Uniting Amala Gordon ACT
RACS ID 2949
200 Woodcock Drive
GORDON ACT 2906
Approved provider: The Uniting Church in Australia Property Trust (NSW)
Following an audit we decided that this home met 44 of the 44 expected outcomes of the
Accreditation Standards and would be accredited for three years until 15 February 2020.
We made our decision on 23 December 2016.
The audit was conducted on 22 November 2016 to 23 November 2016. The assessment
team’s report is attached.
We will continue to monitor the performance of the home including through unannounced
visits.
Most recent decision concerning performance against the
Accreditation Standards
Standard 1: Management systems, staffing and organisational
development
Principle:
Within the philosophy and level of care offered in the residential care service, management
systems are responsive to the needs of care recipients, their representatives, staff and
stakeholders, and the changing environment in which the service operates.
Expected outcome
Quality Agency decision
1.1 Continuous improvement
Met
1.2 Regulatory compliance
Met
1.3 Education and staff development
Met
1.4 Comments and complaints
Met
1.5 Planning and leadership
Met
1.6 Human resource management
Met
1.7 Inventory and equipment
Met
1.8 Information systems
Met
1.9 External services
Met
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
2
Dates of audit: 22 November 2016 to 23 November 2016
Standard 2: Health and personal care
Principles:
Care recipients’ physical and mental health will be promoted and achieved at the optimum
level in partnership between each care recipient (or his or her representative) and the health
care team.
Expected outcome
Quality Agency decision
2.1 Continuous improvement
Met
2.2 Regulatory compliance
Met
2.3 Education and staff development
Met
2.4 Clinical care
Met
2.5 Specialised nursing care needs
Met
2.6 Other health and related services
Met
2.7 Medication management
Met
2.8 Pain management
Met
2.9 Palliative care
Met
2.10 Nutrition and hydration
Met
2.11 Skin care
Met
2.12 Continence management
Met
2.13 Behavioural management
Met
2.14 Mobility, dexterity and rehabilitation
Met
2.15 Oral and dental care
Met
2.16 Sensory loss
Met
2.17 Sleep
Met
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
3
Dates of audit: 22 November 2016 to 23 November 2016
Standard 3: Care recipient lifestyle
Principle:
Care recipients retain their personal, civic, legal and consumer rights, and are assisted to
achieve active control of their own lives within the residential care services and in the
community.
Expected outcome
Quality Agency decision
3.1 Continuous improvement
Met
3.2 Regulatory compliance
Met
3.3 Education and staff development
Met
3.4 Emotional support
Met
3.5 Independence
Met
3.6 Privacy and dignity
Met
3.7 Leisure interests and activities
Met
3.8 Cultural and spiritual life
Met
3.9 Choice and decision-making
Met
3.10 Care recipient security of tenure and
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.
Expected outcome
Quality Agency decision
4.1 Continuous improvement
Met
4.2 Regulatory compliance
Met
4.3 Education and staff development
Met
4.4 Living environment
Met
4.5 Occupational health and safety
Met
4.6 Fire, security and other emergencies
Met
4.7 Infection control
Met
4.8 Catering, cleaning and laundry services
Met
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
4
Dates of audit: 22 November 2016 to 23 November 2016
Audit Report
Uniting Amala Gordon ACT 2949
Approved provider: The Uniting Church in Australia Property Trust (NSW)
Introduction
This is the report of a re-accreditation audit from 22 November 2016 to 23 November 2016
submitted to the Quality Agency.
Accredited residential aged care homes receive Australian Government subsidies to provide
quality care and services to care recipients in accordance with the Accreditation Standards.
To remain accredited and continue to receive the subsidy, each home must demonstrate that
it meets the Standards.
There are four Standards covering management systems, health and personal care, care
recipient lifestyle, and the physical environment and there are 44 expected outcomes such
as human resource management, clinical care, medication management, privacy and dignity,
leisure interests, cultural and spiritual life, choice and decision-making and the living
environment.
Each home applies for re-accreditation before its accreditation period expires and an
assessment team visits the home to conduct an audit. The team assesses the quality of care
and services at the home and reports its findings about whether the home meets or does not
meet the Standards. The Quality Agency then decides whether the home has met the
Standards and whether to re-accredit or not to re-accredit the home.
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: Uniting Amala Gordon ACT
RACS ID: 2949
1
Dates of audit: 22 November 2016 to 23 November 2016
Scope of audit
An assessment team appointed by the Quality Agency conducted the re-accreditation audit
from 22 November 2016 to 23 November 2016.
The audit was conducted in accordance with the Quality Agency Principles 2013 and the
Accountability Principles 2014. The assessment team consisted of two registered aged care
quality assessors.
The audit was against the Accreditation Standards as set out in the Quality of Care Principles
2014.
Assessment team
Team leader:
Janice Stewart
Team member:
Judith Charlesworth
Approved provider details
Approved provider:
The Uniting Church in Australia Property Trust (NSW)
Details of home
Name of home:
Uniting Amala Gordon ACT
RACS ID:
2949
Total number of allocated
places:
42
Number of care recipients
during audit:
30
Number of care recipients
receiving high care during
audit:
1
Special needs catered for:
N/A
Street/PO Box:
200 Woodcock Drive
City/Town:
GORDON
State:
ACT
Postcode:
2906
Phone number:
02 6249 4100
Facsimile:
N/A
E-mail address:
Nil
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
2
Dates of audit: 22 November 2016 to 23 November 2016
Audit trail
The assessment team spent two days on site and gathered information from the following:
Interviews
Category
Number
Service managers
2
Registered nurses
2
Organisational quality improvement coordinator
1
Head of residential
1
Homemakers
2
Physiotherapist
1
Regional maintenance manager
1
Care recipients/representatives
11
Chaplain
1
Organisational business operations manager
1
Residential business head
1
Care staff
2
Care, laundry and catering staff
5
Clinical learning and development delivery manager
1
Sampled documents
Category
Number
Care recipients’ files
6
Observation charts: bowels, weights, vital signs, blood glucose
levels, wound, fluid balance, pain and behaviours
24
Care recipient agreements
2
Medication charts
4
Personnel files including confidentiality agreements
4
Other documents reviewed
The team also reviewed:

