Emerald Hill Residence
RACS ID:
3064
Approved provider: Claremont and Southport Aged Care Limited
Home address:
203 Napier St SOUTH MELBOURNE VIC 3205
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 07 July 2020.
We made our decision on 29 May 2017.
The audit was conducted on 18 April 2017 to 19 April 2017. 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.
1.1
Continuous improvement
Met
1.2
Regulatory compliance
Met
1.3
Education and staff development
Met
1.4
Comments and complaints
Met
1.5
Planning and leadership
Met
1.6
Human resource management
Met
1.7
Inventory and equipment
Met
1.8
Information systems
Met
1.9
External services
Met
Standard 2: Health and personal care
Principles: Care recipients’ physical and mental health will be promoted and achieved at the
optimum level in partnership between each care recipient (or his or her representative) and
the health care team.
2.1
Continuous improvement
Met
2.2
Regulatory compliance
Met
2.3
Education and staff development
Met
2.4
Clinical care
Met
2.5
Specialised nursing care needs
Met
2.6
Other health and related services
Met
2.7
Medication management
Met
2.8
Pain management
Met
2.9
Palliative care
Met
2.10 Nutrition and hydration
Met
2.11 Skin care
Met
2.12 Continence management
Met
2.13 Behavioural management
Met
2.14 Mobility, dexterity and rehabilitation
Met
2.15 Oral and dental care
Met
2.16 Sensory loss
Met
2.17 Sleep
Met
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
2
Standard 3: Care recipient lifestyle
Principle: Care recipients retain their personal, civic, legal and consumer rights, and are
assisted to achieve active control of their own lives within the residential care services and in
the community.
3.1
Continuous improvement
Met
3.2
Regulatory compliance
Met
3.3
Education and staff development
Met
3.4
Emotional Support
Met
3.5
Independence
Met
3.6
Privacy and dignity
Met
3.7
Leisure interests and activities
Met
3.8
Cultural and spiritual life
Met
3.9
Choice and decision-making
Met
3.10 Care recipient security of tenure and responsibilities
Met
Standard 4: Physical
Principle: Care recipients live in a safe and comfortable environment that ensures the quality
of life and welfare of care recipients, staff and visitors
4.1
Continuous improvement
Met
4.2
Regulatory compliance
Met
4.3
Education and staff development
Met
4.4
Living environment
Met
4.5
Occupational health and safety
Met
4.6
Fire, security and other emergencies
Met
4.7
Infection control
Met
4.8
Catering, cleaning and laundry services
Met
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
3
Audit Report
Name of home: Emerald Hill Residence
RACS ID: 3064
Approved provider: Claremont and Southport Aged Care Limited
Introduction
This is the report of a Re-accreditation Audit from 18 April 2017 to 19 April 2017 submitted to
the Quality Agency.
Accredited residential aged care homes receive Australian Government subsidies to provide
quality care and services to care recipients in accordance with the Accreditation Standards.
To remain accredited and continue to receive the subsidy, each home must demonstrate that
it meets the Standards.
There are four Standards covering management systems, health and personal care, care
recipient lifestyle, and the physical environment and there are 44 expected outcomes such
as human resource management, clinical care, medication management, privacy and dignity,
leisure interests, cultural and spiritual life, choice and decision-making and the living
environment.
Each home applies for re-accreditation before its accreditation period expires and an
assessment team visits the home to conduct an audit. The team assesses the quality of care
and services at the home and reports its findings about whether the home meets or does not
meet the Standards. The Quality Agency then decides whether the home has met the
Standards and whether to re-accredit or not to re-accredit the home.
During a home’s period of accreditation there may be a review audit where an assessment
team visits the home to reassess the quality of care and services and reports its findings
about whether the home meets or does not meet the Standards.
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: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
4
Scope of this document
An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit
from 18 April 2017 to 19 April 2017.
The audit was conducted in accordance with the Quality Agency Principles 2013 and the
Accountability Principles 2014. The assessment team consisted of three registered aged
care quality assessors.
The audit was against the Accreditation Standards as set out in the Quality of Care Principles
2014.
Details of home
Total number of allocated places: 146
Number of care recipients during audit: 143
Number of care recipients receiving high care during audit: 70%
Special needs catered for: Memory support unit – 15 beds
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
5
Audit trail
The assessment team spent two days on site and gathered information from the following:
Interviews
Position title
Number
Chief executive officer
1
Director of care and quality
1
Human resource manager
1
Chief financial officer
1
Quality manager
1
Registered nurses
4
Homemakers and floor supervisors (care
staff )
8
Physiotherapists
2
Executive and administration assistants
2
Information technology officer
1
Catering staff
3
Care recipients
17
Representatives
6
Hairdresser
1
Cleaning and laundry staff
3
Maintenance staff
1
Sampled documents
Document type
Number
Care recipients’ files
14
Agreements
14
Medication charts
8
Personnel files
11
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
6
Other documents reviewed
The team also reviewed:

Archive process

Audits and audit schedule

Care recipients’ information pack, compendium and handbook

Cleaning schedules and checklists

Clinical audit schedule and results

Clinical incident, infection and benchmarking data and summary reports

Comments and complaints records

Consolidated compulsory reporting register and associated records

Dietary sheets

Education and competency records

Electronic care information system

Emergency response procedures

Essential services records and monitoring tools

Food safety plan and kitchen external certifications

Hazard alert forms and incident reports

Human resource management documentation

Initial essential safety measures report dated 8 December 2016

Leisure and lifestyle records and documents

Medication self-administration documents

Meeting schedule, minutes and memoranda

Newsletters

Orientation program and checklists

Outbreak information packs

Plan for continuous improvement and associated documentation

Police certificate, statutory declaration and professional registration databases

Policies and procedures

Position descriptions and duty lists

Preventative maintenance records and monitoring tools

Re-accreditation self-assessment

Reactive maintenance records

Risk assessments – bed poles and mobility scooters

Rosters

Safety data sheets

Staff and volunteer handbook
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
7

Statements of strategic intent

Supplier agreements

Surveys

Test and tagging records
Observations
The team observed the following:

Activities in progress

Care recipient artwork

Care recipients using computer room

Charter of care recipients’ rights and responsibilities – residential care

Chemical storage

Cleaning and laundry service in progress

Do not disturb signage

Equipment and supply storage areas

Evacuation kits

External complaints and advocacy information

Feedback forms and lodgement boxes

Fire exits, egress, equipment and assembly areas

Infection control equipment

Interactions between staff and care recipients

Living environment

Meal and refreshment service and assistance to care recipients

Medication storage

Noticeboards and information displayed

Occupancy permit

Re-accreditation signage

Security systems

Short observation in the L1-2 lounge room

Sign in/out and food registers

Staff work areas and care stations
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
8
Assessment information
This section covers information about the home’s performance against each of the expected
outcomes of the Accreditation Standards.
Standard 1 – Management systems, staffing and organisational development
Principle: Within the philosophy and level of care offered in the residential care services,
management systems are responsive to the needs of care recipients, their representatives,
staff and stakeholders, and the changing environment in which the service operates.
1.1
Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
There is a system at the home to pursue continuous improvement across the Accreditation
Standards. The continuous improvement program includes processes for identifying areas
for improvement, implementing change, monitoring and evaluating the effectiveness of
improvements. Feedback is sought from care recipients, representatives, staff and other
stakeholders to direct improvement activities. Improvement activities are documented on the
plan for continuous improvement. Management uses a range of monitoring processes such
as audits and quality indicators to monitor the performance of the home's quality
management systems. Outcomes are evaluated for effectiveness. Care recipients,
representatives, staff and other personnel are provided with feedback about improvements.
During this accreditation period the home has implemented initiatives to improve the quality
of care and services it provides. Recent examples of improvements in Management systems,
staffing and organisational development are:

During December 2016 the home engaged an external consultant to carry out a gap
analysis of the home's systems across the four Standards. The resulting document led to
the implementation of a number of recommendations aimed at strengthening the home’s
existing systems, and includes the introduction of new planning schedules, monitoring
tools and reporting pathways. As a number of the interventions are recent, evaluation is
ongoing.

The home recently upgraded to the latest version of the electronic care documentation
management system. Management said this has enabled easier access to support from
the service provider, who is now more responsive to any system queries raised by the
home. Management said the system is more user-friendly and includes upgraded
features for data and risk analysis.
1.2
Regulatory compliance
This expected outcome requires that “the organisation’s management has systems in place
to identify and ensure compliance with all relevant legislation, regulatory requirements,
professional standards and guidelines”.
Team’s findings
The home meets this expected outcome
The home has an effective system to identify relevant legislation, regulatory requirements
and guidelines, and for monitoring these in relation to the Accreditation Standards. The
organisation's management has established links with external organisations to ensure they
are informed about changes to regulatory requirements. Where changes occur, the
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
9
organisation takes action to update policies and procedures and communicate the changes
to care recipients, their representatives and staff as appropriate. There are generally
effective systems and processes in place to monitor compliance with regulatory
requirements. Staff have an awareness of legislation, regulatory requirements, professional
standards and guidelines relevant to their roles. Relevant to standard 1, management are
aware of the regulatory responsibilities in relation to police certificates and the requirement to
provide advice to care recipients and their representatives about re-accreditation site audits;
there are processes to ensure these responsibilities are met.
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
The organisation has systems to ensure management and staff has appropriate knowledge
and skills to perform their roles effectively across the Accreditation Standards. All staff attend
organisational orientation on employment and then annually. Staff access online education
and attend in-service education and specialised training facilitated by external providers.
Staff undertake competencies relevant to their roles to monitor and maintain practice.
Education responds to staff training needs, feedback, audit results and care recipients’
current and changing needs. There are processes to inform staff of training, track attendance
and to evaluate the effectiveness of education provided. Staff are satisfied with the range of
education and professional development opportunities available to them.
Examples of education and training attended by staff and in relation to Standard 1
Management systems, staffing and organisational development include:

Electronic documentation system

Leadership workshop

Model of care and company values

Reducing employee turnover.
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 processes to ensure care recipients, their representatives and others are provided
with information about how to access complaint mechanisms. Care recipients and others are
supported to access these mechanisms. Facilities are available to enable the submission of
confidential complaints and ensure privacy of those using complaints mechanisms.
Complaints processes link with the home's continuous improvement system and where
appropriate, complaints trigger reviews of and changes to the home's procedures and
practices. The effectiveness of the comments and complaints system is monitored and
evaluated. Results show complaints are considered and feedback is provided to
complainants if requested. Management and staff have an understanding of the complaints
process and how they can assist care recipients and representatives with access. Care
recipients, their representatives and other interested people have an awareness of the
complaints mechanisms available to them and are satisfied they can access these.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
10
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 has documented the home's vision, mission, values and commitment to
quality. This information is communicated to care recipients, representatives, staff and others
through a range of documents and is displayed within 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 sufficient, appropriately skilled and qualified staff to deliver care and services in
accordance with the service’s model of care, vision and mission. Policies and processes
guide the recruitment and selection of staff and ensure compliance to relevant legislation.
Management and key staff monitor and adjust staffing in response to changes in care
recipients’ needs, analysis of data and feedback. Organisational orientation includes
mandatory training and reinforces company values and the household model of care.
Checklists and booklets guide local orientation programs supplemented by a buddy shift with
experienced staff. All roles have position descriptions and staff sign employment
agreements. Management monitors staff performance during the probation period and
thereafter through observation, competency assessment and appraisals. There are
processes to replace staff on planned and unplanned leave. Staff said management supports
them and care recipients and representatives are satisfied with the level and quality 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 findings
The home meets this expected outcome
The home has processes to monitor stock levels, order goods and maintain equipment to
ensure delivery of quality services. Goods and equipment are securely stored and, where
appropriate, stock rotation occurs. Preventative maintenance and cleaning schedules ensure
equipment is monitored for operation and safety. The home purchases equipment to meet
care recipients' needs and maintains appropriate stocks of required supplies. Staff receive
training in the safe use and storage of goods and equipment. Staff, care recipients and
representatives are satisfied with the supply and quality of goods and equipment available at
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
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
11
The home has generally effective systems to provide all stakeholders with access to current
and accurate information. Management uses primarily electronic systems to manage and
disseminate information relating to care, services, policies and protocols and includes an
electronic care documentation system. Management and staff generally have access to
information that assists them in providing care and services. Electronic and hard copy
information is stored securely and processes are in place for backup, archiving and
destruction of obsolete records, in keeping with legislative requirements. Key information is
generally collected, analysed, revised and updated on an ongoing basis. Staff interviewed
stated they are satisfied they have access to current and accurate information. Care
recipients and representatives interviewed are satisfied the information provided is
appropriate to their needs, and supports them in their decision-making. The home has
recently reviewed information management systems across the standards to identify and
correct deficits and is addressing these in an ongoing manner.
1.9
External services
This expected outcome requires that "all externally sourced services are provided in a way
that meets the residential care service’s needs and service quality goals".
Team’s findings
The home meets this expected outcome
The home has mechanisms to identify external service needs and quality goals. The home's
expectations in relation to service and quality is specified and communicated to the external
providers. The home has agreements with external service providers which outline minimum
performance, staffing and regulatory requirements. External contractors provide evidence of
criminal history record checking, registrations, certifications and insurance information, as
relevant, as part of the contractual engagement process. There are processes to review the
quality of external services provided and, where appropriate, action is taken to ensure the
needs of care recipients and the home are met. Staff are able to provide feedback on
external service providers. Care recipients, representatives and staff are satisfied with the
quality of externally sources services.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
12
Standard 2 – Health and personal care
Principle: Care recipients’ physical and mental health will be promoted and achieved at the
optimum level in partnership between each care recipient (or his or her representative) and
the health care team.
2.1
Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
The continuous improvement program demonstrates improvements in the area of health and
personal care. For a description of the system refer to expected outcome 1.1 Continuous
improvement. During this accreditation period the organisation has implemented initiatives to
improve the quality of care and services it provides. Recent examples of improvements in
Health and personal care are:

The implementation of the 'business intelligence' module as part of the home's electronic
care documentation system has enabled management to access more comprehensive
clinical data to enable more effective analysis and decision making. This has recently
been applied to identify the need for clinical and care support in a specific area of the
home between the hours of six and seven a.m. in the morning. In response management
adjusted the roster to ensure the presence of staff in this area during this time.
Management said although the change has only recently been implemented feedback
from staff indicate there has been a reduction in the number of care recipients
expressing frustration and agitation in the early morning.

The recent gap analysis identified the pharmacy was not providing a medication review
for individual care recipients. This led to the engagement of an external provider to carry
out structured reviews. The new provider commenced medication reviews in March
2017.

In response to a trend of clinical incidents and a care recipient with a chronic wound,
management carried out a review of the management of wounds and skin integrity of
care recipients. Education was provided by a wound specialist to both homemakers and
nurse mentors and included assessment, observation and documenting processes, the
introduction of new products and wound photographing. Existing processes were also
strengthened. Management said this has led to better wound management and
improved general documentation. An audit process has been introduced to monitor this
on an ongoing basis.
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
There is a system to identify and meet regulatory compliance obligations in relation to health
and personal care. For a description of the system refer to expected outcome 1.2 Regulatory
compliance. Relevant to Standard 2, management are aware of the regulatory
responsibilities in relation to specified care and services, professional registrations,
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
13
medication management and the unexplained absence of a care recipient. There are
systems to ensure these responsibilities are met.
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
Systems support management and staff knowledge and skills to enable them to perform their
roles effectively in relation to care recipients’ health and personal care. For a description of
the system refer to expected outcome 1.3 Education and staff development.
Recent education relating to Standard 2 Health and personal care includes:

Appropriate management of continence aids

Behaviour management

Malnutrition in aged care.
2.4
Clinical care
This expected outcome requires that “care recipients receive appropriate clinical care”.
Team’s findings
The home meets this expected outcome
There are mechanisms to ensure care recipients receive clinical care that is appropriate to
their needs and preferences. Care needs are identified on entry and on an ongoing basis
through a review and transfer of information, consultation with the care recipient and/or their
representative and assessment processes. Individual care plans are developed by qualified
staff and reviewed regularly. There are processes to ensure staff have access to current
information to inform care delivery including care plans, progress notes and handovers. Care
recipients' clinical care needs are monitored, evaluated and reassessed through incident
analysis, reviews and feedback. Changes in care needs are identified and documented, and
where appropriate, referrals are made to medical officers or other health professionals. Staff
provide care consistent with individual care plans. Care recipients and representatives
interviewed are satisfied with the clinical care being provided.
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 through assessment processes
on entry to the home. Care is planned and managed by appropriately qualified staff. This
information, together with instructions from medical officers and health professionals is
documented in the care plan. Specialised nursing care needs are reassessed when a
change in care recipient needs occurs and on a regular basis. Staff have access to
specialised equipment, information and other resources to ensure care recipients' needs are
met. Specialised nursing care is delivered by appropriately qualified staff consistent with the
care plan. Care recipients and representatives are satisfied with how care recipients'
specialised nursing care needs are managed.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
14
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
Care recipients are referred to appropriate health specialists in accordance with their
assessed needs and preferences. There is an effective system for referral to a range of
health professionals including physiotherapy, podiatry, nutrition and speech pathology.
Dental, hearing, and eye care services attend the home and care recipients are supported to
attend private external services according to their choice and preference. Referral to medical
specialists such as geriatricians and aged persons mental health specialists occurs as
needed and clinical directives are incorporated into care processes. Care recipients and
representatives are satisfied with the home’s process for referral to health specialists
according to their needs and preferences.
2.7
Medication management
This expected outcome requires that “care recipients’ medication is managed safely and
correctly”.
Team’s findings
The home meets this expected outcome
Care recipients’ medication is managed safely and correctly. Care staff undertake medication
administration and competency training is completed annually. Medical practitioners monitor
and revise care recipient medication requirements. Staff have access to medication policies
and procedures and monitoring of the system occurs. Medications administered on an as
needs basis are recorded and there is evaluation of medication effectiveness. Monitoring of
medication incidents occurs and review is undertaken accordingly. Multidisciplinary
medication meetings are held to monitor and evaluate the medication system. Care
recipients and representatives are satisfied with how staff undertake medication
administration.
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
Care recipients' pain is identified through assessment processes on entry to the home and as
needs change. Specific assessment tools are available for care recipients who are not able
to verbalise their pain. Care plans are developed from the assessed information and are
evaluated to ensure interventions remain effective. Medical officers and allied health
professionals are involved in the management of care recipients' pain. Staff assess care
recipients' verbal and non-verbal indicators of pain and implement appropriate actions,
including utilising a range of strategies to manage comfort levels. Care recipients and
representatives are satisfied care recipients are as free as possible from pain.
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
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
15
There are care systems to ensure the comfort and dignity of terminally ill care recipients is
maintained. Palliative care plans outline care needs and preferences for treatment options
which are completed in consultation with the care recipient, representative, medical
practitioner and other health professionals. Key clinical staff with palliative care training
coordinate the program and there is access to a palliative care support service if required.
Staff said they have sufficient resources for the provision of palliative care and described
care measures they undertake when caring for terminally ill care recipients including comfort
and dignity measures.
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
Care recipients' nutrition and hydration requirements, preferences, allergies and special
needs are identified and assessed on entry. Care recipients' ongoing needs and preferences
are monitored, reassessed and care plans updated. There are processes to ensure catering
and other staff have information about care recipient nutrition and hydration needs. Staff
monitor care recipients' nutrition and hydration and identify those care recipients who are at
risk. Nutritional supplements, modified cutlery, equipment and assistance with meals are
available. Staff have an understanding of care recipients' needs and preferences including
the need for assistance, texture modified diet or specialised equipment. Care recipients and
representatives are satisfied care recipients' nutrition and hydration requirements are met.
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
Care recipients’ skin integrity is consistent with their general health. Care recipients' skin care
requirements, preferences and special needs are assessed and identified, in consultation
with care recipients and/or representatives. Care plans reflect strategies to maintain or
improve care recipients' skin integrity and are reviewed regularly. Referral processes to other
health specialists are available if a need is identified. Staff promote skin integrity through the
use of moisturisers, pressure relieving devices and repositioning. Wound care treatment is
monitored and the incidence of skin tears and pressure injuries is documented and evaluated
through the incident reporting system. Care recipients and representatives are satisfied with
the assistance provided to maintain skin integrity.
2.12 Continence management
This expected outcome requires that “care recipients’ continence is managed effectively”.
Team’s findings
The home meets this expected outcome
Care recipients' continence needs and preferences are identified during the assessment
process and reassessments occur as required. Strategies to manage care recipients'
continence are documented in the care plan and regular evaluation occurs to ensure
strategies remain effective. Staff have an understanding of individual care recipients'
continence needs and how to maintain privacy and dignity when providing assistance.
Changes in continence patterns are identified, reported and reassessed to identify alternative
management strategies. Care recipients and representatives are satisfied with the support
provided to care recipients in relation to continence management.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
16
2.13 Behavioural management
This expected outcome requires that “the needs of care recipients with challenging
behaviours are managed effectively”.
Team’s findings
The home meets this expected outcome
The needs of care recipients with challenging behaviours are managed effectively. Behaviour
assessments and care plans outline individual triggers and effective intervention strategies.
Evaluation of the effectiveness of behaviour care plans occurs in consultation with medical
practitioners and referral to psychogeriatric services occurs as required. The lifestyle
program includes activities for care recipients with dementia related illness which are
personalised to enhance the quality of life and wellbeing for each care recipient. Care
recipients and representatives are satisfied staff manage behaviours in a caring and
supportive manner.
2.14 Mobility, dexterity and rehabilitation
This expected outcome requires that “optimum levels of mobility and dexterity are achieved
for all care recipients”.
Team’s findings
The home meets this expected outcome
Care recipients' mobility, dexterity and rehabilitation needs are identified through assessment
processes and in consultation with the care recipient and/or their representative. Nurses and
physiotherapists undertake assessments and care planning to establish care recipient
capabilities and outline strategies to promote safe mobility and dexterity. Strategies to
manage care recipients' mobility and dexterity are documented in the care plan and are
regularly evaluated and reviewed to ensure care recipients' needs are met. Falls prevention
strategies are incorporated into care planning, and care recipients are reviewed by the
physiotherapist after a fall. Data in relation to falls is evaluated through the incident reporting
system. Care recipients and representatives are satisfied with the support provided for
achieving optimum levels of 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
Care recipients' oral and dental health needs are identified through assessment processes
and in consultation with the care recipient and/or their representative. Care strategies are
documented on the care plan and are regularly evaluated and reviewed to ensure care
recipients' changing needs are met. Equipment to meet care recipients' oral hygiene needs is
available. Staff provide assistance with oral and dental care and where necessary referrals
are made to health specialists such as dentists. Care recipients and representatives are
satisfied with the level of oral and dental care provided by staff.
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
Care recipients’ sensory losses are identified and managed effectively. Sensory
assessments and care plans outline individual care recipient needs. Sensory needs are
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
17
incorporated into nutritional and skin care regimes and participation in interests and activities.
Referral to other health professionals such as speech pathologists, audiologists and
optometrists occurs as required. Staff check the working condition of aids and assist care
recipients in using devices such as hearing aids and glasses on a daily basis. Care recipients
and representatives are satisfied with the attention given to 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, including settling routines and personal preferences, are
identified through assessment processes on entry. Care plans are developed and reviewed
to ensure strategies to support natural sleep remain effective and reflect care recipients'
needs and preferences. Staff utilise a variety of methods to promote sleep and consult with
the care recipients’ medical practitioner if medication is required. Care recipients said the
home is quiet at night and staff provide assistance as needed and according to their
preferences.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
18
Standard 3 – Care recipient lifestyle
Principle: Care recipients retain their personal, civic, legal and consumer rights, and are
assisted to achieve control of their own lives within the residential care service and in the
community.
3.1
Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
The continuous improvement program demonstrates improvements in the area of care
recipient lifestyle. For a description of the system refer to expected outcome 1.1 Continuous
improvement. During this accreditation period the organisation has implemented initiatives to
improve the quality of care and services it provides. Recent examples of improvements in
Care recipient lifestyle are:

Management observations identified the large glass panelled entrances into the
residential area on each level provided a direct line of vision into care recipient living
areas. To promote greater privacy for care recipients and following consultation with
stakeholders, management arranged for the installation of decorative window film at
each entrance. Management said stakeholder feedback has been mostly positive.
Management said the opaque glass has also been of benefit to care recipients who may
express anxiety about not being able to proceed through a keypad secured door.

Management exploration of contemporary research literature promoting music and
memories led to an application for a grant to purchase small electronic devices that store
and play digital audio and video files. Thirty devices were subsequently bought and a
music therapist engaged to commence a music and reminiscing program. Both
individually-focussed and group music programs have been introduced resulting in
positive feedback from care recipients and representatives. Management said incidents
of aggression and anxiety have reduced.
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
There is a system to identify and meet regulatory compliance obligations in relation to care
recipient lifestyle. For a description of the system refer to expected outcome 1.2 Regulatory
compliance. Relevant to Standard 3, management are aware of the regulatory
responsibilities in relation to compulsory reporting, user rights, security of tenure and care
recipient agreements. There are systems to ensure these responsibilities are met.
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
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
19
Systems support management and staff knowledge and skills to enable them to perform their
roles effectively in relation to care recipient lifestyle. For a description of the system refer to
expected outcome 1.3 Education and staff development.
Recent education topics relating to Standard 3 Care recipient lifestyle include:

Dementia education for volunteers

Elder abuse and mandatory reporting

Grief and loss

Montessori in aged care.
3.4
Emotional support
This expected outcome requires that "each care recipient receives support in adjusting to life
in the new environment and on an ongoing basis".
Team’s findings
The home meets this expected outcome
Management and staff provide initial and ongoing emotional support to care recipients and
representatives. Staff meet with prospective care recipients and representatives to explain
the household model of care and services available and provide a tour of communal and
private living areas. An initial information pack, application form and handbook are provided.
On arrival, lifestyle and homemaker staff familiarise care recipients to the home and get to
know their interests and preferences. Lifestyle history and leisure assessments identify family
and life history, important life events and individual preferences for emotional support and
regular reviews ensure ongoing support as needed. Staff, volunteers and pastoral and
spiritual carers provide ongoing emotional support to care recipients and representatives
through individual visits, structured activities and cultural and community connections. Care
recipients and representatives are satisfied with emotional support provided to them.
3.5
Independence
This expected outcome requires that "care recipients are assisted to achieve maximum
independence, maintain friendships and participate in the life of the community within and
outside the residential care service".
Team’s findings
The home meets this expected outcome
Management and staff demonstrate they support care recipients to achieve optimal
independence, maintain friendships, family connections and participate within their
community. Staff identify and document strategies to support physical and social
independence according to individual preferences, needs and goals. Mobility, sensory and
mealtime aids and equipment are used and meaningful activities, an appropriate living
environment and outdoor spaces promote independence. Care recipients are encouraged to
exercise choices in their daily routines, meals and snacks, and to participate in activities
within and outside the home. Families and visitors are welcome and staff support social
interactions and co-ordinate community outings for individuals and groups. Care recipients
and representatives are satisfied staff assist and encourage 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
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
20
Each care recipient’s right to privacy, dignity and confidentiality is recognised and respected.
Care recipients and staff are provided with privacy and confidentiality information and
consent to use, release and display personal information and images. Personal information is
securely stored and computerised system access is password protected. Care recipients use
‘do not disturb’ signs to ensure that staff refrain from entering their private space unless
requested. Staff knock on doors before entering, address care recipients by their preferred
name and are discreet when managing care needs. Outdoor spaces, lounges, sitting areas,
a private dining room and café are available to care recipients for quiet time or to socialise
with families and friends. Personalisation of rooms is encouraged and management and staff
support and encourage care recipients to receive visitors at any time. Care recipients and
representatives said staff maintain care recipients’ privacy and dignity and are respectful.
3.7
Leisure interests and activities
This expected outcome requires that "care recipients are encouraged and supported to
participate in a wide range of interests and activities of interest to them".
Team’s findings
The home meets this expected outcome
Care recipients are encouraged and supported to participate in a wide range of activities of
interest to them. Lifestyle history and assessments capture past and current interests,
preferences for social interaction and community and family links. Leisure care plans
document individual needs, goals and preferences and are regularly reviewed. Monthly
facility and house activities calendars on display provide a structured program covering a
wide range of activities. Activities include physical, sensory, cognitive, entertainment, visiting
pets, social and cultural events. Music therapy provides individual engagement and social
enjoyment. Social activity charting monitors participation levels and combines with feedback
to inform future activities. Community groups and volunteers are welcome and care
recipients receive assistance to go on outings and to maintain individual interests. Friends
and family are encouraged to be involved in life at the home and to join in activities. Care
recipients and representatives are satisfied with the frequency and variety of activities
provided.
3.8
Cultural and spiritual life
This expected outcome requires that "individual interests, customs, beliefs and cultural and
ethnic backgrounds are valued and fostered".
Team’s findings
The home meets this expected outcome
Management ensure that care recipients’ individual interests, customs, beliefs and cultural
and ethnic backgrounds are valued and fostered. Care plans document cultural and spiritual
needs. Special occasions, cultural events and days of significance are included in the
monthly activities calendar and birthdays celebrated according to care recipient preferences.
Denominational ministers and pastoral carers provide spiritual support as requested and
conduct regular religious services. Staff access culturally specific information, use
communication cards and access interpreters if needed. Care recipients and representatives
are satisfied with the cultural and spiritual support provided.
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".
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
21
Team’s findings
The home meets this expected outcome
Management and staff are committed to promoting care recipients’ right to participate in
choices and decisions regarding their clinical care and lifestyle preferences and encourage
and respect their decisions. Assessments, care and lifestyle plans and dietary sheets
document individual preferences and are reviewed regularly. Care recipients and
representatives are provided with information to assist them in making informed decisions
about care needs and rights and responsibilities. Powers of attorney and guardianship
appointments advocate on behalf of care recipients when required. Care recipients and
representatives give feedback about the care and services provided during care
conferences, using feedback processes or by attending meetings. Care recipients and
representatives are satisfied staff support and respect individual choices and decisions.
3.10 Care recipient security of tenure and responsibilities
This expected outcome requires that "care recipients have secure tenure within the
residential care service, and understand their rights and responsibilities".
Team’s findings
The home meets this expected outcome
Care recipients have secure tenure within the residential care service, and understand their
rights and responsibilities. Relevant staff communicates information about care recipients’
rights and responsibilities, security of tenure, advocacy services and specified care and
services, this information is contained in agreements, information packs and handbooks.
Care recipient agreements specify the home’s capacity to provide care and services and
describe their responsibilities in assisting the care recipient and their representative should
care needs change. A process of consultation and agreement precedes a change in care
recipients’ accommodation. Care recipients and representatives said security of tenure is
understood and respected.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
22
Standard 4 – Physical environment and safe systems
Principle: Care recipients live in a safe and comfortable environment that ensures the quality
of life and welfare of care recipients, staff and visitors.
4.1
Continuous improvement
This expected outcome requires that “the organisation actively pursues continuous
improvement”.
Team’s findings
The home meets this expected outcome
The continuous improvement program shows ongoing improvements in the area of physical
environment and safe systems. For a description of the system refer to expected outcome
1.1 Continuous improvement. During this accreditation period the organisation has
implemented initiatives to improve the quality of the physical environment and the services it
provides. Recent examples of improvements in Physical environment and safe systems are:

In response to increasing amounts of lost property, management explored new ways to
minimise the amount of lost clothing. This led to the introduction of a month demarcator
on the lost clothing rack to differentiate between new items and those that have been
lost for some time. Management said the lost property trolley has also been made more
accessible to care recipients and their families. Management said lost property
processes are more structured.

