, representatives, staff and other stakeholders. Documents and staff practices show that these statements in addition to the overall organisational strategic plan direct workers and general organisational behaviour towards a common goal. These statements are evidenced in staff and residents’ handbooks, literature about the home, in staff orientation and induction package.

Home name: Regis Port Stephens RACS ID: 0611 10 Dates of audit: 13 December 2016 to 15 December 2016 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 systems and processes to ensure that sufficient, suitably skilled and qualified staff are available to provide services to care recipients in accordance with the Accreditation Standards and the philosophy and objectives of the home. The home has processes for recruitment and orientation including a ‘buddy system’ for new staff. When staff are not able to work, replacements are found using part time or casual staff and occasionally agency staff, as evidenced through the review of rosters. Management adjust staffing levels based upon care recipient needs and staff and care recipient feedback. Management are committed to providing ongoing education to all staff as evidenced by the planned education program. Care recipients/representatives are satisfied with the availability of skilled and qualified staff and the quality of care and services provided.

1.7 Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings

The home has stocks of appropriate goods and equipment to support quality service delivery. Specific staff are designated for maintaining adequate stock levels and ensuring such stock meets the required quality standards. The home has appropriate storage to ensure the integrity of the stock and stock is rotated as required. Equipment is purchased or replaced in response to identified needs. The home has preventative and reactive maintenance programs. External contracts are in place for the maintenance of specialised equipment. Equipment undergoes a trial prior to purchase if appropriate and staff are educated on the use of new equipment. Staff state there are sufficient amounts of supplies and equipment available to ensure the provision of quality care and services.

1.8 Information systems

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

Team’s findings

There are systems for the creation, storage, archiving and destruction of documentation within the home. Confidential information such as care recipient and staff files are stored securely. Information is disseminated through meetings, email, notice boards, newsletters, memoranda, communication books and diaries, handover reports and informal lines of communication. The computers at the home are password protected and the system is maintained and backed up. There is a system of surveys and audits to provide information

Home name: Regis Port Stephens RACS ID: 0611 11 Dates of audit: 13 December 2016 to 15 December 2016 regarding care recipient and staff needs and the quality of care provided at the home. Care recipients and staff state they are kept well informed and are consulted on matters that may impact them through the display of information such as notices, memos, newsletters, policies and procedures, and at various meetings and informal discussions.

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 has systems and processes to ensure external services are provided to meet the care and service needs of care recipients. Preferred external suppliers are managed by the organisation and service agreements or contracts are arranged which include specifications of service delivery. Contracts/agreements include qualifications, insurance, registration details and criminal history certificates as appropriate. All work performed is monitored for quality and staff provide feedback regarding the effectiveness of services. Staff are satisfied with the quality of services provided by external suppliers and the processes to ensure services meet both the home and care recipients’ needs.

Home name: Regis Port Stephens RACS ID: 0611 12 Dates of audit: 13 December 2016 to 15 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 system for actively pursuing continuous improvement. Examples of recent improvements relating to Accreditation Standard Two: Health and personal care include:

 In response to feedback from clinical staff in relation to equipment required during hypoglycaemic events, new hypoglycaemic kits were introduced. These new hypoglycaemic kits include a blood sugar level monitoring machine, test strips, and items to alleviate hypoglycaemia such as jelly beans, glucose tablets, and high energy drinks. These new kits are conveniently situated on each floor. Feedback has been positive from staff regarding the convenience of the new kits.

 Feedback was received by staff that the central repository of supplies was at times inconvenient, and did not always contain items required. In response, management implemented a new system which seeks input from staff each week to fulfil the orders. Clinical managers from each area oversee the ordering process and distribute supplies into convenient areas for staff to access.

 A new national initiative for dementia was introduced with the implementation of scented, heated hand towels. These hand towels are soaked in an appetite stimulating essential oil and placed in a towel hot box. The towels are provided to care recipients in the memory support areas, prior to meals to help enhance appetite and provide a feeling of refreshment. Care recipients have stated they enjoy the smell and warmth of the towels and were observed to enjoy the experience and meals.