Asset register

Care recipient admission package including: privacy consent, care recipient handbook,
information brochures, care recipient admission pack guidelines
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
3
Dates of audit: 22 November 2016 to 23 November 2016

Cleaning schedules, environmental cleaning for outbreak information

Comments, complaints and suggestions register

Equipment orders and stock control documentation

Food safety program, audit results and ACT Food licence, seasonal menus, dietician
menu review, food temperature monitoring, equipment temperature checklists, kitchen
equipment and servery cleaning schedules, care recipient meal preference notes

Human resource management including staff handbook, new employee orientation
package, job descriptions, duty statements, master roster and working rosters, staff
availability and casual list, statutory declarations and staff working visa lists

Incident and accident reports, hazard log, risk assessments

Infection control: resource material, outbreak management records, infection
surveillance data, vaccination programs, audit reports, water analysis and pest control
reports

Information management including: minutes of meetings, handover reports, information
notice boards, memoranda, communication diaries, care recipient handbook,
newsletters

Lifestyle program, social and spiritual assessments, care plans and hobbies and
interests folders

Maintenance systems include equipment and high cleaning schedules, preventative
and routine maintenance, maintenance requests, warm water testing records

Medication: reviews, schedule 8 drug registers, self-administration assessments, patch
application, warfarin, nurse initiated medications, PRN, and fridge temperature
monitoring books

Policy and procedures, including accident and incident reporting and medication
incidents

Quality system including: Continuous improvement logs, audit schedule and reports,
feedback brochures

Regulatory compliance including: police record check matrix, elder abuse reporting,
consolidated records, professional registrations, government legislative alert
documentation

Self-assessment report for re-accreditation and associated documentation

Staff and Care recipients’ information handbooks

Staff signed memoranda

Work, health and safety manual, safe workplace audits, networking meeting minutes
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
4
Dates of audit: 22 November 2016 to 23 November 2016
Observations
The team observed the following:

Activities in progress and resources

Equipment and supply storage areas and equipment in use

Infection control: food safety, outbreak management kit, sharps waste disposal, spill
kits, personal protective equipment, colour coded equipment, hand washing and hand
hygiene equipment and waste management

Information on display: Aged Care Quality Agency re-accreditation site audit, vision,
philosophy and values, comments and complaints, advocacy services and charter of
care recipients’ rights and responsibilities, menus

Interactions between staff and care recipients/representatives

Living environment

Meals service

Medication: administration, fridges and secure storage

Memorial book acknowledging the passing away of care recipients

Secure storage of care recipients and staff information

Security cameras, locked keypads, night patrol documentation, automatic night lock up
systems, fire fighting equipment, evacuation kits

Short group observation

Staff practices and work areas

White board with care recipients’ complex care needs in staff area
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
5
Dates of audit: 22 November 2016 to 23 November 2016
Assessment information
This section covers information about the home’s performance against each of the expected
outcomes of the Accreditation Standards.
Standard 1 – Management systems, staffing and organisational development
Principle: Within the philosophy and level of care offered in the residential care service,
management systems are responsive to the needs of care recipients, their representatives,
staff and stakeholders, and the changing environment in which the service operates.
1.1 Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
Uniting Amala has an overarching organisational system that enables it to actively pursue
continuous improvement and monitor its performance against the Accreditation Standards.
The identification of areas for improvement occurs through meetings, audits, comments and
complaints, reporting of incidents and accidents, clinical indicators and verbal feedback.
Strategies are developed and monitored to ensure satisfactory outcomes are achieved. Staff
and care recipients/representatives are aware of the systems for continuous improvement
and confirmed they are involved in continuous improvement activities. Interviews with care
recipients/representatives and staff confirmed feedback has resulted in improvements for
care recipients.
The home has made planned improvements in relation to Accreditation Standard One Management systems, staffing and organisational development, including:

As care recipient occupancy in the facility increased, management identified the need
to review registered nurse staffing levels. As a result of the review, extra staff have
been employed to ensure a registered nurse is on duty twenty four hours per day.
Management said this has resulted in increased monitoring of staff, and improved care
for care recipients.

