August 3, 2019

Aged Care Quality and Safety Commission Complaint letter and Audit report Carino Care


Decision not to revoke accreditation following review audit
Decision not to vary period of accreditation following review audit

Service and approved provider details

Name of service:
Carino Care at Russell Lea
RACS ID:
2748
Name of approved provider:
Carino Care Pty Ltd
Address details:
72-74 Russell Street RUSSELL LEA NSW 2046
Date of review audit:
13 May 2019 to 16 May 2019

Summary of decision

Decision made on:
24 June 2019
Decision made by:
Authorised delegate of the Aged Care Quality and Safety Commissioner (Commissioner) under section 76 of the Aged Care Quality and Safety Commission Act 2018 to decide under section 77 of the Aged Care Quality and Safety Commission Rules 2018 (Rules) about the accreditation of a service after receiving a review audit report.
Decision:
Not to revoke the accreditation of the service under section 77 of the Rules.
Not to vary the period of accreditation under section 77(4)(a) of the Rules.
Accreditation expiration date
30 November 2019
Number of expected
outcomes met:       
20 of 44
Expected outcomes not met:
1.6 -  Human Resource Management
2.1  - Continuous Improvement
2.2 – Regulatory Compliance
2.3 – Education and staff development
2.4 – Clinical Care
2.5 – Specialised nursing care needs
2.7 – Medication Management
2.8 – Pain Management
2.9 – Palliative Care
2.10 – Nutrition and Hydration
2.11 – Skin Care
2.12 – Continence Management
2.13 – Behaviour Management
2.14 – Mobility, dexterity and rehabilitation
3.1 – Continuous Improvement
3.3 – Education and staff development
3.4 – Emotional Support
3.6 – Privacy and dignity
3.7 -Leisure interests and activities
3.8 – Cultural and spiritual life
4.1 – Continuous improvement
4.3 – Education and staff development
4.4 – Living environment
4.7 – Infection control
Revised plan for continuous improvement due:
By 09 July 2019
Timetable for making improvements:
By 30 November 2019
This decision is published on the Aged Care Quality and Safety Commission’s (Commission) website under section 80 of the Rules.



Review Audit Report
Review audit
Name of service: Carino Care at Russell Lea
RACS ID: 2748
Approved provider: Carino Care Pty Ltd
Introduction
This is the report of a Review Audit from 13 May 2019 to 16 May 2019 submitted to the Aged Care Quality and Safety Commissioner (Commissioner).
There are four Accreditation Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment. 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.
An approved provider of a service applies for re-accreditation before its accreditation period expires and an assessment team visits the service to conduct a site audit. The team assesses the quality of care and services at the service and collects evidence of whether the approved provider of the service meets or does not meet the Accreditation Standards. Following a site audit, the Commissioner will make a decision whether to re-accredit or not to re-accredit the service.
An accredited service may have a review audit where an assessment team visits the service to reassess the quality of care and services at the service. Following a review audit, the Commissioner will make a decision whether to revoke or not to revoke the accreditation of the service.
Scope of this document
A review audit against the 44 expected outcomes of the Accreditation Standards was conducted from 13 May 2019 to 16 May 2019.
This review audit report provides an assessment of the approved provider’s performance, in relation to the service, against the Accreditation Standards, and any other matters the assessment team considers relevant.


