Published Decision (SA and RA) s11

BlueCross Waterdale

RACS ID: 3020 Approved provider: Third Age Australia Pty Ltd Home address: 250 Waterdale Road IVANHOE VIC 3079

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 13 April 2020. We made our decision on 13 April 2017. The audit was conducted on 11 April 2017 to 11 April 2017. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. 1. Most recent decision concerning performance against the Accreditation Standards Standard 1: Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement Met 1.2 Regulatory compliance Met 1.3 Education and staff development Met 1.4 Comments and complaints Met 1.5 Planning and leadership Met 1.6 Human resource management Met 1.7 Inventory and equipment Met 1.8 Information systems Met 1.9 External services Met Standard 2: Health and personal care 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 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: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 2 Standard 3: Care recipient lifestyle Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community. 3.1 Continuous improvement Met 3.2 Regulatory compliance Met 3.3 Education and staff development Met 3.4 Emotional Support Met 3.5 Independence Met 3.6 Privacy and dignity Met 3.7 Leisure interests and activities Met 3.8 Cultural and spiritual life Met 3.9 Choice and decision-making Met 3.10 Care recipient security of tenure and responsibilities Met Standard 4: Physical 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: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 3 Audit Report

Name of home: BlueCross Waterdale RACS ID: 3020 Approved provider: Third Age Australia Pty Ltd 2. Introduction This is the report of a Re-accreditation Audit from 11 April 2017 to 11 April 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. 3. 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: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 4 4. Scope of this document An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 11 April 2017 to 11 April 2017. The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014. 5. Details of home Total number of allocated places: 171 Number of care recipients during audit: 0 Number of care recipients receiving high care during audit: 0 Special needs catered for: Specialist dementia specific unit

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 5 6. Audit trail The assessment team spent one day on site and gathered information from the following: Interviews

Position title Number

‘IT’ systems manager 1

Care recipients/representatives 0

Clinical services manger 1

Consultant dementia services 1

Hospitality/quality services 2

Hotel services manager 1

Lifestyle coordinator 1

Maintenance staff 2

Property operations 1

Quality and risk manager 1

Residence manager 1

Volunteers 0

Sampled documents

Document type Number

Care recipients’ files 0

Summary/quick reference care plans 1

Medication charts 0

Personnel files 2

Other documents reviewed The team also reviewed: ‘IMPREVO’ monitoring system ‘STAR connect’ system ‘STARFish’ philosophy Action for improvement system Audit schedule

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 6 Brochures from Carers’ Victoria and the Australian Aged Care Complaints Commissioner, in multiple languages, waiting for positioning at central points Care planning assessment system Care recipient information pack Comments, complaints and concerns forms waiting for positioning at central points Continuous improvement plan Education calendar Evacuation maps Food safety plan Job descriptions Mandatory reporting system Minutes of meetings Newsletter Occupancy permit Police certificate matrix Policies and procedures Pro forma documentations Proposed staffing profile Recruitment policies and procedures Restraint documentation (examples) and charting Self -assessment Self-medication risk assessment (example) Staff handbook Statutory declaration Strategic directions document, which includes vision and a commitment to quality statement The Charter of care recipients’ rights and responsibilities – residential care, ready for framing. Observations The team observed the following: Built-in communication panel in each care recipient’s room for remote communication with staff Built-in sensor mats, programmable for either side of bed Care recipients’ rooms with en-suites Chapel Cinema Domestic washing machine in memory support unit Equipment and supply storage areas Fob entry and exit / building security