Recently it was identified there were no formalised break times for staff, and this was
causing confusion at times. In consultation with staff, guidelines for morning, lunch and
tea breaks have been developed. Staff take into consideration care recipients’ needs
and preferences before taking breaks. Generally, staff feedback has been positive, and
management are still monitoring the effectiveness of this initiative.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
6
Dates of audit: 22 November 2016 to 23 November 2016
1.2 Regulatory compliance
This expected outcome requires that “the organisation’s management has systems in place
to identify and ensure compliance with all relevant legislation, regulatory requirements,
professional standards and guidelines”.
Team’s findings
The home meets this expected outcome
There are systems to ensure compliance with relevant legislation, regulatory requirements,
professional standards and guidelines. The organisation receives regulatory compliance
information from government departments and agencies as well as professional conferences
and networks. Management at the home monitors compliance through observation of staff
practices, performance appraisals, the audit program and feedback. Relevant changes in
legislation and guidelines are communicated to staff through meetings, memoranda,
noticeboards, toolbox talks and education sessions. Staff state they are satisfied with the
information provided to them about legislation, regulatory requirements, professional
standards and guidelines relevant to their work. Examples of compliance with regulatory
requirements specific to Accreditation Standard One - Management systems, staffing and
organisational development include:

A system and processes ensure all staff, allied health professionals and volunteers
have current criminal history checks.

The provision of information to care recipients and stakeholders about internal and
external complaint mechanisms.

Notification of the re-accreditation audit to care recipients/representatives occurred via
notices in the home and verbal notification.
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
There are processes to ensure management and staff have the appropriate knowledge and
skills to perform their roles effectively. The review of documentation and interviews with
management and staff demonstrated training needs are identified. Compulsory and planned
education opportunities and competency testing ensure staff have the necessary knowledge
and skills to meet the needs of care recipients in their care. Guest speakers, qualified staff,
online and external education opportunities are used to ensure a variety of training is
provided. There is a recruitment procedure and orientation process for new staff. All staff
interviewed reported they have access to education on a regular basis.
Review of the education documentation and interviews confirmed education has been
provided in relation to Accreditation Standard One - Management systems, staffing and
organisational development. Examples include:

Four staff have been trained as super users in the electronic incident management
program, and the electronic care management program, as well as mentoring.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
7
Dates of audit: 22 November 2016 to 23 November 2016

Electronic incident and care management systems.

Bullying and harassment.
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
There are internal and external mechanisms for care recipients/representatives and other
interested parties to provide feedback about comments and complaints. External and internal
complaints information is accessible to care recipients/representatives and visitors. There is
a secure feedback box for confidential lodgement of feedback forms. Interviews and the
review of meeting minutes confirmed meetings provide a forum for comments, suggestions
and complaints to be raised. Care recipients/representatives and staff interviewed are aware
of the home’s feedback system and expressed satisfaction with the resolution of concerns
they raised. Care recipients/representatives stated they prefer to speak directly with
management and staff regarding any issues, as they find these avenues result in satisfactory
outcomes.
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 organisation’s purpose and values are documented and the commitment to quality is
expressed through the statements. Observations and documentation reviews demonstrated
the organisation’s values are available to all stakeholders in printed format and are on
display in the home.
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
There is a system and processes for the provision of appropriately skilled and qualified staff,
sufficient to provide services in accordance with the Accreditation Standards and the
organisation’s values. The home has processes for recruitment, orientation and ensuring
staff are eligible to work in aged care. Rostering processes ensure shifts are filled with
suitably qualified staff. Management report they adjust staffing levels based upon care
recipient care needs, clinical data and staff and care recipient feedback. Staff are
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
8
Dates of audit: 22 November 2016 to 23 November 2016
encouraged to pursue further education through in-house and external training opportunities.
Staff stated they are confident they have the relevant knowledge and skills to carry out their
work. Care recipients/representatives are satisfied with the staff and the skill they
demonstrate in the provision of care. They stated staff are attentive to care recipients’ needs
and generally responsive to their requests for assistance.
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
Staff and care recipients/representatives stated they have access to appropriate and
adequate goods and equipment to ensure quality service delivery. Management oversees
the home’s budget and there is a preferred suppliers list that enables the timely purchasing
and receipt of goods and equipment. Equipment needs are identified through audits and
input from staff and care recipients/representatives feedback. There is a corrective and
preventative maintenance program to ensure equipment operates safely and is cleaned
regularly. Observations showed sufficient stocks of appropriate goods and equipment
throughout the home.
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
There is a system for the creation, storage, archiving and destruction of documentation within
the home. We observed that confidential information such as care recipient and staff files are
stored securely. Processes are in place to consult with care recipients and/or their
representatives and to keep them informed of activities within the home. Information is
disseminated through meetings, notice boards, memoranda, communication books and
diaries, newsletters, information technology systems and informal lines of communication.
The computers at the home are secure and have a backup system. The audit system
identifies the need to review: policies, procedures and staff work practices. Care
recipients/representatives and staff stated they are kept informed and are consulted about
matters that may impact them.
1.9 External services
This expected outcome requires that "all externally sourced services are provided in a way
that meets the residential care service’s needs and service quality goals".
Team’s findings
The home meets this expected outcome
Externally sourced services are provided in a way that meets the home’s needs and service
quality goals. Service contracts with external providers and service suppliers are established
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
9
Dates of audit: 22 November 2016 to 23 November 2016
and regularly reviewed on an organisational level. There are systems for ensuring
contractors have the relevant insurances, licences and criminal history checks. The home
has a preferred supplier/contractor list. A range of allied health professionals provide on-site
care and services for care recipients. The home monitors the quality of goods and services
provided by external service providers through observation and feedback mechanisms such
as meetings and surveys. Staff and care recipients/representatives interviews indicated
satisfaction with current external services.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
10
Dates of audit: 22 November 2016 to 23 November 2016
Standard 2 – Health and personal care
Principle: Care recipients’ physical and mental health will be promoted and achieved at the
optimum level, in partnership between each care recipient (or his or her representative) and
the health care team.
2.1 Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
In relation to Accreditation Standard Two - Health and personal care the home has made
planned improvements including:

It was recently identified there was not a case conferencing schedule to ensure all care
recipients have the opportunity of a case conference within three months of admission.
As a result, a new schedule has been developed. All care recipients and their families
have received a letter inviting them to attend a case conference. Advanced care plans
are discussed at this meeting if they have not been completed on admission. Case
conferences by telephone or email in some cases have been organised. There has
been a positive response to the invitation, and several families have applied to attend a
case conference to date.

Management identified it often took several days for results from international
normalised ratio (INR) testing to be returned. Two coagulant monitor devices have
been purchased which provide instant readings identifying if care recipient’s INR
readings are within acceptable range, and staff have attended education in the
operation of the machines. This has resulted in earlier interventions and improved care
recipient health outcomes.
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
Refer to expected outcome 1.2 Regulatory Compliance for a description of the overall system
related to this expected outcome. Examples of regulatory compliance with regulations
specific to Accreditation Standard Two - Health and personal care include:

There is a system of review by an accredited pharmacist of care recipients’ medication
management.

Schedule eight medications are stored and managed in line with legislative
requirements.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
11
Dates of audit: 22 November 2016 to 23 November 2016

The home maintains a register of registered nurses and allied health professionals’
registrations and authorities to practice.
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
Refer to expected outcome 1.3 Education and staff development for a description of how the
home monitors and provides education to ensure management and staff have appropriate
skills and knowledge. Review of education documentation and interviews confirmed
education relating to Accreditation Standard Two - Health and personal care has been
provided for management and staff. Examples include:

One staff member has completed a one day workshop on incontinence and pelvic floor
exercises for care recipients.

One registered nurse has attended a two day workshop on wound management and
best practice in dressings.