Details about the service

Number of total allocated places
46
Number of total care recipients
38
Number of care recipients on site during audit
38
Service provides support to specific care recipient characteristics
-       N/A
Audit trail
The assessment team spent four days on site and gathered information from the following:
Interviews
Position title
Number
Chief executive officer
1
Facility manager
1
Care manager
1
Registered nurse
5
Care staff
7
Administration assistant
2
Catering staff
2
Care recipients and/or representatives
17
Physiotherapist
1
Lifestyle coordinator and staff
2
Cleaning staff and supervisor
3
Maintenance staff
1
Sampled documents
Document type
Number
Care recipients’ files
21
Medication charts
9
Personnel files
5
Other evidence reviewed by the team
The assessment team also considered the following during the review audit:
·           Audit documentation May 2019, WHS audit February 2019, audit September 2019
·           Clinical indicator data
·           Comment, complaint and suggestion folder
·           Compulsory reporting register
·           Continuous improvement plan
·           Contractor handbook, contractor agreements
·           Emails regarding proposed building works, memorandums
·           Education attendance records, mandatory education matrix, RN bootcamp agenda,
·           Professional staff and allied health professional registrations.
·           Fire equipment safety reports
·           Hospitality services: food safety system documentation, menu, cleaning schedules, NSW Food Authority report
·           Human resource management: AIN duty list, agency staff induction, performance management, police check and personnel documentation matrix
·           Legionella testing report
·           Medication reports, information
·           Meeting minutes
·           Policies and procedures
·           Preventative maintenance schedules, repairs/maintenance folder
·           Psychotropic medication diagnostic chart
·           Restraint documentation
·           Stock monitoring forms
Observations
The assessment team observed the following:
·           Activities in progress
·           Emergency evacuation box, fire detection and fighting equipment, annual fire statement,
·           Infection outbreak box, spill kits, sharps container, clinical and cytotoxic waste bins, colour code equipment.
·           Interactions between staff, care recipients and visitors
·           Internal and external complaints and advocacy information available, secure boxes accessible to care recipients/stakeholders for secure lodgement
·           Living environment
·           Meal services
·           NSW Food Authority food safety licence


Assessment of performance

This section covers information about the assessment of the approved provider’s performance, in relation to the service, 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”.
Assessment of the expected outcome
The service does not meet this expected outcome
The organisation cannot demonstrate that it actively pursues continuous improvement. The service does not have effective systems in place to monitor the delivery of care and services across all accreditation standards. As a result, the service and not identified deficiencies in care and services and has not implemented actions to address deficiencies.
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”.
Assessment of the expected outcome
The service meets this expected outcome
There are systems to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation receives information from information services and government departments which provide ongoing information about industry issues and regulatory changes. The chief executive officer monitors legislation, regulations and guidelines and updates policies in response to changes. Information regarding regulatory compliance is provided to the facility manager through corporate management meetings and email advice. The facility manager ensures compliance with regulatory obligations in the service and monitors staff practices. Communication to staff about changes in policy and procedure occurs through electronic notifications, meetings and memorandums.
Examples of compliance with regulatory requirements specific to Accreditation Standard 1; Management systems, staffing and organisational development include:
·           There is a system in place to ensure all staff, allied health professionals and contractors have current police checks.
·           The provision of information to care recipients and stakeholders about internal and external complaint mechanisms.
1.3       Education and staff development
This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome

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".
Assessment of the expected outcome
The service meets this expected outcome
There are internal and external mechanisms for care recipients, care recipients’ representatives and other interested parties to put forward comments, suggestions and complaints. External and internal complaints information brochures are accessible to care recipients and visitors. There are secure mail boxes for the confidential lodgement of feedback forms. Interviews and the review of meeting minutes confirm care recipient and staff meetings and surveys provide forums for comments, suggestions and complaints to be raised. Care recipients and staff are aware of how to raise a complaint.
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".
Assessment of the expected outcome
The service meets this expected outcome
The organisation’s vision, mission and values is documented in the organisation’s information provided to care recipients, representatives and staff.
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".
Assessment of the expected outcome
The service does not meet this expected outcome
There are not appropriately skilled and qualified staff at the service. Deficiencies have been identified with clinical decision-making skills of registered nurses. Issues relating to the performance of some staff has also been identified. There has been turnover in the management team and insufficient monitoring and management of staff. Whilst most feedback relating to staff attitudes was generally positive there were some concern expressed.
1.7       Inventory and equipment
This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".
Assessment of the expected outcome
The service meets this expected outcome
The service’s processes to monitor and reorder goods are effective and ensures stocks of appropriate goods are available and provided as needed. Goods, including chemicals are securely and appropriately stored. Processes to ensure that equipment is maintained in good working order is being re-established after a period in which preventative maintenance was not undertaken. Staff are satisfied with the availability and suitability of goods and equipment. The assessment team identified some deficiencies in equipment provision.
1.8       Information systems
This expected outcome requires that "effective information management systems are in place".
Assessment of the expected outcome
The service does not meet this expected outcome
The service does not have effective information management systems in the service. Significant deficits in information management exist across all four Accreditation Standards which is resulting in lack of monitoring of the service’s processes and practices. Lack of effective information system is resulting deficiencies in the delivery of care and services and the maintenance of an appropriate living environment which meets the needs of care recipients, ensures health of safety of care recipients, staff and others is maintained. Some staff do not have good knowledge of the computerised documentation and medication systems. The assessment team identified deficiencies in clinical care documentation.
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".
Assessment of the expected outcome
The service meets this expected outcome