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 7 Hairdressing salon Internal and external living environment Kitchen Large foyer with seating Laundry Lifts x 3, with fob security entry/exit Medication storage rooms including dangerous drug safes Memory support unit Multi-purpose room New building commissioning work being undertaken New fire service framed maps being installed New furniture awaiting placement around the home Notice on front of home advertising an open day Sensory room (Halcyon room) with programmable visual/audio programs Storage areas Treatment areas Visitor and contractor registration book.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 8 7. Assessment information This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The management team of BlueCross Waterdale are in the process of implementing the BlueCross continuous improvement system across the home, the basis of which is derived from the BlueCross strategic directions document. The manager of the home leads the quality management system along with assistance from the corporate management quality team. Opportunities for improvement are identified through a variety of inputs including a scheduled auditing system, feedback mechanisms from stakeholders such as comments, complaints and compliment forms and meetings. There is an established continuous improvement plan with monitoring and evaluation of improvements will be occurring regularly at both the home and corporate level. Communication of continuous improvement activities to staff and other stakeholders will occur at relevant meetings. Examples of current improvement activities in relation to Standard 1 – Management systems, staffing and organisational development include:  Due to the home being a new build, BlueCross executive management identified a need to establish a preadmission clinic for potential care recipients. The purpose of this is to ensure the smooth transition from the community to residential care for care recipients. Evaluation will be undertaken at the completion of the project.  Management sought and have had approved funding to undertake an intensive orientation program for new staff which will take place over five days. A plan has been written for the program and to date the clinical care coordinator, clinical services manager and the quality coordinator have undertaken this. 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 manager of BlueCross Waterdale and BlueCross have systems in place to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation receives alerts and notifications from a range of industry bodies, legal services and government departments in relation to regulatory obligations and changes to legislation. There is a system to inform managers of regulatory requirements and monitoring occurs to ensure all legislative requirements are met. Staff are informed of their obligations through orientation, education, meetings and policies. There is a system to monitor the currency of police certificates and professional registrations.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 9 1.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Management and staff have appropriate knowledge and skills to perform their roles effectively. All new staff will engage in an orientation program, which includes a suite of competencies specific to their roles. An annual calendar specifies mandatory training sessions and a variety of relevant aged care subject matters responsive to care recipients' needs. Education delivery includes in-service, toolbox sessions and specialised training facilitated by external providers. Management has mechanisms to monitor attendances and has a system to ensure effectiveness. Staff will undertake ongoing competencies to maintain and monitor their practices. Management said staff are able to make suggestions verbally, in meetings or in writing to enhance their development and are encouraged and supported by management to attend courses and conferences to increase their skills and qualifications. The education opportunities on offer are across the Accreditation Standards. Education planned for the next 12 months relating to Standard 1- Management systems, staffing and organisational development includes:  Computer training  Customer service  Electronic documentation  Positive workplace behaviours. 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 Management have systems to ensure care recipients, their representatives and other interested parties have access to internal and external complaints mechanisms. The care recipient information booklets and care recipient agreement provide information about internal and external complaint mechanisms. Staff are provided with information in relation to complaint handling during orientation, education sessions and in documents. The organisation has a system for responding to complainants in a timely and appropriate manner. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The home has documented its ‘Strategic Directions’ which includes a vision, ‘The 4 Ps’ for enriching care recipients lives and its commitment to quality. The ‘Strategic Directions’ plan also includes a statement about developing, rewarding and recognising staff excellence.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 10 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 organisation’s system is currently being utilised to ensure appropriately skilled and qualified staff are recruited so as to ensure services will be delivered in accordance with the Accreditation Standards and the residential care services philosophy and objectives. The manager, assisted by human resources, undertakes a comprehensive selection assessment process for staff and all staff will undergo a multiple day induction program prior to commencing. There is a probationary period, a system for performance review and a staff awards program. Staff have position descriptions, duty lists and policies and procedures to guide practice. Specialist care staff will be recruited to provide ongoing care for care recipients’ living with dementia. 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 Stocks of appropriate goods and equipment for quality service delivery are available. The organisation is committed to purchase goods and equipment from companies who can provide assurance of quality service and product. Management have implemented a stock control system, where inventory is regularly checked and reordered to maintain required stock levels. Electrical equipment is tested and tagged as per an ongoing schedule. There are safe and secure storage facilities for all equipment located throughout the home. New equipment is trialled prior to purchase and staff are trained in its use prior to its implementation. There is a reactive ‘FIXIT’ program and preventive maintenance system to ensure functionality of all plant and equipment. 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 Management at the home are in the process of implementing the organisation’s information management system. Care recipients and representatives will be provided with information during the preadmission process, including a handbook and care recipient agreement. Ongoing information will be provided through care consultations, meetings and the incident reporting system. Communication of information to staff will include orientation, position descriptions, policies and procedures, education, meetings and memoranda. Confidential documents will be stored according to legislative requirements. The electronic care documentation system is in place and access is password protected. There is a backup system for IT supported by the corporate IT department. An archive system is being established. Management plan to collect, analyse and trend key data and discuss results at quality and staff meetings.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 11 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 Management of the home have implemented the organisation’s processes for providing externally sourced services to meet the anticipated needs of care recipients and service quality goals. There is a preferred supplier list and contracted services are based on the ongoing quality of service delivery being ensured. The organisation ensures credentialing and legislatives requirements are met prior to commencing contracts with external services. There is a system to monitor contractual obligations and feedback from stakeholders regarding the quality of the service. The home has an orientation process for contractors and a sign in and out register.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 12 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 Management are implementing the organisation’s continuous improvement system. Please refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. Example of current improvement activities in relation to Standard 2 – Health and personal care include:  Executive management reviewed and developed the clinical documentation system from a previous paper based system for nursing care plans and personality profile to a ‘tablet’ format that will be available for all clinical staff use.  Management undertook a review of the medication management system. A new electronic medication system, which has already been trialled at another site with success, will be implemented at BlueCross Waterdale when care recipients are present. 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 Management is implementing the organisation’s regulatory compliance system. Please refer to expected outcome 1.1 Regulatory compliance for information about the home’s regulatory compliance systems and processes. There is a policy for missing care recipients management and the safe storage of medication as per legislative requirements. 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 Management and staff will have appropriate knowledge and skills to provide effective health and personal care to care recipients. Refer to expected outcome 1.3 Education and staff development for more information about the home's systems and processes. Education undertaken in the last 12 months relating to Standard 2 - Health and personal care includes:  Continence  Dementia and responsive behaviours  Diabetes management