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 system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Two: Health and personal care include:

 Registered nurses are responsible for overseeing the care planning and assessment processes and the delivery of specialised nursing care to care recipients.

 There is a system to manage unexplained absences of care recipients in accordance with regulatory requirements.

Team’s findings

Refer to expected outcome 1.3 Education and staff development, for information on how the home ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of recent education and training relevant to Accreditation Standard Two: Health and personal care include:

 Palliative care

 Medication management

 Nutrition & hydration

 Pain management

2.4 Clinical care

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

Team’s findings

The home has systems to ensure care recipients receive appropriate clinical care. The clinical managers and registered nurses maintain the clinical care of the care recipients. A comprehensive program of assessment is undertaken when care recipients enter the home

Home name: Regis Port Stephens RACS ID: 0611 14 Dates of audit: 13 December 2016 to 15 December 2016 and a care plan is developed. Care recipients and/or their representatives are consulted in the assessment and care planning process regularly and at case conferences. Documentation review confirms allied health professionals and medical officers are involved in the planning and delivery of care recipients’ clinical care. Registered nurses develop and review care plans on a regular basis and when care recipients’ identified needs and preferences change. A range of care based audits, clinical indicators and care recipient surveys are used to monitor the quality of care. Staff are provided with equipment, resources, education and supervision to ensure care recipients receive appropriate clinical care. Staff interviews demonstrate they are knowledgeable about the care requirements and preferences of care recipients. Care recipients/representatives are satisfied with the clinical care the care recipients receive.

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 has systems to ensure care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff. Specialised nursing care needs are assessed and documented on care plans when care recipients move into the home. Changes are documented in the progress notes, clinical monitoring charts and in the care plans. Care plans are regularly reviewed and evaluated in consultation with care recipients and/or their representatives. Registered nurses direct care recipients’ specialised nursing care and equipment is supplied as necessary to meet identified needs. External nursing specialist services are accessed as required including wound and palliative nurse specialists. Staff have appropriate training, resources, equipment and support to provide specialised nursing care for care recipients. Care recipients are satisfied with the specialised nursing care provided.

2.6 Other health and related services

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

Team’s findings

The home has systems to assist staff to identify, assess and refer care recipients to appropriate health specialists in accordance with the care recipient’s needs and preferences. Review of documentation including care recipients’ files demonstrates that care recipients are referred to medical specialists and other allied health professionals such as the dietician, speech pathologist, podiatrist, behaviour management specialists and physiotherapists. External providers of specialist services visit care recipients in the home or care recipients are assisted to attend appointments outside the home. Care recipients/representatives are satisfied with the referral process and are consulted when referral to health specialists is required.

Home name: Regis Port Stephens RACS ID: 0611 15 Dates of audit: 13 December 2016 to 15 December 2016 2.7 Medication management

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

Team’s findings

The home has systems to ensure care recipients’ medication is managed safely and correctly. Medication needs and preferences are assessed on entry to the home and as care recipients’ needs and preferences change. Registered nurses, enrolled nurses and medication competency trained care staff administer medication which is prescribed by medical officers and dispensed by a pharmacist using a bubble package system. Care recipients’ medications are regularly reviewed by a medical officer and the pharmacist. Review of medication charts confirms care recipients’ identifying information is documented clearly including photographs, name, date of birth and allergies. Observation and staff interview demonstrates medication is stored safely in locked areas and dispensed in accordance with the home’s policy. Review of documentation confirmed that medication incidents are recorded and addressed appropriately. Care recipients who wish to manage their own medications are able to if assessed as safe to do so. Care recipients are satisfied with their medication management.

