Decision not to revoke accreditation Salisbury Private Nursing Home

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					           Decision not to revoke accreditation
             Salisbury Private Nursing Home

Following a review audit the Aged Care Standards and Accreditation Agency Ltd has
decided not to revoke the accreditation of Salisbury Private Nursing Home in
accordance with the Accreditation Grant Principles 1999.

The home’s period of accreditation remains unchanged and will expire on 10 June
2012.

The Agency has found the home complies with 44 of the 44 expected outcomes of
the Accreditation Standards. This is shown in the ‘Agency findings’ column
appended to the following executive summary of the assessment team’s review audit
report.

The assessment team recommended that the home did not comply with expected
outcomes 1.8 Information systems, 2.4 Clinical care, 2.8 Pain management, 2.10
Nutrition and hydration and 2.16 Sensory loss. The Agency considered additional
information including a submission from the approved provider and actions taken by
the home since the review audit and found that the home does comply with these
expected outcomes.

The Agency is satisfied the home will undertake continuous improvement measured
against the Accreditation Standards.

The Agency will undertake support contacts to monitor progress with improvements
and compliance with the Accreditation Standards.


Information considered in making an accreditation decision
The Agency has taken into account the following:
• the review audit report; and
• information (if any) received from the Secretary of Department of Health and Ageing; and
• information (if any) received from the approved provider; and
• information (if any) from current or former residents (or their representatives); and
• any other relevant information; and
• whether the decision-maker is satisfied that the residential care home will undertake
    continuous improvement measured against the Accreditation Standards.
                      Home and approved provider details



Details of the home
Home’s name:                       Salisbury Private Nursing Home

RACS ID:                           6952

Number of beds:                    76            Number of high care residents:                     75

Special needs group catered for:                       •   People with dementia or related disorders

                                                       •   People with culturally and linquistically
                                                           diverse backgrounds

                                                       •   People with acquired brain injury



Street:                                 147 Frost Road

City:        SALISBURY                  State:   SA                   Postcode:           5106
             SOUTH

Phone:                                  08 8250 0900                  Facsimile:          08 8250 9333

Email address:                          salisbury@salisburyhome.com.au




Approved provider
Approved provider:                      Salisbury Private Nursing Home Pty Ltd




Assessment team
Team leader:                            Suzette Hayter

Team members:                           Sandra Lloyd-Davies

Dates of audit:                         13 September 2010 to 17 September 2010




Home name: Salisbury Private Nursing Home                    Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                                     AS_RP_00849 v2.5
                                                       2
                                                                                   Accreditation
 Executive summary of assessment team’s report
                                                                                     decision
Standard 1: Management systems, staffing and
            organisational development
                                                   Assessment team
 Expected outcome                                                                  Agency findings
                                                   recommendations
 1.1     Continuous improvement                      Does comply                     Does comply
 1.2     Regulatory compliance                       Does comply                     Does comply
 1.3     Education and staff development             Does comply                     Does comply
 1.4     Comments and complaints                     Does comply                     Does comply
 1.5     Planning and leadership                     Does comply                     Does comply
 1.6     Human resource management                   Does comply                     Does comply
 1.7     Inventory and equipment                     Does comply                     Does comply
 1.8     Information systems                        Does not comply                  Does comply
 1.9     External services                           Does comply                     Does comply

Standard 2: Health and personal care
                                                   Assessment team
Expected outcome                                                                   Agency findings
                                                   recommendations
 2.1     Continuous improvement                      Does comply                     Does comply
 2.2     Regulatory compliance                       Does comply                     Does comply
 2.3     Education and staff development             Does comply                     Does comply
 2.4     Clinical care                              Does not comply                  Does comply
 2.5     Specialised nursing care needs              Does comply                     Does comply
 2.6     Other health and related services           Does comply                     Does comply
 2.7     Medication management                       Does comply                     Does comply
 2.8     Pain management                            Does not comply                  Does comply
 2.9     Palliative care                             Does comply                     Does comply
 2.10 Nutrition and hydration                       Does not comply                  Does comply
 2.11 Skin care                                      Does comply                     Does comply
 2.12 Continence management                          Does comply                     Does comply
 2.13 Behavioural management                         Does comply                     Does comply
 2.14 Mobility, dexterity and rehabilitation         Does comply                     Does comply
 2.15 Oral and dental care                           Does comply                     Does comply
 2.16 Sensory loss                                  Does not comply                  Does comply
 2.17 Sleep                                          Does comply                     Does comply




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               3
                                                                                    Accreditation
 Executive summary of assessment team’s report
                                                                                      decision
Standard 3: Resident lifestyle
                                                    Assessment team
Expected outcome                                                                    Agency findings
                                                    recommendations
 3.1     Continuous improvement                       Does comply                     Does comply
 3.2     Regulatory compliance                        Does comply                     Does comply
 3.3     Education and staff development              Does comply                     Does comply
 3.4     Emotional support                            Does comply                     Does comply
 3.5     Independence                                 Does comply                     Does comply
 3.6     Privacy and dignity                          Does comply                     Does comply
 3.7     Leisure interests and activities             Does comply                     Does comply
 3.8     Cultural and spiritual life                  Does comply                     Does comply
 3.9     Choice and decision-making                   Does comply                     Does comply
 3.10 Resident security of tenure and                 Does comply                     Does comply
      responsibilities

Standard 4: Physical environment and safe systems
                                                    Assessment team
Expected outcome                                                                    Agency findings
                                                    recommendations
 4.1     Continuous improvement                       Does comply                     Does comply
 4.2     Regulatory compliance                        Does comply                     Does comply
 4.3     Education and staff development              Does comply                     Does comply
 4.4     Living environment                           Does comply                     Does comply
 4.5     Occupational health and safety               Does comply                     Does comply
 4.6     Fire, security and other emergencies         Does comply                     Does comply
 4.7     Infection control                            Does comply                     Does comply
 4.8     Catering, cleaning and laundry               Does comply                     Does comply
         services

Assessment team’s reasons for recommendations to the Agency

The assessment team’s recommendations about the home’s compliance with the
Accreditation Standards are set out below. Please note the Agency may have findings
different from these recommendations.