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 13  Medication management  Pain management  Palliative care  Wound care. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome Management demonstrate there is a system to ensure care recipients receive appropriate clinical care. Staff will complete a suite of assessments when care recipients move into the home and based on this information staff complete a personalised care plan. Consultation during this process will occur with the care recipient, representative, medical practitioner and allied health personnel as necessary. Regular care plan review will occur to ensure documented clinical strategies and interventions remain effective. There is access to policies, procedures, training and equipment to assist staff in undertaking their clinical care duties. Staff will consult with care recipients and representatives regularly. 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 There will be appropriately qualified nursing staff available to identify, assess and manage care recipients’ specialised nursing care needs. There are policies and procedures relation to wound management, diabetes management, blood pressure monitoring, catheter management, enteral feeding and weight management, readily accessible to staff. Consultation will occur with the care recipient, representative and medical practitioner as required. There is a registered nurse on each shift and locum services are available for after- hours medical support as needed. There is easy access to a range of health professionals as required with referrals occurring more broadly as needed. Provision of relevant equipment assists the delivery of specialised nursing care. 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 Management said staff will ensure the referral of care recipients to specialists and other health services as required and preferred. Medical practitioners will visit the home regularly with locum services available after hours if needed. A range of health specialists, including physiotherapists, podiatry, dietitian, wound consultants, palliative care and speech pathologist visit the home with referrals occurring to additional health professionals as required. Further referrals will occur based on identified need or specific request with support provided to care recipients to access external appointments. Care plans will reflect the specified care required.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 14 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 Management demonstrate there is a system to ensure care recipients’ medication is managed safely and correctly. Qualified staff will administer medication from sachets, dose administration aids and original packaging. Staff will administer medication according to medical directive via a medication chart. All staff administering medications will undergo an annual competency and medication is appropriately stored, in accordance with legislative requirements. Staff will date opened creams, ointments and drops and refrigerate medication as appropriate. Medication monitoring systems include consultant pharmacy reviews and regular meetings of a medication advisory team. Staff regularly review care recipients who choose to manage their own medications to determine continued competency to do so. 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 Management and staff demonstrate there are processes to ensure all care recipients are as free as possible from pain. Staff assess care recipients for pain on moving into the home, regularly as part of the scheduled review process and as required. Corresponding care plans document identified strategies to reduce the incidence of pain, which may include the application of heat packs, provision of pressure relieving mattresses and regular repositioning. Provision of exercises encourages movement and assists with the reduction of pain. Where medication is required outside of scheduled times, nursing review occurs to monitor effectiveness of interventions and to determine if medical review is needed. 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 Management demonstrate there is a system to ensure the comfort and dignity of terminally ill care recipients. Care recipients and representatives are provided with the opportunity to document the care recipient’s end of life wishes. In conjunction with relevant policies and procedures, this information guides staff care during the care recipient’s terminal care phase. Staff have access to external palliative care providers and medical staff in the provision of palliative care. There is additional equipment available as required. Access to an external palliative care service allows staff to have access to a variety of resources to enhance the comfort of care recipients. There are also facilities available for representatives to stay during this time. 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