2.8 Pain management

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

Team’s findings

The home has systems to ensure all care recipients are as free as possible from pain. A range of pain assessments including nonverbal pain assessments are undertaken by nursing staff and the physiotherapist/occupational therapist to identify care recipients’ pain. Care plans are developed for each care recipient and they include individualised interventions. Interventions used to assist care recipients to manage their pain include application of heat packs, gentle exercise, massage and analgesic medication. Pain management measures are evaluated for effectiveness and care recipients are referred to their medical officers as required. Care recipients are satisfied with the way their pain is managed.

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 who are terminally ill are regularly assessed in consultation with their representatives and medical officer to ensure their comfort and dignity is maintained. During case conferences care recipients/representatives are offered an opportunity to provide information regarding care recipients’ end of life wishes and advanced care directives. Interviews demonstrate that staff are aware of maintaining the respect and dignity of care recipients who are terminally ill and providing support to families. Palliative consultants are

Home name: Regis Port Stephens RACS ID: 0611 16 Dates of audit: 13 December 2016 to 15 December 2016 utilised to direct care strategies. Pastoral and counselling services are available to care recipients and families if required. We observed supplies of equipment used for palliative care including specialised pressure relieving equipment.

2.10 Nutrition and hydration

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

Team’s findings

The home has systems to ensure care recipients receive adequate nourishment and hydration including initial and ongoing assessments of care recipients’ needs and preferences. Care plans are developed and reviewed regularly and as required. The registered nurse identifies care recipients at risk of weight loss and malnutrition by monitoring monthly weight records. A dietician and speech pathologist are available when required. Nutritional supplements, modified cutlery, equipment and assistance with meals are provided as needed. Staff are aware of special diets, care recipients’ preferences and special requirements such as any modified texture meals, dietary needs lists in the kitchen, beverage and supplement lists and the care recipients’ care plans. Care recipients have input into menu planning through care recipient meetings, comments and complaints mechanisms and informal discussions with staff. The menu is displayed for care recipients in the dining areas of the home. Care recipients are satisfied with the catering services provided.

2.11 Skin care

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

Team’s findings

The home has systems to ensure each care recipient’s skin integrity is consistent with their general health. Care recipients’ skin integrity is assessed when they move into the home through the initial assessment process. Ongoing assessment occurs regularly and as care recipients’ needs and preferences change. Care staff confirm they monitor care recipients’ skin integrity as part of daily care and report any changes to the registered nurse for review and referral as appropriate. Wound management is overseen by registered nurses. Wounds are assessed regularly using comprehensive wound assessment. Skin tears and infections are recorded and data is analysed by the management team. A podiatrist attends the home on a regular basis. A range of skin protective devices are available, including pressure relieving mattresses and limb protectors. These are available to all care recipients and are consistent with individual care plans and identified care recipient needs. Care recipients are satisfied with the provision of skin care and the range of equipment available.

Home name: Regis Port Stephens RACS ID: 0611 17 Dates of audit: 13 December 2016 to 15 December 2016 2.12 Continence management

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

Team’s findings

The home has systems to ensure care recipients’ continence is managed effectively. Clinical documentation review and interviews with staff confirm continence management strategies are developed for each care recipient following initial and ongoing assessment. Staff assist care recipients with their toileting regime, monitor skin integrity and receive training and supervision in the management of continence and the use of continence aids. The home has sufficient stock of continence aids to meet care recipient needs. Care recipients/representatives are satisfied with the management of care recipients’ continence needs. Staff were observed being considerate of care recipients’ privacy and dignity at all times.

2.13 Behavioural management

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

Team’s findings

The home has systems to effectively manage care recipients whose behaviours impact their quality of life. In consultation with care recipients and their representative’s assessment, monitoring is undertaken on entry to the home and on an ongoing basis as care recipients’ needs and preferences change. These behaviours, triggers that lead to these behaviours and successful interventions are identified and documented on care recipients’ care plans. Care plans are regularly reviewed and evaluated for effectiveness. Care recipients are referred to their medical officer and behaviour management specialists for clinical review and assessment when necessary. Staff receive ongoing training and we observed their interactions with care recipients to be respectful and dignified. Care recipients/representatives are satisfied with the management of care recipients’ behaviours.