One registered nurse is attending a five day program over 12 months, which involves
best clinical practice and uniformity of processes throughout the organisation.
2.4 Clinical care
This expected outcome requires that “care recipients receive appropriate clinical care”.
Team’s findings
The home meets this expected outcome
The Uniting Amala care system supports staff to assess, implement, evaluate and
communicate the care recipients’ clinical care needs and preferences. Care recipients’ files
showed staff regularly assess care recipients’ care needs and update care plans in
collaboration with the care recipients/representatives and the relevant health professionals.
Staff use validated assessment tools and evidence based interventions to meet the ongoing
needs of the care recipients. Case conferencing supports consultation with care
recipients/representatives in relation to changing care needs and preferences. Staff
demonstrated they have the knowledge and skills to deliver clinical care aligned with care
recipients’ care plans and the home’s policies. Management regularly evaluate and improve
assessment tools, care planning, care delivery and staff practices. Care
recipients/representatives expressed satisfaction with the care provided by the staff.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
12
Dates of audit: 22 November 2016 to 23 November 2016
2.5 Specialised nursing care needs
This expected outcome requires that “care recipients’ specialised nursing care needs are
identified and met by appropriately qualified nursing staff”.
Team’s findings
The home meets this expected outcome
Care recipients’ specialised nursing care needs are identified, managed and evaluated by
appropriately qualified staff. Registered nurses monitor specialised nursing care and care
recipients’ care plans are evaluated on an ongoing bases. There are processes for staff to
consult on best practice assessment and care with internal resource staff and external
specialists and services. Management monitor assessment tools and staff practices and
provide staff education on care recipients’ specialised nursing care needs. Care
recipients/representatives are satisfied with the specialised nursing care provided at the
home.
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
The home has an effective system to refer care recipients to medical practitioners and allied
health services to meet their needs and preferences. Care recipients’ needs are assessed on
entry to the home and at regular intervals and referrals are planned, documented,
communicated and followed up by staff. Staff demonstrated a good understanding of the
referral process and the procedure to assist care recipients to access appointments with
external health and related services. There is a process to monitor staff practices and referral
mechanisms. Care recipients/representatives stated staff inform and support them to access
health specialists and service of their choice and they are satisfied with this referral process.
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
There is a system to implement, monitor and evaluate care recipients’ medication
management. Staff have access to medication policies, procedures, ongoing education and
complete annual competencies. Care recipients’ medications are reviewed regularly and
adjusted accordingly in consultation with care recipients/representatives and the relevant
health professionals. We observed medications being administered safely and correctly and
securely stored by appropriately qualified staff. The medication incident and auditing
processes link into the continuous improvement system and support management to monitor
and evaluate medication management. Care recipients/representatives expressed
satisfaction with medication management and the timely administration of their medications.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
13
Dates of audit: 22 November 2016 to 23 November 2016
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
There is a system to assess and monitor care recipients’ pain and develop care plans to
communicate and evaluate strategies to manage the pain. The physiotherapist, registered
nurses and homemakers provide medication and/or non-medication strategies to support
optimal pain management for care recipients. Staff have a sound understanding of care
recipients’ pain requirements and management. Staff receive regular education on pain
management from internal and external resources. Care recipients/representatives
expressed satisfaction with the approach to pain management.
2.9 Palliative care
This expected outcome requires that “the comfort and dignity of terminally ill care recipients
is maintained”.
Team’s findings
The home meets this expected outcome
The home has policies and procedures to guide staff in the provision of best practice
palliative care. Staff document care recipients’ end of life preferences and wishes and
develop palliative care plans when care recipients reach the end of life stage. There is a
multidisciplinary approach to support care recipients’ physical, emotional, cultural and
spiritual end of life needs and preferences. Staff have the knowledge and skills to manage
palliative care for care recipients and have access to pastoral care support and palliative
care expertise and resources. Management regularly evaluate and review palliative care
services. Care recipients/representatives are satisfied with the comfort and dignity provided
to care recipients during end of life care.
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
There is a multidisciplinary approach to regularly assessing, monitoring and updating care
recipients’ nutritional and hydration needs and preferences. Nutritional and hydration care
plans are developed in collaboration with care recipients/representatives with an awareness
of cultural, religious, allergies and medical requirements. The home environment facilitates
and staff encourages care recipients to access food and drinks anytime day or night.
Management regularly monitor and review processes and staff practices to ensure care
recipients’ needs and preferences are met. Care recipients/representatives stated they enjoy
the home-style, open plan kitchen and have regular input into the food choices on the menu.
They are satisfied with the menu and the dining experience.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
14
Dates of audit: 22 November 2016 to 23 November 2016
2.11 Skin care
This expected outcome requires that “care recipients’ skin integrity is consistent with their
general health”.
Team’s findings
The home meets this expected outcome
The home has a system to assess, monitor and maintain care recipients’ skin integrity
consistent with their health. The care recipients’ skin care needs are assessed on entry to
the home and at regular intervals in collaboration with care recipients/representatives and
relevant health professionals. This information is communicated in individualised care plans
that are regularly evaluated and updated. There are procedures to identify care recipients at
risk of impairment to skin integrity and interventions and aids to protect their skin. Staff assist
care recipients to care for their skin, monitor and record skin irregularities and report
incidents. Care recipients/representatives expressed satisfaction with the skin care provided
at the home.
2.12 Continence management
This expected outcome requires that “care recipients’ continence is managed effectively”.
Team’s findings
The home meets this expected outcome
There is a system to ensure care recipients’ continence needs are managed effectively.
Continence is managed through initial and ongoing assessments and individualised care
plans with input from the care recipients/representatives and other appropriate health
professionals. Care recipients’ continence interventions are regularly monitored and
evaluated for effectiveness and changes communicated to staff. Staff have an understanding
of care recipients’ continence needs and preferences. Staff have access to internal resource
staff and external continence specialist services. Care recipients/representatives expressed
satisfaction with the continence management program.
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
There are appropriate programs and interventions to meet care recipients’ behavioural
needs. Care recipients’ behavioural needs are assessed on entry to the home and at regular
intervals in consultation with care recipients/representatives and other relevant health
professionals. Care plans are developed and regularly updated and staff have the knowledge
and skills to deliver the behavioural strategies. Staff stated and we observed the home’s
environment and the ‘person first’ approach assists in supporting the care recipients with the
behavioural needs. Staff have access to internal and external expertise to support care
recipients with behavioural needs. The incident reporting process, monitoring of staff
practices and feedback mechanisms support management to evaluate and review the
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
15
Dates of audit: 22 November 2016 to 23 November 2016
homes’ behaviour management program. Care recipients/representatives are satisfied with
the management of care recipients with behavioural needs.
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
The home has policies and practices to support care recipients to maintain an optimal level
of mobility and dexterity. The physiotherapist assesses care recipients’ mobility and dexterity
and staff implement and monitor the mobility care plans. The mobility plans are reviewed
regularly with care recipients/representatives and appropriate health professionals. There is
a falls prevention and protection program and adequate mobility equipment and independent
living aids. The effectiveness of the program is assessed through audits, monitoring of staff
practices, regular review of care recipients’ care plans and reporting and analysing the
incidents of falls. Care recipients/representatives expressed satisfaction with the care
provided to maintain and enhance mobility and dexterity.
2.15 Oral and dental care
This expected outcome requires that “care recipients’ oral and dental health is maintained”.
Team’s findings
The home meets this expected outcome
The oral and dental health of care recipients is assessed on entry to the home in consultation
with care recipients/representatives and other appropriate health professionals. An
individualised care plan is developed to meet care recipients’ needs and preferences. There
are policies and processes to regularly monitor and review care recipients’ ongoing oral and
dental health needs and facilitate referrals to appropriate health professionals. Staff have the
knowledge and skills to deliver care consistent with the care recipients’ oral and dental health
needs and preferences. Care recipients/representatives are satisfied with the oral and dental
care provided to care recipients.
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
There is a system to ensure care recipients’ sensory losses are identified and managed in
consultation with the appropriate external health professionals and services. Care recipients’
senses are assessed on entry to the home, reviewed regularly and care plans are developed
to communicate their needs and preferences. Staff have the knowledge and skills to manage
the care recipients’ sensory losses. The lifestyle, interests and hobbies program supports
and assists care recipients with sensory deficits. Sensory therapies and lifestyle program are
monitored and evaluated to ensure they meet the needs and preferences of care recipients.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
16
Dates of audit: 22 November 2016 to 23 November 2016
Care recipients/representatives are satisfied with the management of care recipients’
sensory needs.
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
Care recipients’ sleep patterns are assessed regularly with consideration for related pain,
health conditions and behavioural management needs. Care plans are developed and
regularly updated to communicate the care recipients’ sleep patterns and interventions to
assist care recipients who have difficulty sleeping. Management evaluates and reviews the
effectiveness of practices in meeting care recipients’ sleep needs. Care recipients/
representatives are satisfied with the approach to achieving natural sleep patterns.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
17
Dates of audit: 22 November 2016 to 23 November 2016
Standard 3 – Care recipient lifestyle
Principle: Care recipients retain their personal, civic, legal and consumer rights, and are
assisted to achieve control of their own lives within the residential care service and in the
community.
3.1 Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
Refer to expected outcome 1.1 Continuous Improvement for a description of the overall
system of continuous improvement. In relation to care recipient lifestyle, care recipient and
representative meetings, the complaints system and care recipient satisfaction surveys are
used to gather feedback from care recipients.
The home has made planned improvements in Accreditation Standard Three – Care
recipient lifestyle including:

Following care recipient dissatisfaction with a trial of on-line exercises, the
physiotherapist now conducts a gentle exercise class one day per week. Care recipient
feedback has been positive, and attendance at exercises has increased.

A new ten seater wheelchair accessible bus has recently been purchased. All staff with
car licences are able to drive the bus. Regular weekly bus trips are organised
according to care recipient requests. Care recipients reported they look forward to the
bus outings.

At organisational level, a new care recipient handbook has been developed. All care
recipients have received a copy of the updated handbook. Management said the new
handbook includes more comprehensive information on financial matters, security of
tenure, and advocacy.
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
Refer to expected outcome 1.2 Regulatory compliance for a description of the overall system
related to this expected outcome. Examples of regulatory compliance with regulations
specific to Accreditation Standard Three – Care recipient lifestyle include:

Management has a system for compulsory reporting for alleged and suspected
reportable assaults as required under amendments to the Aged Care Act 1997. A
compulsory reporting register is in place.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
18
Dates of audit: 22 November 2016 to 23 November 2016

Staff obligations to maintain confidentiality of care recipients’ information and to respect
care recipients’ privacy is included in the staff handbook and described in the
employment contract that staff sign upon the commencement of their employment.

The ‘Charter of care recipients’ rights and responsibilities’ is included in documents that
are provided to care recipients and/or their representatives.
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
Refer to expected outcome 1.3 Education and staff development for a description of how the
home monitors and provides education to ensure management and staff have appropriate
skills and knowledge. Review of the education documentation and interviews confirmed
education relating to Accreditation Standard Three – Care recipient lifestyle has been
provided for staff. Examples include:

Person first education focused on understanding each care recipient as an individual.