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 15 Management demonstrate there is a process to provide care recipients with nourishment and hydration. The assessment of care recipients’ nutritional needs occurs on moving into the home taking into consideration personal preferences, allergies, medical requirements and the level of assistance required. There is information available to guide staff in providing meals according to care recipients’ specific needs with updates occurring as required and in response to dietary changes. Staff will monitor clinical indicators, which include weights to ensure any unplanned weight variations are noted. Referrals to medical practitioners, speech pathologists and dietitians occur for additional support and advice. Nutritional supplements are available to enhance care recipients’ nutritional status when required 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 There is a system to maintain care recipients’ skin integrity in accordance with their general health and wellbeing. Review of skin integrity occurs for all care recipients on moving into the home. This includes assessing for existing wounds or pressure areas and establishing strategies to maintain skin integrity in accordance with care recipients’ health status. Consultation occurs with the care recipient, representative and medical practitioner during this process. Corresponding care plans will document individual care recipient’s skin care needs, which may include daily moisturising, use of pressure relieving mattresses or application of limb protectors. Staff will make referrals to wound care specialists as needed with specific management regimes documented on wound care charts to promote healing. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome Management demonstrate there are processes to ensure care recipients’ continence is managed effectively. There are ongoing review and evaluation systems for identifying and managing care recipients’ continence care requirements. Processes include initial assessments in consultation with care recipients and representatives, regular care plan reviews and reassessments in response to identified changing continence care requirements. Strategies to promote effective continence care include regular toileting times, increased hydration, provision of a high fibre diet and regular exercise. There is equipment available to enhance care recipients’ independence as required and staff state there are sufficient supplies of continence aids allocated to individuals based on assessed needs. 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 Management demonstrate there are processes to ensure the needs of care recipients with challenging behaviours are managed effectively. These include the development of assessments, corresponding care plans and ongoing evaluation. These processes occur in consultation with the care recipient, their representative and medical practitioner. Referrals occur to the care recipient’s medical practitioner and mental health professionals as required. The availability of a memory support care unit provides a safe environment for care recipients living with dementia. The development of a dedicated staffing model assists staff in

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 16 building relationships with care recipients so staff are familiar with care recipients’ overall needs. Management state this will aid in the promotion of a calm environment and decreases anxiety and agitation. 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 Management demonstrate there is a system to promote care recipients’ mobility and dexterity. Assessment of each care recipient’s mobility and dexterity needs occurs upon moving into the home, in consultation with the care recipient and their representative. The corresponding care plan will document identified strategies to enhance care recipients’ mobility and dexterity and includes interventions to minimise falls risk. There is a range of equipment available to aid transfer and mobility with staff required to participate in manual handling training. Physiotherapists’ review occurs as required. Provision of group exercises and pain management strategies promotes movement, enhancing mobility and dexterity. Management monitors and reports on falls data to identify trends and implement falls prevention strategies to minimise recurrence. 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 Management demonstrate there are processes to ensure care recipients’ oral and dental health is maintained. These include the development of assessments, corresponding care plans and ongoing evaluation. Care plans will capture the level of staff assistance required for the daily management of care recipients’ teeth, mouth and dentures as appropriate. There is access to dental services in response to identified need and specific request. Formulation of specific management strategies for care recipients with swallowing difficulties occurs and may include the provision of texture modified diets and staff assistance as required. 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