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”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.1 Continuous improvement for a description of deficiencies in the service’s overall system of continuous improvement. In relation to Standard 2 – Health and personal care the system is not effective in monitoring performance and identifying issues relevant to the health and personal care for care recipients.
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”.
Assessment of the expected outcome
The service does not meet this expected outcome
Whilst the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, these systems have not been effective in relation to Accreditation Standard 2; Health and personal care. The service has not ensured a safe medication system that meets regulatory requirements or complied with regulatory requirements in relation to the use of chemical restraint.
2.3       Education and staff development
This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.3 Education and staff development regarding deficiencies in the service’s overall system of education and staff development. Whilst review of documentation and individual training records shows some education relating to Accreditation Standard 2 - Health and personal care has been provided to staff, review of care recipient health and personal care demonstrates management and staff do not have the necessary skills and competencies to undertake their roles.
2.4       Clinical care
This expected outcome requires that “care recipients receive appropriate clinical care”.
Assessment of the expected outcome
The service does not meet this expected outcome
Decline in clinical condition is not always identified and/or managed appropriately. Assessments are not always completed in a timely manner. Care plans are not always current. We observed gaps in clinical care provision impacting negatively on care recipients.
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”.
Assessment of the expected outcome
The service does not meet this expected outcome
Care recipient specialised nursing care is not always identified and met by appropriately qualified nursing staff. The service’s monitoring system has not identified gaps in clinical care for individual care recipients or trends. Diabetic and oxygen management is not always provided as directed. Enteral feeds are not always well managed. Complex pain management and wound care are not provided as directed. 
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”.
Assessment of the expected outcome
The service meets this expected outcome
The service has access to physiotherapy, podiatry and dietician services. Care recipients have access to medical practitioners as required. However, we observed some gaps in the referral system to support behaviour management, mental health and speech pathology services.
2.7       Medication management
This expected outcome requires that “care recipients’ medication is managed safely and correctly”.
Assessment of the expected outcome
The service does not meet this expected outcome
Medication is not managed safely or correctly. The computerised medication documentation system has been recently introduced to improve staff practices however the system is new to the service and staff remain unfamiliar with some aspects of medication management. There has been a significant increase in medication incidents and the newly contracted pharmacist has experienced packing errors.  There have been considerable issues identified in relation to medication and medication administration.
2.8       Pain management
This expected outcome requires that “all care recipients are as free as possible from pain”.
Assessment of the expected outcome
The service does not meet this expected outcome
Care recipients experience unmanaged pain. Efficacy of administered analgesia is rarely documented. Prescribed analgesia is not always available. Care recipients and representatives said at times care recipients experience unrelieved pain.
2.9       Palliative care
This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.
Assessment of the expected outcome
The service does not meet this expected outcome
There is minimal end of life planning. Care recipients have died in pain and distress due to constipation, unmanaged pain and anxiety. Staff have insufficient skills to support palliative care provision. It is apparent issues with medication management, pain management, clinical care; issues with inventory and equipment, gaps in privacy and dignity and emotional support as well as the living environment demonstrate the service has not provided a peaceful or comfortable death.
2.10    Nutrition and hydration
This expected outcome requires that “care recipients receive adequate nourishment and hydration”.
Assessment of the expected outcome
The service does not meet this expected outcome
Unplanned weight loss or gain is not sufficiently monitored to support optimal nutritional wellbeing. Staff do not appear to have the skills to support nutrition and hydration. The assessment team identified gaps in provision of nutritional supplements and enteral feeds.
2.11    Skin care
This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.
Assessment of the expected outcome
The service does not meet this expected outcome
Care recipients experience pain and distress in relation to poor management of skin care. Wounds are not attended as directed. Strategies to manage skin care are not always undertaken and skin care supplies are not always available. Personal care is not always attended in a timely manner. Continence care does not always support maintenance of skin care.
2.12    Continence management
This expected outcome requires that “care recipients’ continence is managed effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome
The service does not have a system to manage continence for all care recipients who are incontinent. There is no scheduled toileting program for care recipients. We identified instances of constipation which has impacted negatively on care recipient health and comfort. There was negative feedback from some care recipients and representatives relating to continence management.
2.13    Behavioural management
This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome
Care recipient challenging behaviours are not managed effectively. Staff do not have skills and knowledge to effectively manage care recipients with challenging behaviours. Unmanaged behaviours around verbal agitation impacts on other care recipients. There was some negative feedback from care recipients and representatives and staff about behavioural management.
2.14    Mobility, dexterity and rehabilitation
This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.
Assessment of the expected outcome
The service does not meet this expected outcome
The service has not had equipment to support care recipient mobility dexterity and rehabilitation. Staff do not have the skills to support care recipient mobility in a meaningful manner. Whilst the service has a physiotherapy team which supports care recipient pain and mobility; care recipients continue to have many and repeated falls.
2.15    Oral and dental care
This expected outcome requires that “care recipients’ oral and dental health is maintained”.
Assessment of the expected outcome
The service meets this expected outcome
There are systems to ensure care recipients’ oral and dental health is maintained. Oral and dental health and care is documented on care plans. A dental hygienist visits the service and develops oral care plans. Care recipients and representatives state care recipients are provided with oral and dental care.
2.16    Sensory loss
This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.
Assessment of the expected outcome
The service meets this expected outcome
Sensory loss is assessed on entry to the home and referrals are made to ensure care recipients’ care needs are managed effectively. Specialist equipment is maintained in working order. Care recipients and representatives report staff are generally supportive of care recipients with sensory loss as part of daily care.
2.17    Sleep
This expected outcome requires that “care recipients are able to achieve natural sleep patterns”.
Assessment of the expected outcome
The service meets this expected outcome
Care recipients generally natural sleep. Sleep is assessed on entering the service. There was generally positive feedback about the night time environment.