Two home-maker staff attended organisational “knowledge community for hobby and
interests” networking education. This education provides a systematic approach to
continuous improvement planning and management across all areas of care recipient
lifestyle planning.
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
The home has a system to support care recipients to adjust to life in the new environment
and during their stay at the home. The care recipient’s social, cultural and spiritual history,
and support needs are documented. This information is used to develop an individualised
care plan with strategies to support each care recipient’s emotional needs. The pastoral care
and lifestyle, hobbies and interests program offers additional emotional support for new care
recipients and on an ongoing basis. Management evaluates and reviews the way emotional
support is delivered. Care recipients/representatives are satisfied with the emotional support
provided at the home.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
19
Dates of audit: 22 November 2016 to 23 November 2016
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
There is a system to assist care recipients to maintain their independence and links with their
friends and the community. On entry to the home care recipients are assessed for what
independence means to them and how this can be achieved in relation to physical,
emotional, cultural, social and financial aspects of their lives. This information and the agreed
strategies to promote independence are communicated in an individualised care plan and
this is regularly evaluated and revised. The home provides equipment, aids, qualified staff
and programs to assist residents with mobility, communication and cognitive needs.
Management evaluates and reviews the way independence is promoted and supported. Care
recipients/representatives are satisfied with the support given to care recipients to achieve
optimal independence.
3.6 Privacy and dignity
This expected outcome requires that "each care recipient’s right to privacy, dignity and
confidentiality is recognised and respected".
Team’s findings
The home meets this expected outcome
The home has policies, feedback mechanisms and an environment that supports care
recipients’ right to privacy and dignity. Staff understand each care recipient has a right to
privacy and dignity and practices are consistent with policies and procedures. Care
recipients’ information is securely stored and we observed staff attending to care recipients’
needs in a respectful and courteous manner. Information on the care recipients’ rights and
responsibilities is given to new care recipients and displayed in the home. Management
evaluates the way privacy and dignity is recognised and respected. Care
recipients/representatives expressed satisfaction with the way staff respect their right to
privacy and dignity.
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
There is a comprehensive lifestyle program developed from care recipients’ previous and
current interests and hobbies plus life stories and special life events. The program is focused
on care recipients preferences such as group and/or one-to-one activities; supporting care
recipients to organise interest groups (poetry club); activities within the home and external
outings. There are designated staff (home-makers) to organise, implement and review the
lifestyle program in consultation with care recipients/representatives. The staff have
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
20
Dates of audit: 22 November 2016 to 23 November 2016
resources and strategies to support care recipients with cognitive, communication, sensory
and mobility limitations to participate in lifestyle program. The home environment encourages
and staff supports care recipients with interests in assisting with household activities, such as
cooking, setting the table and tiding up. Management monitor the effectiveness of the
lifestyle programs. Care recipients/representatives are satisfied with the lifestyle program.
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
There is a system to promote care recipients’ individual interests and to ensure their
customs, beliefs and cultural backgrounds are fostered and respected. On entry to the home
each care recipient’s cultural and spiritual needs are identified and documented. The lifestyle
and pastoral care programs facilitate religious services and visits to meet the needs and
preferences of care recipients. Staff know and understand the needs of care recipients from
other cultures. The lifestyle program incorporated activities, events and celebrations in
consultation with the relevant care recipients to value their cultural and spiritual needs.
Management evaluates the effectiveness of practices to foster care recipients’ cultural and
spiritual needs. Care recipients/representatives are satisfied with the way staff value and
support their cultural and spiritual needs.
3.9 Choice and decision-making
This expected outcome requires that "each care recipient (or his or her representative)
participates in decisions about the services the care recipient receives, and is enabled to
exercise choice and control over his or her lifestyle while not infringing on the rights of other
people".
Team’s findings
The home meets this expected outcome
The home has a system to ensure each care recipient is able to exercise choice and control
over their care and lifestyle. Care recipients’ specific needs and preferences are regularly
assessed and communicated to staff and external health service providers in care plans.
Care recipients, representatives and staff stated care recipients make choices about their
meals, personal and health care, health professionals, environment and activities as long as
they do not infringe on the rights of other care recipients. Management review practices to
ensure care recipients are supported to participate in decision-making. Care
recipients/representatives are satisfied with their participation in decision-making and ability
to make choices.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
21
Dates of audit: 22 November 2016 to 23 November 2016
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
Care recipients interviewed confirmed they feel secure in their tenure, and that they
understand their rights and responsibilities. A residential agreement is offered to all care
recipients and/or their representative and is discussed with them prior to entry to the home.
Information about security of tenure, care recipients’ rights and responsibilities, fee payment
options, cooling-off periods and rules of occupancy are also discussed prior to entry to the
home. Care recipients/representatives indicated they have received an information pack
during the entry process and they feel comfortable to raise any issue about tenure and their
rights and responsibilities with the house home-maker or management.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
22
Dates of audit: 22 November 2016 to 23 November 2016
Standard 4 – Physical environment and safe systems
Principle: Care recipients live in a safe and comfortable environment that ensures the
quality of life and welfare of care recipients, staff and visitors.
4.1 Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
Refer to expected outcome 1.1 Continuous Improvement for a description of the overall
system of continuous improvement. The home has made planned improvements relating to
Accreditation Standard Four - Physical environment and safe systems, including:

Review of the facility evacuation pack identified the packs needed improvement. As a
result, care recipient lists for each household have been updated with more
comprehensive information on each care recipient. Care recipient lists now include
allergies, next of kin details, mobility status and diagnosis. Different coloured hard hats
have also been purchased to allow staff to easily identify chief wardens, wardens and
floor wardens in the case of an emergency. Management said these changes will
improve care recipient safety and staff effectiveness in the case of an emergency.