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 has systems to ensure optimum levels of mobility and dexterity are achieved for all care recipients. Care recipients’ mobility and dexterity needs and preferences are assessed on entry to the home, on a regular basis or as needs change. The physiotherapist and occupational therapist develops individual exercise and mobility programs for care recipients with identified needs. Care recipients are assessed on moving into the home for mobility, dexterity and transfers, falls risk and pain management. The physiotherapy and exercise programs are implemented by the physiotherapist, occupational therapist, physiotherapy assistant and care staff. Programs are regularly reviewed and evaluated by

Home name: Regis Port Stephens RACS ID: 0611 18 Dates of audit: 13 December 2016 to 15 December 2016 the physiotherapist and registered nurses. Staff are trained in falls prevention, manual handling and the use of specialist mobility and transfer equipment. Assistive devices such as mobility frames, mechanical lifters and wheelchairs are available if required. Falls’ incidents are referred to the physiotherapist, documented and the data is analysed by the management team. Care recipients are satisfied with the way their mobility and dexterity needs are managed.

2.15 Oral and dental care

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

Team’s findings

The home has systems to ensure care recipients’ oral and dental health is maintained. Documentation review confirms care recipients’ oral and dental needs and preferences are assessed when they move to the home and individual care plans are regularly reviewed and evaluated to meet changing needs. Diet and fluids are provided in line with the care recipient’s oral and dental health needs and preferences, and specialist advice for care recipients with swallowing problems is sought if needed. A dental provider with a mobile clinic visits the home and some care recipients visit their dentist of choice in the community. Care recipients are satisfied with the assistance they receive for oral and dental care.

2.16 Sensory loss

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

Team’s findings

Initial assessment identifies care recipients’ sensory loss when they move into the home. Management strategies are implemented, regularly reviewed and evaluated in consultation with the care recipient and referral to specialist services is arranged as needed. The environment is monitored for lighting, including natural light, and that rooms and walkways are uncluttered to ensure they facilitate care recipient safety. Staff said they use a variety of strategies to manage sensory loss, including appropriate equipment and support to promote independence. The home has recently installed sensory interactive walls and care recipients and representatives said they are an enjoyable sensory activity. Care recipients informed us staff are attentive to their individual needs, including the care of glasses, hearing devices and if needed assistance to move around the home.

2.17 Sleep

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

Team’s findings

Care recipients’ sleep patterns and known strategies to assist sleep are assessed when they move into the home and their care plans are regularly reviewed and evaluated by

Home name: Regis Port Stephens RACS ID: 0611 19 Dates of audit: 13 December 2016 to 15 December 2016 appropriately qualified staff. Care staff are available to assist care recipients during the night. Care recipients’ preferences for rising and retiring are respected and accommodated by staff. A review of documentation and discussions with staff show care recipients are offered comforts such as heat packs, snacks, warm drinks, and one on one support to assist them achieve natural sleep patterns. Disturbances in sleep patterns are monitored and referred to the medical officer as needed. Lighting and noise levels are subdued at night. Care recipients are satisfied with the management of their sleep and the night time environment.

Home name: Regis Port Stephens RACS ID: 0611 20 Dates of audit: 13 December 2016 to 15 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

Refer to expected outcome 1.1 Continuous Improvement, for information about the home’s system for actively pursuing continuous improvement. Examples of recent improvements relating to Accreditation Standard Three: Care recipient lifestyle includes:

 A major refurbishment recently took place on site improving several areas in the home. In the memory support wing several enhancements to promote activity and interaction have been incorporated, which include the following:

– Men’s lounge room – this room has been decorated and setup with several male activities

– Sensory room – this room includes a new electronic sensory interactive wall for care recipients to experience

– Large fish tanks have been installed in the dining/lounge area

 Feedback from care recipients/representatives has been positive.