Home name: Salisbury Private Nursing Home              Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                               AS_RP_00849 v2.5
                                                4
                         REVIEW AUDIT REPORT
                        NOT TO REVOKE/TO VARY
    Name of home              Salisbury Private Nursing Home
    RACS ID                   6952

Executive summary
This is the report of a review audit of Salisbury Private Nursing Home 6952, 147 Frost Road
SALISBURY SOUTH, SA 5106 from 13 September 2010 to 17 September 2010 submitted to
the Aged Care Standards and Accreditation Agency Ltd.

Assessment team’s recommendation regarding compliance
The assessment team considers the information obtained through the audit of the home
indicates that the home complies with:

•     39 expected outcomes.

The assessment team considers the information obtained through the audit of the home
indicates the home does not comply with the following expected outcomes:

•     1.8 Information systems
•     2.4 Clinical care
•     2.8 Pain management
•     2.10 Nutrition and hydration
•     2.16 Sensory loss.

Assessment team’s recommendation
The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd
not revoke accreditation of Salisbury Private Nursing Home.

The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd
vary the period of accreditation of Salisbury Private Nursing Home.

Assessment team’s recommendations regarding support contacts
The assessment team recommends there be at least one unannounced support contact each
year during the period of accreditation.

Assessment team’s reasons for recommendation
The team has assessed the quality of care provided by the home against the Accreditation
Standards and the reasons for its recommendations are outlined below.




Home name: Salisbury Private Nursing Home              Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                               AS_RP_00849 v2.5
                                                  5
                                   Review audit report
Scope of audit
An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd
conducted the audit from 13 September 2010 to 17 September 2010.

The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the
Accountability Principles 1998. The assessment team consisted of two registered aged care
quality assessors.

The audit was against the 44 expected outcomes of the Accreditation Standards as set out in
the Quality of Care Principles 1997.

Assessment team
 Team leader:                 Sandra Lloyd-Davies
 Team member:                 Suzette Hayter

Approved provider details
 Approved provider:           Salisbury Private Nursing Home Pty Ltd

Details of home
 Name of home:                Salisbury Private Nursing Home
 RACS ID:                     6952


 Total number of
                              76
 allocated places:
 Number of residents
                              75
 during review audit:
 Number of high care
 residents during             75
 review audit:
                              People with dementia or related disorders
 Special needs
                              People with culturally and linquistically diverse backgrounds
 catered for:
                              People with acquired brain injury


 Street:                      147 Frost Road                              State:           SA
 City:                        SALISBURY SOUTH                             Postcode:        5106
 Phone number:                08 8250 0900                                Facsimile:       08 8250 9333
 Email address:               salisbury@salisburyhome.com.au




Home name: Salisbury Private Nursing Home                 Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                                  AS_RP_00849 v2.5
                                                    6
Assessment team’s recommendation:
The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd
not revoke accreditation of Salisbury Private Nursing Home.

The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd
vary the period of accreditation of Salisbury Private Nursing Home.

Assessment team’s recommendations regarding support contacts
The assessment team recommends there be at least one unannounced support contact each
year during the period of accreditation.

Assessment team’s reasons for recommendation
The team has assessed the quality of care provided by the home against the Accreditation
Standards and the reasons for its recommendations are outlined below.

Audit trail
The assessment team spent four days on-site and gathered information from the following:

Interviews
                                            Number                                                Number
 Executive officer                            1          Residents/representatives                    16
 Nurse manager                                1          Laundry staff                                 1
 Registered nurses                            2          Volunteer                                     1
 Enrolled nurse                               2          Cleaning staff                                1
 Care staff                                   5          Catering staff                                2
 Administration assistant                     1          Maintenance officer                           1
 Lifestyle staff                              2

Sampled documents
                                            Number                                                Number
 Residents’ files which include;
 progress notes, palliative care
 directives, allied health referrals,
 pathology reports, referral
 information and communication.
 Assessments including the
 following; medication, pain,
 restraint, nutrition and hydration,          13         Medication charts                             6
 skin, continence, behaviour,
 mobility, dexterity and
 rehabilitation, oral and dental,
 sensory, sleep, leisure and
 lifestyle which include cultural,
 spiritual, emotional and social
 needs.
 Care plans including leisure and
                                              13         Personnel files                               4
 lifestyle
 Palliative care plan                         1          Wound care plans                              1