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 17 Management demonstrate a system for effective identification and managing care recipients’ sensory losses. When care recipients move into the home, staff will undertake a suite of assessments to identify strategies required minimising any impact of identified sensory loss. Corresponding care plans will detail strategies to support care recipients including details of assistive devices such as glasses and hearing aids and level of staff assistance required to fit these. Care plan development and subsequent review includes consultation with care recipients, representatives and allied health professionals. A diverse lifestyle program is available to enhance care recipients’ taste and touch through a range of activities that include such activities as cooking. 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 Management demonstrate they have strategies that will enable care recipients to achieve natural sleep patterns. An assessment process includes identification of sleep patterns and habits and personal preferences to promote sleep. Development of care plans include consultation with care recipients and representatives and the use of settling strategies such as the provision of additional blankets, pillows and refreshments. Management said staff would receive training in providing alternatives to sedative use, which include warm milk drinks, psychological support, maintaining usual/preferred routines, and pain relief measures as required.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 18 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 Management are implementing the organisation’s continuous improvement system. Please refer to expected outcome 1.1 Continuous improvements for information about the home’s continuous improvement systems and processes. Examples of current improvement activities in relation to Standard 3 – Care recipient lifestyle include:  Resulting from a consultant’s report and recommendations management reviewed the care and services being available for care recipients’ living with dementia. The new ‘Banyule’ wing of the home has been designed around Montessori principles and includes a nostalgia kitchen. Staff working in the area will undertake specialist training in providing care delivery and will be working in the area on an ongoing basis.  The findings of the above mentioned report also gave rise to the addition of a ‘”Halcyon’ room being incorporated in the build. The new area is a sensory area and includes music, videos, visual displays and mood lighting all of which can be electronically programmed to fit the requirement of the care recipient at the time. 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 Management is implementing the organisation’s regulatory compliance system. Please refer to expected outcome 1.1 Regulatory compliance for information about the home’s regulatory compliance system and processes. There is a policy for elder abuse and mandatory reporting requirements. Care recipients will be offered a residential agreement on entry to the home. 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 Management and staff have appropriate knowledge and skills to perform their roles effectively in relation to care recipients' lifestyle outcomes. Refer to expected outcome 1.3 Education and staff development for more information about the home's systems and processes.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 19 Education that will be undertaken in the next 12 months relating to Standard 3 - Care recipient lifestyle includes:  Choice and decision making  Dementia and responsive behaviours  Elder abuse  Inclusive practice (LGBTI)  Independence promotion  Montessori training. 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 Management will provide initial and ongoing emotional support to care recipients and representatives. New care recipients and representatives will meet with management and receive an information pack and handbook explaining services and levels of care. There will be a tour of the home conducted and meetings with other care recipients and staff. Care plans will document preferences, emotional triggers and strategies for the care recipients to enjoy life at the home. Care recipients will be encouraged to personalise their rooms and staff invite representatives to join in activities and maintain close contact. The home has access to external specialist services if required. Regularly reviewed care plans will capture change and the activity program schedules individual time with care recipients. 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 Management demonstrate they will support care recipients to achieve optimal independence, maintain friendships, family connections and community links. The home’s assessment and care planning process identifies care recipients’ cognitive, mobility and dexterity levels, any risk taking behaviours and preferences for social interaction. Exercise programs are planned to assist maintain mobility and strength and lifestyle programs include sensory stimulation activities and community outings. Care recipients will be assisted to vote in elections, staff will organise outings for care recipients to attend community groups and entertain visitors. Supplied equipment aids and utensils encourage independence and audits ensure the environment is free of hazards. 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

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 20 Management respect each care recipient’s right to privacy, dignity and confidentiality. The home provides information to care recipients and staff on privacy and confidentiality policies. Care recipients will sign consent forms for the release of personal information and the display of photographs and names, on entry to the home. Accommodation is in single rooms with ensuite bathrooms. There are numerous internal and external areas to meet with visitors and rooms to hold private functions. Files are kept in secure areas, handover will occur discreetly and care recipients will have access to a key to lock their door and to a secure drawer in their room. Management said staff will knock on doors before entering and will address care recipients by their preferred name. 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 Management said staff will support and encourage care recipients to participate in a range of activities and events both in groups and individually. Lifestyle profiles capture past and current interests, preferences for social interaction and community and family links. Care plans will document these choices and regular reviews reflect changes in the individual needs of the care recipients. Activity evaluations, feedback from meetings and participation records will monitor satisfaction and care recipients’ suggestions for future planning. Community groups and volunteers are welcomed at the home and care recipients will receive assistance to go on outings and to maintain individual hobbies. Friends and family will be encouraged to be involved in life at the home and to join in activities. Management said staff will assist care recipients to attend the daily. 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 Management demonstrate the organisation fosters and values care recipients’ cultural and spiritual lives. Initial assessments and care plans will document preferences including celebratory days, beliefs, religious choices, cultural preferences and palliative care wishes. Staff will access interpreters if needed. Multicultural groups within the home get together regularly as part of the lifestyle program. Various denominations will hold group and individual religious services. Special events and significant days will be celebrated and care recipients’ dietary preferences accommodated. Management said care recipients will be supported to meet 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 Management said staff will be committed to promoting the care recipients’ right to participate in choices and decisions regarding their clinical care and lifestyle preferences. Authorised powers of attorney or guardianship information will be available where required. Regular risk