The recent gap analysis identified the potential for confusion and delay when reading
emergency maps that are not oriented to the position within the building. New
emergency evacuation maps were ordered to replace existing maps. Management and
staff said the maps are easier to read.
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
There is a system to identify and meet regulatory compliance obligations in relation to the
physical environment and safe systems. For a description of the system refer to expected
outcome 1.2 Regulatory compliance. Relevant to Standard 4, management and staff are
generally aware of the regulatory responsibilities in relation to work, health and safety, fire
systems and food safety. There are generally effective systems to ensure these
responsibilities are met.
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
Systems support management and staff knowledge and skills to enable them to perform their
roles effectively in relation to the physical environment and safe systems. For a description of
the system refer to expected outcome 1.3 Education and staff development.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
23
Examples of education and training relating to Standard 4 Physical environment and safe
systems include:

Chemical training

Fire and emergency – clinical and non-clinical

Food hygiene

Infection control and hand washing

Kitchen and laundry principles, labelling and cleanliness

Manual handling

Occupational health and safety / refresher training.
4.4
Living environment
This expected outcome requires that "management of the residential care service is actively
working to provide a safe and comfortable environment consistent with care recipients’ care
needs".
Team’s findings
The home meets this expected outcome
The home's environment reflects the safety and comfort needs of care recipients, including
comfortable temperatures, noise and light levels, sufficient and appropriate furniture and
safe, easy access to internal and external areas. Environmental strategies are employed to
minimise care recipient restraint. The safety and comfort of the living environment is
assessed and monitored through feedback from meetings, surveys, incident and hazard
reporting, audits and inspections. There are appropriate preventative and routine
maintenance programs for buildings, furniture, equipment and fittings. Staff support a safe
and comfortable environment through hazard, incident and maintenance reporting
processes. Care recipients and representatives are satisfied the living environment is safe
and comfortable.
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 organisation actively works to provide a safe working environment that meets regulatory
requirements. Management inform staff of occupational health and safety requirements
through orientation, education, policies and procedures and manual handling training.
Occupational health and safety is monitored through observations, internal audits, industry
inspections, incident and hazard reports and maintenance. Chemicals are stored safely,
safety data sheets support the safe use of chemicals and appropriate safety signs and
personal protective equipment is used. Equipment is stored safely and there are processes
to ensure electrical equipment is tested and tagged. Staff said management support a safe
working environment through appropriate equipment, training and maintenance.
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
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
24
Policies and procedures relating to fire, security and other emergencies are documented and
accessible to staff and include an emergency evacuation plan. Processes to ensure
emergency equipment is inspected and maintained are generally effective. Staff are provided
with education and training about fire, security and other emergencies when they commence
work at the home and there are processes to enable staff to access training on an ongoing
basis. There are processes to ensure emergency exits are clearly marked and free from
obstruction. Staff have an understanding of their roles and responsibilities in the event of a
fire, security breach or other emergency and there are routine security measures. Care
recipients and representatives are made aware of what they should do on hearing an alarm
and said 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
There is an effective infection control program in place. There is an infection surveillance
system and infection data is analysed, trended and reviewed by clinical management and
discussed at relevant meetings. Policies and procedures including outbreak procedures are
available for staff to follow. Hand hygiene, personal protective equipment and appropriate
waste disposal systems are in place throughout the facility. Care recipients at risk of
infections are monitored by medical practitioners and nursing staff and there is evaluation of
response to treatment. There is a planned pest control program. Catering, cleaning and
laundry procedures follow infection control guidelines. There is a food safety program and
current council and external audit certification. Cleaning schedules are in place and
environmental audits are undertaken. Care recipients, representatives and staff are satisfied
with the infection control program.
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
Hospitality services are provided in a way that enhances care recipients’ quality of life and
the working environment of staff. A dietitian approves the rotating winter and summer menu
and alternative meal choices and snacks are available. All meals are freshly prepared on site
and served according to dietary requirements and preferences in line with the food safety
program. All personal clothing and linen is laundered onsite. There are two laundries
available for use by care recipients with ironing facilities if desired. There is a labelling
system for marking clothing and a process to manage unmarked or lost clothing.
Documented schedules guide the cleaning of common areas, care recipient rooms and
kitchenettes. Response to unscheduled cleaning requests is timely. Catering, cleaning and
laundry services are monitored through verbal and written feedback, internal and external
audits, observation of staff practices and meetings. Care recipients and representatives are
satisfied with the hospitality services provided.
Home name: Emerald Hill Residence
RACS ID: 3064
Dates of audit: 18 April 2017 to 19 April 2017
25