Home name: Salisbury Private Nursing Home                   Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                                    AS_RP_00849 v2.5
                                                     7
Other documents reviewed
The team also reviewed:
• activities calendar
• admission package
• agency checklist
• care plan consultation form
• charter of resident’s rights and responsibilities
• comments and concern folder with forms and data
• continuous improvement and activities forms
• continuous improvement folder
• continuous improvement log
• contract of employment
• correspondence documentation from the complaints investigation scheme
• correspondence documentation from the department of health and ageing
• dietary details
• duty statements
• emergency procedures
• enduring power of attorney
• evacuation plans and emergency response flow charts
• food safety plan and report
• gastro kit
• handover prompt cards
• handover sheets
• icons and legends for communication choking risk and level of assistance
• icons and legends for infection control information
• improvement activities including improvement log, improvement register and current
    improvement activities
• incident and hazard data
• infection control log
• infection guidelines
• job descriptions
• license to possess s4 and s8 medication for administration and schedule 8 drug
    administration register
• maintenance record book
• material safety data sheets
• memoranda folder
• new resident pre-admission details
• nurse initiated medication authorisations
• pharmacy documents
• plan for continuous improvement
• police clearance record
• position change forms
• quality management plan std 3
• recruitment policies and procedures
• residency service agreement
• resident / relative survey
• resident incident register and trends
• resident incidents statistics
• resident single and shared rooms with personal items
• residents’ information handbook
• residents’ surveys
• roster and allocation book
• rosters 2009/ 2010
Home name: Salisbury Private Nursing Home        Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                         AS_RP_00849 v2.5
                                            8
•    schedule of meetings
•    sensory kit
•    skin tears folder
•    staff education and training records 2010
•    staff handbook
•    staff orientation package
•    system overview guidelines folder
•    temperature control logs
•    training and education flyers and attendance sheets
•    transfer/discharge forms
•    triennial fire safety certificate
•    various audits, schedules and reports
•    various clinical pathways and flow charts
•    various committee and meeting minutes
•    various diaries, memos and emails
•    various flow charts and pathways
•    various folders with flow charts and treatment documents
•    various meeting minutes
•    various memos and letters
•    various policies and procedures
•    various questionnaires
•    various schedules
•    various surveys with feedback
•    weight charts
•    wound care guidelines.

Observations
The team observed the following:
• activities in progress
• archive room with boxes and files labelled
• automatic dispensing system of chemicals
• call bell system
• care worker orientation
• chemical storage
• closed circuit television
• coded door access to dementia area
• courtyard gardens
• designated smoking areas
• egress
• electrically tested and tagged items
• equipment and supply storage areas
• exit signs clearly sign-posted
• fire fighting equipment and fire panel
• gastroenteritis kits
• hairdressing salon
• hand-washing facilities and alcohol hand gel
• interactions between staff and residents
• internal and external living environment
• key pad exit/entry
• kitchen, cleaning and laundry facilities
• large site map
• library
• lifestyle office
Home name: Salisbury Private Nursing Home          Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                           AS_RP_00849 v2.5
                                              9
•    living environment, including single and double rooms with communal bathrooms
•    lunch and evening meals with residents being assisted
•    meal preparation in kitchen
•    meal service
•    medication storage and impress system
•    medication trolley and medication round
•    mission statement displayed
•    mobility aids
•    morning and afternoon tea being served and resident being assisted
•    notice boards with various information displayed
•    nurses’ stations
•    out of order signs
•    oxygen equipment
•    palliative care suite
•    recycle, general and confidential waste bins
•    resident ambulating with/out assistance and aids
•    rotating menu
•    secure entry and exit
•    secure perimeter fencing
•    servers for computerised system
•    sluice rooms
•    suctioning equipment
•    suggestion boxes
•    treatment rooms
•    various aged care advocacy information displayed
•    visitor and contractors sign in and out books
•    Wound management in progress.




Home name: Salisbury Private Nursing Home         Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                          AS_RP_00849 v2.5
                                            10
Assessment information of major findings
This section covers information about 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 residents, 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 recommendation
       Does comply

       Salisbury Private Nursing Home has a system to identify opportunities for improvement
       and monitor compliance with the Accreditation Standards. The home uses information
       gathered from comments and concern forms, continuous improvements and activity
       forms, audits, resident and staff meetings, verbal feedback and observation to identify
       opportunities for improvement. The executive officer monitors the continuous
       improvement log and reports progress at various meetings. Improvements are
       evaluated through feedback from resident and staff meetings, audits, surveys and one-
       to-one discussions. Residents are generally satisfied they have opportunities to
       suggest improvements and that these are listened to and actioned by management.
       Staff are not familiar with the continuous improvement program.

       Examples of improvement activities and achievements relating to management
       systems, staffing and organisational development include:
       • During July 2010 management identified that the home did not have a policy and
           procedure to guide and manage staff around their computer security system with
           regard to password security, safe usage and maintenance of equipment. An
           external information technology service provider was contracted who developed
           the appropriate documentation. This was received by the home recently. This
           improvement is still to be evaluated.
       • Management identified the need to purchase more suctioning equipment. The
           home only had one unit and due to the layout of the home further equipment was
           required in order to allow staff easy access during emergencies. Two new units
           have been purchased. This initiative is still to be evaluated.


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 recommendation
       Does comply

       The home has processes for identifying and accessing relevant legislation, regulations
       and professional standards. The home is informed of relevant legislation through its
       membership of peak bodies and correspondence with the Department of health and
       ageing. Staff are informed about changes in legislation and regulations through the
       home’s communication processes, including meetings and memoranda. The home
       monitors regulatory compliance relating to management systems, staffing and
       organisational development through resident and staff meetings, staff appraisals,
       internal auditing processes and staff feedback.
Home name: Salisbury Private Nursing Home            Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                             AS_RP_00849 v2.5
                                              11
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 recommendation
       Does comply

       The home has processes to identify, plan and monitor staff education based on staff
       requests and professional development in relation to management systems. Education
       is provided through internal and external training programs. Relevant staff are trained
       in the use of the home’s electronic information management system. Training needs
       are identified and monitored through the appraisal process, work practices, observation
       and requests from staff. The home records staff attendance at training sessions and
       has processes for following up attendance at mandatory training. An orientation
       program is provided for commencing staff. Management and staff are satisfied they
       have access to sufficient education and training to perform their roles effectively.
       Residents are who are able to communicate verbally are satisfied that management
       and staff have the appropriate knowledge and skills to meet their care needs.