 The refurbishment included a new café area. This café is for the enjoyment of care recipients, and their visitors, away from the wings, and includes a redesigned courtyard area with new outdoor furnishings.

 To promote privacy and dignity for the care recipients in shared rooms, new slimline wall dividers have been installed between care recipient bed areas. These wall dividers allow the display of personal items for each care recipient in the form of bookshelves, while allowing the privacy curtains to fold away behind them when required. A new family room has also been setup in the twin shared wing allowing for increased privacy when a care recipient is palliating, and allows for families to stay with their relative in the room. The room includes a sofa bed and kitchenette to provide refreshments for those staying.

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

Team’s findings

Refer to expected outcome 1.2 Regulatory compliance, for information about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Three: Care recipient lifestyle includes:

 The Charter of Care Recipients’ Rights and Responsibilities is on display in the home, and included in the resident handbook which is given to care recipients on entry to the home.

 The home has a system for compulsory reporting in accordance with current legislation.

Team’s findings

Refer to expected outcome 1.3 Education and staff development, for information on how the home ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of recent examples of education and training relevant to Accreditation Standard Three: Care recipient lifestyle include:

 Privacy and dignity

 Customer service

 Cultural awareness

 Confidentiality

Home name: Regis Port Stephens RACS ID: 0611 22 Dates of audit: 13 December 2016 to 15 December 2016 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 has systems to ensure that each care recipient receives support in adjusting to life in the new environment and on an ongoing basis. Information regarding the care recipients’ cultural, spiritual, emotional, linguistic and clinical assessments, interests and hobbies are obtained on entry to the home. Visiting families and friends are welcomed, birthdays and anniversaries are celebrated and outings are arranged. Care recipients are encouraged to decorate their room with personal items to help create a homelike atmosphere. Care recipients are satisfied with the way they are assisted to adjust to life at the home and the ongoing caring 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 has systems to assist care recipients to achieve maximum independence, maintain friendships and participate in the community. On entry to the home assessments of clinical status and physical capabilities identify the independence level of care recipients and the amount of assistance they require on a daily basis. A range of individual and general strategies are in place to promote independence including visits from community organisations, bus outings, provision of newspapers and magazines, access to Internet and telephones. Care recipients are encouraged to participate in activities outside the home whenever possible. Care recipients and representatives are satisfied with the assistance the home provides in relation to care recipients’ independence and continuing participation in the life of the community within and outside the home.

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 has systems to ensure privacy and dignity is respected in accordance with care recipients’ individual needs. The assessment process identifies each care recipient’s personal and spiritual needs, including the care recipient’s preferred name. Permission is sought from care recipients for the disclosure of personal information and the display of photographs. Staff education promotes privacy and dignity and staff sign confidentiality agreements. Staff handovers and confidential care recipient information is discussed in private and care recipient files are stored securely. There are areas available within the

Home name: Regis Port Stephens RACS ID: 0611 23 Dates of audit: 13 December 2016 to 15 December 2016 home where care recipients, relatives and friends can meet privately. We observed staff interaction and communication with care recipients as respectful of care recipients’ privacy and dignity. Care recipients are satisfied with management of privacy and dignity at the home.

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 encourages and supports care recipients to participate in a range of interests and activities of interest to them. Care recipients’ leisure interests, recreational activity choices and social interaction needs are assessed on entering the home and on an ongoing basis. The activities program includes special events, external entertainers, pet therapy, bus outings, movies, reminiscing, exercises, art programs, word games, mind exercises, trivia and music. The activities provided to care recipients cater for their various levels of physical and cognitive abilities. Review of documentation and observation shows the home encourages and supports care recipients to participate in a wide range of interests and activities of interest. Care recipients who are too frail or choose not to attend activities are provided with individual therapy from staff. Care recipients/representatives are informed of the activities through newsletters, meetings, planners, display boards and personal reminders. Care recipients are satisfied with the activities provided.