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 21 assessments and care plan reviews capture change. Brochures will be on display, handbooks and agreements containing information on care recipients’ rights and responsibilities, the complaints process, external advocacy services and clinical care and lifestyle choices will be made available to care recipients and representatives. Audits and feedback from meetings will monitor satisfaction. Staff will have access to policies and procedures and ongoing education on this outcome. Care recipients will have opportunities provided to continue to make independent 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 Management has implemented systems to provide care recipients with secure tenure and understanding their rights and responsibilities. An information package and handbook will be provided to prospective care recipients and/or their representatives assist them in understanding the process of entering into aged care, including the provision of care and services. Care recipients and representatives will receive further information upon their entry to the home, offered an agreement which outlines secure tenure, explanation of fees and charges, services provided and The Charter of care recipients’ rights and responsibilities – residential care.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 22 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 Management are implementing the organisation’s continuous improvement system. Please refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes. Examples of current improvement activities in relation to Standard 4 – Physical environment and safe systems include:  Management wanted to provide a more tailored style of service delivery for care recipients based on a ‘hotel style’ service delivery model. To support this initiative a new management position has been created to oversee food services, laundry and cleaning services.  This newly built home replaces an old building which was demolished. The building is designed to enable a community access via encouraging the community into the home with a coffee shop and gym being located on site. 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 Management is implementing the organisation’s regulatory compliance system. Please refer to expected outcome 1.1 Regulatory compliance for information about the home’s regulatory compliance system and processes. The home has prepared a food safety plan that is to be finalised at the current week. An organisational wide occupational health and safety committee already exits and there will be home based elected occupational health and safety representative working at the home. 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 Management said staff will have appropriate knowledge and skills to perform their roles effectively in relation to the physical environment and safe systems. Refer to expected outcome 1.3 Education and staff development for more information about the home's systems and processes. Education planned over the next 12 months in relation to Standard 4 - Physical environment and safe systems includes:  Catering staff training (includes food safety training)

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 23  Chemical training  Cleaning/sanitising  Fire safety  Infection control  Texture modified foods  Work, health and safety. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs". Team’s findings The home meets this expected outcome Management is actively working towards providing a safe and comfortable living environment. The new home provides accommodation to care recipients in single rooms with ensuites and has some larger suites with living rooms and small kitchenettes. The new building is designed to promote integration with the community and includes small intimate areas for people to gather and larger living and dining rooms. Management are implementing environmental monitoring, the preventative and reactive maintenance system is in place and a system for monitoring incidents and hazards is available. Care recipient surveys and meetings will be available to provide feedback regarding satisfaction with the comfort of the environment. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome Management has implemented systems and processes to provide and maintain a safe working environment that meets regulatory requirements. Work health and safety practices are incorporated into position descriptions, included in orientation and compulsory training is being provided. Policies and procedures are in place and staff will be provided with training in incident and hazard reporting. A workplace health and safety committee is established and meets regularly. A schedule of workplace inspections has commenced and is being acted on when necessary. 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 Management has implemented systems and processes to provide a safe environment and that minimise fire, security and emergency risks. The home has been fitted with the required fire and emergency systems including fire detection and firefighting equipment. Approved organisational wide contractors will undertake the required inspections and maintain the system and equipment. Evacuation maps are displayed, there are nominated evacuation points and emergency exits with illuminated signs are freely accessible. Evacuation lists will be commenced and maintained once care recipients enter the home. All staff will undertake

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 24 compulsory fire and emergency training. A security system has been installed, external doors are secure and release automatically in the event of an emergency and small ‘fobs’ provide access to areas that require to be secured. 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 Management will implement the organisation’s infection control program to prevent, identify, manage and contain infections. An infection surveillance program will commence and be coordinated by the clinical staff. Results will be analysed and trended and discussed at relevant meetings. Policies and procedures including outbreak procedures are available for staff to follow. Hand hygiene, personal protective equipment, outbreak kits and appropriate waste disposal systems are in the process of being installed throughout the facility. There is a contracted pest control program in place. Catering, cleaning and laundry procedures will follow infection control guidelines. There is a food safety program and council certification is in progress. Cleaning schedules are in place and environmental audits will be undertaken. Vaccinations will be offered to care recipients and staff. 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 Management is in the process of implementing hospitality services in a way that enhances care recipients’ quality of life and staff working environment. Catering services will provide food and beverage services to include care recipient preferences, nutritional needs and special requirements. A rotating seasonal menu is prepared and alternative options will be offered. A ‘Food Safety Plan’ has been developed and is awaiting council certification. Cleaning will be provided by in-house staff. Cleaning schedules are prepared and appropriate equipment is being procured. Care recipients’ personal clothing will be laundered on site. Flat linen will be outsourced and a contract for this service is already being in place. Feedback mechanisms for hospitality services currently exist for care recipients to use when they take up residence at the home.

Home name: BlueCross Waterdale Dates of audit: 11 April 2017 to 11 April 2017 RACS ID: 3020 25