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

       Team’s recommendation
       Does comply

       Residents and representatives are generally satisfied that the home provides them with
       access and information regarding internal and external complaint mechanisms. The
       home has systems to assist representatives and residents to feel comfortable to make
       a complaint and that they are aware of the processes available to them. These
       processes include providing information in the resident handbook and agreement,
       resident meetings and there are internal and external complaints and advocacy
       information on display. The home generally logs complaints to identify recurring issues
       and to ensure complaints have been actioned and feedback has been provided.
       Complaints may result in an opportunity for improvement.


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 recommendation
       Does comply

       The home has documented its philosophy of care in the resident and staff handbooks.
       Further information on the home’s services is documented in the residency agreement
       and available to residents and representatives on request. The home has audited
       financial reports.




Home name: Salisbury Private Nursing Home            Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                             AS_RP_00849 v2.5
                                              12
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 recommendation
       Does comply

       The home has a system to monitor and maintain sufficient numbers of appropriately
       skilled staff. Review and monitoring of staffing levels is undertaken by the executive
       officer in consultation with senior management, using information from staff meetings,
       annual performance appraisals, verbal feedback and changes to resident care needs.
       Commencing staff undertake an orientation program and are ‘buddied’ with an
       experienced member of staff for initial shifts. Job descriptions and duty statements
       guide staff practice. Unplanned shift vacancies are filled from a pool of casual staff or
       agency staff as required. Staff are required to attend mandatory training annually. Staff
       registrations and police clearance requirements are monitored to meet legislative
       requirements. Residents and representatives who are able to respond verbally are
       satisfied with the responsiveness of staff and the level of care 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 recommendation
       Does comply

       The home has systems and processes to ensure the availability of appropriate stocks
       of goods and equipment for quality care and services. The home has a preventative
       and corrective maintenance program and access to external contractors for the
       maintenance of plant and equipment as required. Clinical supplies are stored securely
       with access by authorised personnel. Stock levels are monitored by designated staff in
       their area of responsibility. Staff and residents are satisfied there are adequate and
       appropriate stocks of goods and equipment available to provide care and services.


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

       Team’s recommendation
       Does not comply

       While the home has information systems and processes they are not always
       implemented consistently. Not all stakeholders are aware of current systems and
       processes used by the home to allow them access to current and appropriate
       information to perform their roles. Staff stated they follow care documents when
       providing care and services to residents, however, information provided on care
       documents is not always validated by assessments.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               13
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 recommendation
       Does comply

       The home has systems and processes for ensuring externally sourced services meet
       residential care service’s needs and quality requirements. The home has agreements
       with external contractors in relation to fire safety systems, chemical supplies, allied
       health services and pharmacy. Staff and resident feedback contributes to the
       evaluation of service provision. Designated staff monitor satisfaction with external
       services in their area of responsibility. Service suppliers are changed if considered
       unsatisfactory. Residents and staff are satisfied with externally sourced services.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               14
Standard 2 – Health and personal care
Principle: Residents’ physical and mental health will be promoted and achieved at the
optimum level, in partnership between each resident (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 recommendation
       Does comply

       Salisbury Private Nursing Home has a system to identify opportunities for improvement
       and monitor compliance with the Accreditation Standards in relation to health and
       personal care. The home uses comments and concern forms, continuous
       improvements and activity forms, clinical audits, progress notes, resident and staff
       surveys, meetings, and care plan reviews to monitor outcomes for residents.
       Improvements are evaluated through feedback from residents and staff, audits and
       incident data. Residents are satisfied they have opportunities to suggest improvements
       and that these are listened to and actioned by management.

       Improvements and achievements demonstrated by the home in relation to health and
       personal care include:
       • In May 2010 the executive officer identified the need to improve communication of
           residents care needs during transfer to the acute sector. Questionnaires were
           given to various levels of staff such as medical officers, clinical nurses and
           consultant physicians in order to establish how the home could improve
           communication to allow for continuity of care for residents being transferred.
           Evaluation of the questionnaires has resulted in a copy of residents’ care plans
           accompanying them during transfer to assist with the continuity of care. This
           initiative has not been entered onto the home’s plan for continuous improvement.
       • In August 2010 management identified the need to develop a pathway to guide
           staff in the assessment and management of residents’ pressure areas. This
           occurred as a result of increased acuity of residents who entered the home. The
           pathway was developed using evidence based research and has recently been
           implemented. This initiative is still to be evaluated.
       • To alert staff to residents who are at risk of choking and may require assistance
           with meals and fluids, the home has developed symbols which are displayed on
           residents’ beds and in care plans. This initiative was implemented in September
           2010 and is still to be evaluated.
       • Feedback from staff identified the need to obtain a medication chart from residents’
           medical practitioners at the time of admission. The ‘New Resident Pre-Admission
           Details’ form now has this requirement added to prompt residents and/or their
           representatives of the requirement. Verbal feedback from the nurse manager has
           been that having information around residents’ medication requirements at the
           time of their entry to the home has assisted in the continuity of their care. This
           initiative has not been entered onto the home’s plan for continuous improvement.
       • The benefit of logging all improvements was discussed with the executive officer,
           to assist in the monitoring and evaluation thereof. The executive officer stated that
           only large improvements are generally logged.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               15
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 recommendation
       Does comply

       The home has systems to monitor and respond to relevant legislation, regulatory
       requirements, professional standards and guidelines in relation to health and personal
       care. Nurses’ registrations are obtained prior to commencing employment at the home
       and processes are in place to ensure these are updated annually. Staff are informed
       about changes in legislation and regulations through the home’s communication
       processes and documentation is available in the nurses’ stations and staff room. The
       home monitors regulatory compliance through various meetings, incident and hazard
       reports and staff feedback.