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”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.1 Continuous improvement for a description of deficiencies in the service’s overall system of continuous improvement. In relation to Standard 3 – Care recipient lifestyle the system is not effective.
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”.
Assessment of the expected outcome
The service 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 3 – Care recipient lifestyle include:
·           The organisation has procedures for the variation of the residential agreement if a care recipient moves to a different room upon their request or to ensure their care needs are effectively met.
·           The service maintains a register of reportable and non-reportable events is maintained for the reporting of alleged or suspected care recipient assault
3.3       Education and staff development
This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.3 Education and staff development regarding deficiencies in the service’s overall system of education and staff development. There has been limited education delivered relating to Accreditation Standard 3 – Care recipient lifestyle. Deficiencies identified in relation to multiple Standard Three expected outcomes demonstrates management and staff do not have the necessary skills and competencies to undertake their roles in relation to this accreditation standard.
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".
Assessment of the expected outcome
The service does not meet this expected outcome
Feedback was provided about care recipients who have been distressed and not provided with adequate emotional support. End of life care has not been provided to ensure a comfortable and dignified death.
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".
Assessment of the expected outcome
The service meets this expected outcome
Care recipients are assisted to maintain their independence. Exercise and walking programs are encouraged to assist with maintaining mobility and independence. Care recipient bus trips are regularly scheduled. Care recipients are able to pursue activities of interest as much as the living environment permits.
3.6       Privacy and dignity
This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".
Assessment of the expected outcome
The service does not meet this expected outcome
Management does not ensure that each care recipient’s right to privacy, dignity and confidentiality is recognised and respected. Staff do no demonstrate respect for the privacy and dignity of each care recipient.
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".
Assessment of the expected outcome
The service does not meet this expected outcome