Management identified the courtyard doors were kept locked at all times. As a result,
courtyard doors are now on at automatic timer. The doors unlock at a set time each
morning and lock at a set time each night. Care recipients say they enjoy the easy
access to the courtyard, and several care recipients now tend to their own outdoor
garden areas.
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
Refer to Expected outcome 1.2 Regulatory compliance for a description of the overall system
related to this outcome. Examples of regulatory compliance with regulations specific to
Accreditation Standard Four - Physical environment and safe systems include:

There is a system for the regular checking and maintenance of fire safety equipment
and a current fire safety statement is on display. The home is fitted with a sprinkler
system.

There is a current ACT Health license on display. The food safety system is regularly
audited by the Food Authority and meets the legislated requirements for food safety.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
23
Dates of audit: 22 November 2016 to 23 November 2016

Scheduled monitoring is carried out on thermostatic mixing valves for temperature
safety and tests for legionella.
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
Refer to expected outcome 1.3 Education and staff development for a description of how the
home monitors and provides education to ensure management and staff have appropriate
skills and knowledge. Review of the education documentation and interviews confirmed that
education relating to Accreditation Standard Four - Physical environment and safe systems
has been provided for management and staff. Examples include:

Dining experience

Chemical safety

Flood/severe storm (residential) processes

Food hygiene/handling
4.4 Living environment
This expected outcome requires that "management of the residential care service is actively
working to provide a safe and comfortable environment consistent with care recipients’ care
needs".
Team’s findings
The home meets this expected outcome
The home provides accommodation for care recipients in single rooms, with ensuite
bathrooms as well as six rooms, which are two bedded. There are furnished sitting, dining
and recreational areas and a variety of outdoor sitting areas throughout the grounds. The
home is set out with the kitchen as the hub of each house, and fresh baking is done here
daily. There is air conditioning for maintaining comfortable room temperatures throughout the
year, as well as under floor heating. Regular environmental audits are carried out to monitor
safety and identify possible hazards. There are systems for preventative and reactive
maintenance and to ensure the ongoing maintenance of the grounds and gardens.
Observation of the home and feedback from care recipients/representatives and staff
showed management provides a modern, safe and comfortable environment in line with care
recipients’ needs.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
24
Dates of audit: 22 November 2016 to 23 November 2016
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
The home’s management team actively work to provide a safe working environment that
meets regulatory requirements. There is a work, health and safety (WHS) representative and
an organisational WHS committee that works to ensure the living environment for care
recipients and the staff work environment is safe. The monitoring processes include audits,
observation and monitoring of incidents and clinical data. The workplace safety officers
support safety through accident investigation, risk assessments and the development of safe
work practices. Staff highlight risks and hazards through the maintenance, accident and
incident, and hazard reporting systems and are aware of safe work practices. Personal
protective equipment is readily available for staff. Staff members are assessed for functional
ability prior to employment and staff attend manual handling education during orientation and
annually, and we observed staff working safely.
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
There are systems to promote the safety and security of care recipients and staff. These
include emergency and fire evacuation procedures as well as maintenance checks of all fire
equipment and systems. Staff interviews demonstrate they complete fire education during
orientation and are familiar with the fire safety equipment and procedures. There is
evacuation information that ensures vital information is available to staff in an emergency
and an emergency management plan is in place. There are security processes to ensure the
buildings and grounds are secured at night. Care recipients and staff stated they feel safe
and secure in the home.
4.7 Infection control
This expected outcome requires that there is "an effective infection control program".
Team’s findings
The home meets this expected outcome
The home has policies and practices that support an effective infection control program.
There is an infection control committee and the infection control program includes the
offering of influenza vaccination for care recipients and staff, waste management, cleaning,
laundry and a food safety program. Care managers monitor care recipients’ infections and
data is collated and analysed to identify and address matters relating to infection control.
Education is provided to staff and information is provided to care recipients/representatives
and others visiting the home to prevent or address infectious outbreaks. Staff said they have
access to sufficient supplies of appropriate infection control equipment including personal
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
25
Dates of audit: 22 November 2016 to 23 November 2016
protection equipment, spills kits, sharps disposal and clinical waste bins. Our observations
and interviews confirmed the availability of equipment and supplies for managing an
infectious outbreak.
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
There are systems to identify care recipients’ meal requirements and preferences on entry to
the home and as care recipients’ needs change. The facility uses cook-chill as well as
cooking fresh vegetables on care recipient request. The menu is discussed and set during
community circle meetings with care recipients each week. Special occasions and
cultural/religious days are celebrated with special food and meals. The kitchen is the hub of
each house-hold and fresh cakes and biscuits are made daily for care recipients. There is
always fresh fruit, snacks and tea/coffee available. Care staff adhere to cleaning schedules
and processes to ensure the building is maintained in a clean and tidy condition.
Observations demonstrated the home is clean. Linen and towels are outsourced, and each
care recipient has their own washing machine, clothes dryer and clotheshorse. Care
recipients/representatives expressed satisfaction with the meals, the cleanliness of the
environment and the laundry service provided.
Home name: Uniting Amala Gordon ACT
RACS ID: 2949
26
Dates of audit: 22 November 2016 to 23 November 2016