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 recommendation
       Does comply

       Although the home has processes to identify, plan and monitor staff education based
       on staff requests and residents’ care needs, not all staff are aware of guidelines around
       thickening of fluids. Education is provided through internal and external training
       programs. The home records staff attendance at training sessions and has processes
       for following up staff attendance at mandatory training. Training needs are identified
       and monitored through the appraisal process, work practices and requests from staff.
       An orientation program is provided for staff commencing employment. Staff are
       satisfied with the ongoing support provided by management to develop their knowledge
       and skills. Residents who are able to communicate verbally are satisfied that
       management and staff have the appropriate knowledge and skills to meet their care
       needs.


2.4    Clinical care
       This expected outcome requires that “residents receive appropriate clinical care”.

       Team’s recommendation
       Does not comply

       Residents who are able to communicate are satisfied with the manner in which the
       home manages their clinical care. While the home has systems and processes to
       assess, plan and review residents clinical care needs there are not implemented
       consistently. The home’s monitoring processes have not identified gaps identified by
       the team. Staff are not all aware of the home’s processes for assessing residents.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               16
2.5    Specialised nursing care needs
       This expected outcome requires that “residents’ specialised nursing care needs are
       identified and met by appropriately qualified nursing staff”.

       Team’s recommendation
       Does comply

       Residents who are able to communicate verbally indicated that they are satisfied with
       the manner in which staff deliver specialised nursing care. The home has systems and
       processes that identify residents’ specialised nursing care needs and these are met by
       appropriately qualified nursing staff. Specialised nursing care is identified, planned,
       implemented and evaluated. Registered nurses are available to guide care in the home
       at all times. Reporting of issues occurs to registered or enrolled nurses by care staff,
       residents and/or their representative. Monitoring occurs via observation of staff
       practice, clinical audits, incident reporting and feedback from staff, residents and/or
       their representatives. Staff indicate that they receive training to assist them in the
       management of resident specialised needs.


2.6    Other health and related services
       This expected outcome requires that “residents are referred to appropriate health
       specialists in accordance with the resident’s needs and preferences”.

       Team’s recommendation
       Does comply

       Residents who are able to communicate verbally are satisfied with the referral
       arrangements to allied health and medical practitioners. Nursing staff refer residents to
       allied health staff or their medical practitioner as well as to appropriate specialists. A
       physiotherapist visits the home on a weekly basis. A podiatrist visits routinely as well as
       referrals dietician, dentists, palliative care service, audiometry or optical services
       occurs and generally to a speech pathologist. Transport is arranged by staff and
       residents are reminded and prepared for each appointment. Staff confirm they receive
       education to enable them to identify residents’ needs through assessment and
       understand the referral process.


2.7    Medication management
       This expected outcome requires that “residents’ medication is managed safely and
       correctly”.

       Team’s recommendation
       Does comply

       The home has systems and processes to ensure that all residents’ medications are
       managed safely and correctly. Residents are satisfied with the manner in which staff
       manage their medications. Assessments occur to determine the level of assistance
       required. A contract with a pharmacist assists the home in their medication
       management. Medications are packed in a sachet system. These are administered by
       registered and enrolled nurses. Review of residents’ medications occurs frequently and
       are amended as required by authorised prescribers. Medications are stored and
       administered according to guidelines and legislation. Monitoring occurs via audits,
       monitoring staff practice and incident reporting. A medication advisory committee
       meets where incidents, new drugs and education are discussed.



Home name: Salisbury Private Nursing Home              Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                               AS_RP_00849 v2.5
                                                17
2.8    Pain management
       This expected outcome requires that “all residents are as free as possible from pain”.

       Team’s recommendation
       Does not comply

       Residents who are able to communicate verbally indicated that they are satisfied that
       their pain needs are managed effectively. While the home has a system to ensure that
       all resident are as free as possible from pain this is not implemented consistently.


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

       Team’s recommendation
       Does comply

       Residents are appreciative of the palliative care provided at the home. The home has
       systems and processes to maintain the comfort and dignity of terminally ill residents.
       On admission, residents and their representatives are asked to provide information
       regarding their end of life wishes. Palliative care plans are developed. Palliative care
       practices include one-to-one non pharmacological aspects such spiritual support,
       aromatherapy and massage. Specialist care is sought when appropriate. Staff assist
       residents and their families during this time and spiritual support is available. The home
       has a specific palliative care unit which provides privacy and comfort to the resident
       and/or their representatives. Staff indicated they have the knowledge, training and
       compassion to support residents and their families.


2.10 Nutrition and hydration
     This expected outcome requires that “residents receive adequate nourishment and
     hydration”.

       Team’s recommendation
       Does not comply

       Residents that are able to give verbal feedback are generally satisfied with the meals
       provided by the home. The home has systems and processes to assess, plan and
       review resident’s nutrition and hydration however these are not followed consistently.
       Monitoring of residents nutritional status does not occur consistently. Staff are not
       aware of processes around residents requiring thickened fluids or the process around
       usage of the thickening agent.