3.8       Cultural and spiritual life
This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".
Assessment of the expected outcome
The service does not meet this expected outcome
The service does not demonstrate that the individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered. The service does not have comprehensive information to enable care recipients’ interests, customs, beliefs and cultural practices to be fostered and supported. The service has minimal spiritual support and there is no spiritual support for care recipients receiving palliative care.
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".
Assessment of the expected outcome
The service meets this expected outcome
Care recipients and/or their representatives are generally able to exercise choice and control over care, lifestyle and services. Care recipient, representative and staff interviews verified care recipients make choices including meals. Care recipients and representatives are satisfied with their participation in decision-making and ability to make choices. Care recipients and representatives were not consulted when the service engaged a new pharmacy.
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".
Assessment of the expected outcome
The service meets this expected outcome
The service has a system to provide information about contractual arrangements in relation to security of tenure. Care recipients and representatives have information relating to tenure within the residential care service and care recipients understand their rights and responsibilities.


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”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.1 Continuous improvement for a description of deficiencies in the service’s overall system of continuous improvement. In relation to Standard 4 – Physical environment and safe systems, deficiencies in relation to maintenance systems is not ensuring preventative maintenance is undertaken. Limited monitoring has occurred.
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”.
Assessment of the expected outcome
The service 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 4 - 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 service is fitted with a sprinkler system.
·           The benefits of influenza vaccination has been promoted to staff.
4.3       Education and staff development
This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.
Assessment of the expected outcome
The service does not meet this expected outcome
Refer to expected outcome 1.3 Education and staff development regarding deficiencies in the service’s overall system of education and staff development. There has been limited education delivered relating to Accreditation Standard 4 – Physical environment and safe systems. Deficiencies identified in relation to infection control demonstrates management staff do not have the necessary skills and competencies to undertake their roles in relation to this accreditation standard.
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".
Assessment of the expected outcome
The service does not meet this expected outcome
The living environment does not provide a safe and comfortable environment consistent with care recipients’ care needs. The communal areas are crowded and do not provide a relaxing environment with private areas for care recipients and visitors to meet. The living environment is not well maintained. Risks in the environment are not identified and responded to.
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".
Assessment of the expected outcome
The service meets this expected outcome
The service’s management team actively works to provide a safe working environment that meets regulatory requirements. Staff are aware of hazard reporting processes. Management said that if needed equipment is trialled to ensure it meets the service’s safety needs. Personal protective equipment is readily available for staff.
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".
Assessment of the expected outcome
The service 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, readily available emergency information and fire and security monitoring systems. Staff interviews demonstrate they are familiar with fire safety procedures. There is an evacuation box which ensures vital information is available to staff in an emergency. There are security procedures and strategies to ensure the buildings are secure. Care recipients and staff state they feel safe and secure in the service environment.
4.7       Infection control
This expected outcome requires that there is "an effective infection control program".
Assessment of the expected outcome
The service does not meet this expected outcome

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".
Assessment of the expected outcome
The service meets this expected outcome
There are systems to identify care recipient’ meal requirements and preferences on entry to the service and as care recipients’ needs change. All meals are cooked fresh on site using a dietician approved four-week seasonal rotating menu. There are processes for feedback and consultation regarding the menu at regular meetings. Special dietary requirements are catered for. The kitchen has systems and processes to ensure food is handled safely. There are basic cleaning schedules in place. Laundry services are provided externally. Care recipients/representatives expressed satisfaction with the meals, the cleanliness of the environment and the laundry service provided.