3.8 Cultural and spiritual life

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

Team’s findings

Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual cultural interests, customs, religions, ethnic backgrounds and care management choices during the home’s assessment processes. The home recognises and celebrates culturally specific days with festivities consistent with the care recipients residing in the home. For example, Australia Day, Remembrance Day, Christmas, Easter, Mother’s and Father’s day, Easter, multicultural days and birthdays are celebrated. Care recipients are actively encouraged to maintain cultural and spiritual links in the community and involvement from families/representatives is encouraged and welcomed. Care recipients say their spirituality and culture are supported and fostered by the home.

Home name: Regis Port Stephens RACS ID: 0611 24 Dates of audit: 13 December 2016 to 15 December 2016 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 provides each care recipient with input into decisions about the services the home provides for them and they are able to exercise choice and control over their lifestyle through consultation about their individual needs and preferences. Documentation demonstrates care recipients’ personal preferences are identified on entering the home. Management has an open door policy to interact with care recipients/representatives when needed. Care recipients and relatives are encouraged to provide feedback through meetings, surveys, complaints mechanism, newsletters and verbally. Observation of staff practices and staff interviews demonstrate care recipients have choices available to them including shower times, meals, privacy and activities. Care recipients are satisfied with the support from staff with regard to their choice and decision making processes.

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 has systems to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. Information on security of tenure and care recipients’ rights and responsibilities is provided and discussed with prospective care recipients and their representatives prior to and on entering the home. The resident agreement is accompanied by an information package including handbook which provides information about care and services, care recipients’ rights and feedback mechanisms. Any changes in room and/or location within the home are carried out in consultation with care recipients and/or their representatives. Ongoing communication with care recipients and representatives is through meetings and correspondence. Care recipients said they feel secure in their residency at the home and are aware of their rights and responsibilities.

Home name: Regis Port Stephens RACS ID: 0611 25 Dates of audit: 13 December 2016 to 15 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

Refer to expected outcome 1.1 Continuous Improvement, for information about the home’s system for actively pursuing continuous improvement. Examples of recent improvements relating to Accreditation Standard Four: Physical environment and safe systems include:

 To enhance the outdoor environment for care recipients in the Blue gum memory support wing, the courtyard was refurbished. This area has been revitalised for the care recipients’ benefit with the following:

– Gardens revamped, including a garden growing out of a small boat

– Raised garden beds

– Chalk wall

– Grassed areas levelled and simulated turf installed

– Putting green

 This has been a positive result for care recipients.

 Both memory support units have been renovated with new furnishings, foyer entrances, lounge rooms extended with a sunroom, and fish tanks. Care recipients and their families have provided positive feedback about the new changes.

 To provide a safer work environment, the nurse’s stations have been renovated to provide enhanced visual monitoring of the common areas and hallways. This enables the staff to have better visibility of care recipients, and also improves access for care recipients to care staff. Doorways have also been widened to allow better access to lifters and equipment.

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

Team’s findings

Refer to expected outcome 1.2 Regulatory compliance, for information about the home’s system for ensuring compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard Four: Physical environment and safe systems include:

 The home meets compliance with fire safety regulations and has a current annual fire safety statement.

 The home achieved an A rating pass from the New South Wales Food Authority audit.

Team’s findings

Refer to expected outcome 1.3 Education and staff development, for information on how the home ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Examples of recent education and training relevant to Accreditation Standard Four: Physical environment and safe systems include:

 Food safety training

 Manual handling

 Work, health and safety

 Hand washing

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 has systems to provide a safe and comfortable environment consistent with care recipients’ care needs. Care recipients are accommodated in single rooms with ensuite, or

Home name: Regis Port Stephens RACS ID: 0611 27 Dates of audit: 13 December 2016 to 15 December 2016 shared rooms with shared bathroom facilities. Care recipients personalise their areas and all care recipients have access to nurse call bells. There are several lounge and dining rooms, small private areas as well as courtyards and gardens for use with family and friends. Maintenance requests are actioned and preventative maintenance schedules ensure the safety of the internal environment, outside areas and equipment. Regular audits and environmental inspections monitor the internal and external environments. Care recipients’ rooms are monitored, wide corridors are free of clutter and outside paved areas are well maintained. Care recipients/representatives are satisfied with the maintenance and comfort of the environment provided by the home.