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

       Team’s recommendation
       Does comply




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                                18
       Residents who are able to communicate are happy with the way staff support them to
       maintain their skin integrity and/or manage wounds. Systems and process are in place
       and these are implemented to ensure positive outcomes for all residents. Skin
       assessments inclusive of risk assessments occur on admission and repeated as
       required. Care plans reflect assessed needs and strategies include special equipment,
       position changes, nutritional supplements, emollients and topical medication as
       prescribed by the medical practitioner. Wounds are assessed, categorised and
       monitored according to recommended guidelines. Complex wounds are managed by
       the registered nurse. Referrals are made to specialists to assist in the management of
       complex wounds as required. Staff state that they are trained and confident in wound
       management and have access to a variety of resources to guide them.


2.12 Continence management
     This expected outcome requires that “residents’ continence is managed effectively”.

       Team’s recommendation
       Does comply

       Residents that are able to communicate verbally indicate that they receive support from
       staff and are satisfied that their continence is managed effectively. There are systems
       and processes in place to assist staff in the management of residents’ assessed
       incontinence needs and preferences. Residents are generally assessed on admission
       and reviewed with plans generally implemented to maintain their comfort and dignity.
       Continence issues are reported and residents reassessed with changes made.
       Residents’ care plans may include toileting regimes, aids, adequate fluids and diet, and
       level of assistance required to assist staff to provide care. Staff state they have been
       trained to follow plans, manage continence issues, and have access to guidance when
       needed.


2.13 Behavioural management
     This expected outcome requires that “the needs of residents with challenging
     behaviours are managed effectively”.

       Team’s recommendation
       Does comply

       Residents that are able to communicate verbally state that they are satisfied that other
       residents’ challenging behaviours are managed effectively and these do not impact on
       them. Staff interaction and activity programs assists with residents’ independence.
       Challenging behaviours are generally identified and assessed on admission. Plans are
       generally implemented in consultation with residents and/or their representatives and
       monitored for effectiveness. Staff have training and access to guidelines and outside
       agencies for advice in managing complex behaviour. Referrals occur to medical
       practitioners and/or specialist services as needed. Monitoring occurs via incidents, care
       reviews, participation in lifestyles activities and audits.


2.14 Mobility, dexterity and rehabilitation
     This expected outcome requires that “optimum levels of mobility and dexterity are
     achieved for all residents”.

       Team’s recommendation
       Does comply


Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               19
       Residents who are able to communicate verbally state that they are satisfied with their
       mobility. The home has systems and processes that support residents’ levels of
       mobility and dexterity. Residents are generally assessed on admission and reviewed
       with individual plans to assist in the maintenance of their independence as possible. A
       physiotherapist visits the home to assess and develop care plans. He develops
       exercise regimes which care staff implement and sign as this is completed. Group
       exercise sessions are tailored to the group’s abilities, aids are provided and residents
       are encouraged to walk and develop a safe level of independence. Staff indicated that
       they feel they have support and knowledge to provide mobility care.


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

       Team’s recommendation
       Does comply

       Residents and their representatives are satisfied with the oral and dental care given.
       The home has systems and processes in place to assess residents’ oral and dental
       needs and preferences on admission. Regular review occurs and staff feedback to the
       enrolled or registered nurse if there are any issues. Staff indicated that they are aware
       of residents needs and how to provide assistance as needed. Dental services provide
       care to residents according to their wishes.


2.16 Sensory loss
     This expected outcome requires that “residents’ sensory losses are identified and
     managed effectively”.

       Team’s recommendation
       Does not comply

       Residents who are able to communicate verbally are satisfied with the way the home
       assisted them with their sensory deficits. While the home has systems and processes
       to identify and manage resident sensory loss effectively these are not consistent. Key
       staff who participate in either the assessment and/or care plan development and review
       are not aware of the processes in place.


2.17 Sleep
     This expected outcome requires that “residents are able to achieve natural sleep
     patterns”.

       Team’s recommendation
       Does comply

       Residents say they are satisfied with their sleeping arrangements and staff are
       available to help if they do have a problem. The home has systems and processes in
       place to assist residents to achieve natural sleep patterns. Care plans reflect these
       alternative therapies. All residents are assessed on admission and a plan implemented
       to achieve normal sleep patterns. Measures such as pain management and settling
       routines are also implemented to assist residents to settle.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                                20
Standard 3 – Resident lifestyle
Principle: Residents 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 recommendation
       Does comply

       Salisbury Private Nursing Home has processes for monitoring compliance with the
       Accreditation Standards and developing its continuous improvement system relating to
       resident lifestyle. The home uses information from comments and concern forms,
       audits, incident and hazard data, resident and staff meetings to identify opportunities
       for improvement. Residents, representatives and staff are kept informed about the
       activities in the home.

       Examples of improvement activities and achievements relating to resident lifestyle
       include:
       • As a result of a resident survey, residents chose to conduct their meetings in a
            formal manner as these were being conducted in an informal style. Management
            commenced a more formal setting within which to conduct resident meetings
            during September 2010. This initiative is still to be evaluated.
       • Due to more residents under the age of 60 entering the home, management
            introduced an activity called the ‘Boomers Club’. This activity was commenced on
            the 18 August 2010 and is still to be evaluated.


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 resident lifestyle”.

       Team’s recommendation
       Does comply

       The home has processes for identifying relevant legislation, regulations and guidelines
       relating to residents’ lifestyle and generally monitors and communicates this
       information appropriately. Staff are informed about changes in legislation and
       regulations through the home’s communication processes, including informal
       discussion, memoranda and noticeboards. The home’s executive officer monitors
       regulatory compliance. Staff are informed of relevant changes through staff meetings,
       memoranda and education sessions.


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 recommendation
       Does comply



Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               21
       Although the home has processes for identifying, reviewing and planning staff
       education and training relating to residents’ lifestyle needs, staff have not received
       elder abuse training and are unaware of procedures around reportable assaults.
       Education is provided through internal and external training programs. The home
       records staff attendance at training sessions and has processes for following up staff
       attendance at mandatory training. Training needs are identified and monitored through
       the appraisal process, work practices and requests from staff. An orientation program
       is provided for all commencing staff. Training undertaken by staff include, dementia
       training and manual handling. Staff are satisfied with the ongoing support provided by
       management to develop their knowledge and skills. Residents who are able to
       communicate verbally are generally satisfied that management and staff have the
       appropriate knowledge and skills to meet their care needs.


3.4    Emotional support
       This expected outcome requires that "each resident receives support in adjusting to life
       in the new environment and on an ongoing basis".

       Team’s recommendation
       Does comply

       Residents are generally satisfied with the emotional support provided by the home. A
       resident social history is gathered on entry to the home and on an ongoing basis to
       identify residents’ emotional needs. Social, religious, cultural and preferred lifestyle
       information is collected and used to develop a lifestyle program. Residents are
       encouraged to maintain their links with family and friends. Regular pastoral services
       are available to residents if required. Lifestyle staff provide one-to-one support to help
       residents settle into their new environment.


3.5    Independence
       This expected outcome requires that "residents 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 recommendation
       Does comply

       Residents are generally satisfied the home encourages and supports their
       independence. Residents’ current lifestyle preferences, interests and abilities are
       identified during initial assessments. Residents’ capacity for independence, health
       status, personal care and lifestyle needs are reassessed on an ongoing basis. Lifestyle
       staff, care staff and volunteers assist residents to participate in group and individual
       leisure activities and to maintain links with family and friends. Telephones can be
       connected in residents’ rooms upon request. The home supports residents’
       independence by providing access to on-site voting facilities for the recent Federal
       election. Staff encourage residents to maintain their independence where possible.


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

       Team’s recommendation
       Does comply

Home name: Salisbury Private Nursing Home              Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                               AS_RP_00849 v2.5
                                                22
       Residents who able to communicate verbally say that staff are courteous and
       respectful of their privacy. On entry residents are provided with information about their
       rights and responsibilities. Staff indicate they are mindful of appropriate practices, such
       as knocking on residents’ doors and maintaining privacy when delivering or assisting
       with personal care. The home’s strategies for supporting personal care which protect
       the privacy and dignity of residents have not always been effective. Files containing
       residents’ personal information are stored in the nurses’ stations with access by
       authorised staff and visiting health professionals.


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

       Team’s recommendation
       Does comply

       Residents are generally satisfied with the activities program and with the variety of
       group and individual activities provided by the home. Residents’ current interests are
       identified on entry to the home through interview and completion of a social history
       profile in consultation with representatives if necessary. Lifestyle activities are
       developed to accommodate the resident’s physical, sensory and cognitive abilities,
       cultural background and identified interests. An activities program is on display
       throughout the home. Activities are evaluated by lifestyle staff through feedback from
       resident meetings, surveys and one-to-one discussion with residents. Residents are
       supported to participate in activities and interests appropriate to their needs,
       preferences and abilities.


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 recommendation
       Does comply

       Residents and representatives are generally satisfied that their cultural and spiritual
       preferences are supported and valued. The home identifies the cultural and ethnic
       background, spiritual beliefs, social history and preferences of residents on entry to the
       home and on an ongoing basis. Monitoring processes include lifestyle care plan
       reviews and one-to-one discussions with residents. Pastoral services provide one-to-
       one support for residents and regular religious services are held on-site. The home
       celebrates cultural and spiritual events of significance such as Christmas, Fathers’ day
       and residents’ birthdays. Staff support residents to engage in events and activities of
       spiritual significance to them.


3.9    Choice and decision-making
       This expected outcome requires that "each resident (or his or her representative)
       participates in decisions about the services the resident 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 recommendation
       Does comply

Home name: Salisbury Private Nursing Home               Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                                AS_RP_00849 v2.5
                                                 23
       Residents who are able to communicate verbally are satisfied with their participation in
       making decisions and choices about their care needs and other issues that affect their
       daily life. The home uses consultative processes to obtain information from residents
       including surveys, resident meetings and one-to-one discussions. Monitoring
       processes include lifestyle care plan reviews and one-to-one discussions with
       residents. Staff encourage and assist residents to participate in decisions about their
       care, the services provided to them and to make choices based on their individual
       preferences.


3.10 Resident security of tenure and responsibilities
     This expected outcome requires that "residents have secure tenure within the
     residential care service, and understand their rights and responsibilities".

       Team’s recommendation
       Does comply

       The home has processes to inform residents and representatives of the arrangements
       for their security of tenure, rights and responsibilities on entry to the home. Residents
       and representatives are provided with a resident handbook, residential services
       agreement and information on the home’s services. The home informs and consults
       with residents and representatives about changes in rooms and legislation. Residents
       and representatives are generally satisfied their tenure is secure and that the home will
       support their individual needs where possible.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               24
Standard 4 – Physical environment and safe systems
Principle: Residents live in a safe and comfortable environment that ensures the quality of
life and welfare of residents, staff and visitors.

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

       Team’s recommendation
       Does comply

       Salisbury Private Nursing Home has processes for monitoring compliance with the
       Accreditation Standards and developing its continuous improvement system relating to
       the physical environment and safe systems. The home uses information from
       comments and concern forms, continuous improvements and activity forms,
       maintenance records, resident and staff meetings and hazard data to identify
       improvement opportunities. Residents are aware of the continuous improvement
       program and their suggestions are acknowledged and actioned by the home.