4.5 Occupational health and safety

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

Team’s findings

The home has a system to ensure management and staff provide a safe working environment that meets regulatory requirements. The system involves audits, accident reports and hazard reporting procedures and results are discussed at monthly meetings. The home has a volunteer committee of members that are supported by the organisations work, health and safety manager. Policies, procedures and notices inform staff of work health and safety (WHS) issues and guidelines. Preventative and corrective maintenance programs ensure equipment is in good working order and the environment is safe. Safe work procedures and practices were observed and staff have attended relevant education and demonstrate awareness of WHS practices.

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

Systems are in place to promote the safety and security of care recipients and staff in the likely event of an emergency. Trained fire safety officers oversee fire safety at the home and all staff take part in mandatory training in fire awareness and evacuation procedures. The home is fitted with appropriate firefighting equipment and warning systems. There are procedures and equipment to maintain and monitor the security of the home. There is an emergency and disaster plan for the site and emergency flipcharts and evacuation plans are displayed throughout the home. An evacuation kit is maintained and information within it is kept current in case of the need to evacuate. Systems are monitored through internal audits and external inspections. Staff interviewed demonstrated that they were familiar with the equipment and procedures and they confirmed they had attended regular fire safety training. The team observed emergency contact procedure documentation, evacuation kits and contact numbers available for staff to access.

Home name: Regis Port Stephens RACS ID: 0611 28 Dates of audit: 13 December 2016 to 15 December 2016 4.7 Infection control

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

Team’s findings

The home has an effective infection control program. This includes education for staff, provision of equipment, routine monitoring of infections as well as the availability of policies and practice information to guide staff work practices. Infection data is collected and analysed externally and within the organisation. Relevant infection control issues are discussed and reviewed at staff meetings. Infection control procedures such as the use of colour coded cleaning equipment, personal protective equipment and monitoring of temperatures were observed. Audits are undertaken, there are processes for the removal of contaminated/cytotoxic waste, infectious outbreak and spills kits and sharps containers are available. Staff interviewed could describe the use of infection control precautions in their work such as regular hand washing or disinfecting. Staff confirmed they had undertaken education in this area. There is a care recipient vaccination program in operation and staff are encouraged to be vaccinated for influenza. A pest control program is undertaken regularly at the home.

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

There are systems to identify care recipients’ meal requirements and preferences on entry into the home and as care recipient needs change. Where care recipients have special requirements these are documented and provision is made to accommodate their wishes. All meals are cooked fresh on site in a centralised kitchen. The menu is a dietician reviewed, rotational seasonal menu. Care recipients have alternative choices of main course for main meals and a variety of options for breakfast each day. A bain-marie service is provided for care recipients to accommodate individualised portions and preferences. The home has documented processes to guide staff practices on the safe handling of food. The care recipients’ rooms, common areas and bathrooms are cleaned daily. All areas of the home were observed to be clean at all times during the visit. Personal laundry and linen is washed onsite. There is a system for the labelling and sorting of care recipients’ personal laundry to minimise the procedural loss or misplacement of personal items of clothing. The home uses commercial systems, equipment and processes consistent with industry recommendations and guidelines. Care recipients/representatives expressed satisfaction with hospitality services meeting care recipients needs and making their stay more enjoyable. Meals are part of the day they look forward to.

Home name: Regis Port Stephens RACS ID: 0611 29 Dates of audit: 13 December 2016 to 15 December 2016