       Examples of improvement activities and achievements relating to the physical
       environment and safe systems include:
       • Feedback from a medical practitioner was that the nurses’ station in section one of
           the home was too small and difficult to work in. The area has been enlarged and
           alterations were completed in July 2010. Feedback from the medical practitioner
           and staff is that the larger area as improved their work environment.
       • The home has had their closed-circuit television monitoring system updated.
           Monitors are now in the kitchen area and the system is able to store security
           information for up to two months. The upgrade was completed in September 2010.
           Staff stated that these monitors are helpful in assisting in the safety of residents
           and staff.


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 recommendation
       Does comply

       The home has systems to monitor and respond to relevant legislation, regulatory
       requirements and professional standards and guidelines in relation to the physical
       environment and safe systems. Compliance is monitored through internal and external
       audit processes. Internal audit processes including a corrective and preventative
       maintenance program are generally effective. External audit processes, include
       triennial fire inspections, fire fighting equipment inspections and food safety audits.
       Staff are informed of relevant changes through staff meetings, memoranda and
       education sessions.


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 recommendation
       Does comply
Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                                 25
       The home has processes for identifying, reviewing and planning staff education and
       training relating to the physical environment and safe systems. All staff undertake
       mandatory training upon commencement of employment. Additional training needs are
       identified through staff appraisals, resident and staff feedback and hazard data. The
       home has processes for monitoring staff skills and knowledge and following up
       attendance at mandatory training. Staff have participated in training relating to the
       physical environment and safe systems, including food safety practices, manual
       handling and fire and emergency. Staff are satisfied with the ongoing support provided
       to them to develop their knowledge and skills. Residents who are able to communicate
       verbally are satisfied that management and staff have the appropriate knowledge and
       skills to meet their care needs.


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
       residents’ care needs".

       Team’s recommendation
       Does comply

       Residents who are able to communicate verbally are satisfied with the comfort and
       security of the living environment. The home has systems and processes for monitoring
       the safety and comfort of the living environment including internal and external
       environmental audits, incident and hazard data and preventive and corrective
       maintenance programs. Facilities are available to promote resident independence and
       provide opportunities for entertaining guests, including lounge, dining and courtyard
       garden areas. Residents are able to decorate their rooms to reflect their personal taste.
       Restraint is utilized by the home and there is a process of assessment, consultation
       and monitoring. The home monitors resident satisfaction with the living environment
       through comments and concern forms, continuous improvements and activity forms,
       resident meetings, audits and maintenance records. Staff are generally satisfied with
       the safety and comfort of 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 recommendation
       Does comply

       The home has systems and processes to provide a safe working environment that
       meets regulatory requirements. The executive officer monitors incident and hazard
       data to identify trends and this information is discussed at occupational health and
       safety meetings. Workplace inspections and audits are used to monitor the safety of
       the environment and compliance with legislation. The home has processes for
       supporting and managing staff affected by workplace injury. Staff have access to
       policies, procedures and guidelines.


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 recommendation
       Does comply
Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               26
       The home has systems to provide a safe environment and work systems to minimise
       fire, security and emergency risks. Emergency procedures and evacuation plans are on
       display throughout the home and fire and emergency training is conducted annually.
       Contracted external services and internal maintenance processes are generally
       effective in monitoring the security, fire and emergency systems, including electrical
       testing and tagging. The home has a current triennial fire safety certificate. External
       doors are secured with keypad entry/exit and a lock up procedure and closed circuit
       television monitoring assist in maintaining the home’s security. Staff are aware of their
       required response in the event of an emergency. Resident evacuation lists are kept
       with the fire panel at the front of the building.


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

       Team’s recommendation
       Does comply

       Residents state they are satisfied with the way in which the home manages infections.
       Management has implemented systems and processes to provide an effective infection
       control program. The program is managed by the registered nurse. Any infections are
       recorded and trends identified to capture any cross infection and reported at various
       meetings as appropriate. There is information available on site, access to external
       resources, and plans and equipment in place if an infection control risk occurs. Staff
       receive training and education, personal protective equipment is available and state
       they feel confident with guidelines to manage infection control issues. Audits are
       conducted to monitor the homes infection control program. Practical exercises with all
       staff are undertaken by the key person which assists the home in monitoring of staffs’
       hand washing techniques.


4.8    Catering, cleaning and laundry services
       This expected outcome requires that "hospitality services are provided in a way that
       enhances residents’ quality of life and the staff’s working environment".

       Team’s recommendation
       Does comply

       Residents are satisfied with the catering, cleaning and laundry services provided by the
       home. A rotating menu offers choice and variety to meet residents’ individual dietary
       needs and preferences and is reviewed by a dietitian. Residents have the opportunity
       to comment on the catering services directly with staff, at resident meetings, through
       surveys or comments and concern forms. Meals are prepared on-site by appropriately
       qualified staff and alternate meals are available on request. Dietary preferences and
       requirements are documented and notification of changes to catering staff is made by
       the registered nurse. The home monitors its hospitality services and staff practises by
       audits, surveys and staff and resident meetings. Resident clothing is managed on-site
       with linen services outsourced to an external service provider. The laundry operates
       seven days per week. Staff are provided with training, supplies, equipment, work
       schedules, guidelines and procedures to support them to undertake their duties and
       provide quality services to residents.




Home name: Salisbury Private Nursing Home             Dates of audit: 13 September 2010 to 17 September 2010
RACS ID: 6952                                                                              AS_RP_00849 v2.5
                                               27

				
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