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Decision to Accredit
Canossa Nursing Home (Italian)
The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Canossa Nursing Home (Italian) in accordance with the Accreditation Grant Principles 1999. The Agency has also decided that the period of accreditation of Canossa Nursing Home (Italian) is 1 year, until 22 November 2004. The Agency has found that the home complies with 41 of the 44 expected outcomes of the Accreditation Standards. This is shown in the “Agency Findings” column appended to the following executive summary of the assessment team’s site audit report. A serious risk to the health, safety or well being of residents was identified in relation to expected outcome 2.7 Medication management. The Agency closely monitored the home and has found that action has been taken by the approved provider to address the issues. The Agency is satisfied that the serious risk no longer exists and that the home is compliant with the expected outcome. The assessment team reported that the home was also non-compliant with expected outcome 2.3 Education and staff development. After considering information submitted by the approved provider, including the actions taken by the home to resolve the deficiencies, the Agency found that the home was compliant with 2.3 Education and staff development. The home has been placed on a timetable for improvement concerning the remaining non-compliant expected outcomes. Matters of non-compliance have been referred to the Secretary, Department of Health and Ageing, in accordance with the Accreditation Grant Principles 1999. The Agency will undertake support contacts to monitor progress with the improvements and compliance with the Accreditation Standards. Victoria Crawford Manager Operations Services Queensland Information considered in making an accreditation decision
The Agency has taken into account the following matters, as required, by the Accreditation Grant
Principles 1999:
• The desk audit report and site audit report received from the assessment team created for the • Information (if any) received from the Secretary (of Department of Health and Ageing) about matters that must be considered, under Division 38 of the Aged Care Act 1997, for certification of the service; and • Other information (if any) received from the Secretary; and • Information (if any) received from the applicant in response to the statement of major findings that was presented to the applicant at the conclusion of the site audit. This may include information that indicates the service rectified deficiencies identified by the assessment team at the time of the audit; and • Whether it is satisfied that the residential care service will undertake continuous improvement, measured against the Accreditation Standards, if it is accredited. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Service and Approved Provider Details

Service Details
Approved Provider
Corporation of the Order of the Canossian Sisters Assessment Team
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Accreditation
Executive summary of Assessment Team’s Report
Decision
Standard 1: Management Systems, Staffing and
Organisational Development
Assessment Team
Expected Outcome
Agency Findings
Recommendations
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Standard 2: Health and Personal Care
Assessment Team
Expected Outcome
Agency Findings
Recommendations
Compliant
Compliant
Compliant
Compliant
Non-Compliant
Compliant
Non-Compliant
Non-Compliant
Compliant
Compliant
Compliant
Compliant
Non-Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Non-Compliant
Non-Compliant
Non-Compliant
Non-Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Accreditation
Executive summary of Assessment Team’s Report
Decision
Standard 3: Resident Lifestyle
Assessment Team
Expected Outcome
Agency Findings
Recommendations
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Standard 4: Physical Environment and Safe Systems
Assessment Team
Expected Outcome
Agency Findings
Recommendations
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Compliant
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Assessment team’s reasons for recommendations to the Agency

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

Standard 1: Management Systems, Staffing and Organisational Development

1.1 Continuous
Improvement
This Expected Outcome requires that “the organisation actively pursues
continuous improvement”.

Finding: compliant

Canossa Nursing Home actively pursues continuous improvement.
The Deputy Director stated that information is gathered through internal audits,
comments and complaints forms, improvement forms, incident and hazard reports
and minutes of meetings. This information is discussed at Quality meetings and
transferred into actions on action plans. Minutes of Quality Meetings indicated that
there are management team meetings, workplace health and safety team meetings,
infection control team meetings, education committee meetings and infection control
team meetings. Each committee meets one, two or three monthly. In addition, the
Team sighted an external review carried out by the hospitality service provider.
Continuous Improvement projects have been carried out consistently over the last
three years and some examples include:
Concerns expressed by staff led to a review of the continence management system
which led to a continence management program being developed including
education, a change in purchase system and changes in processes of continence
management by staff. This program was introduced in December 2002 and
document review confirms that the costs of continence aids have been reduced and
practice is improving. The Deputy Director stated that she is aware this program still
needs further improvement and forms part of the continuing improvement cycle.
A review of the medication management system was carried out in March 2003 and
new processes have been developed. The Team sighted the new medication forms
and the Deputy Director described the new system. This system had not been
implemented at the time of the site visit.
A Lifestyle Program is being developed which will bring together the diversional
therapy team, the recreational program, the pastoral care program and the
volunteers. This plan has been documented and is currently being implemented.
The aim of the program is to achieve more efficient use of resources, improve
reporting structures, clarify roles and monitor expected outcomes.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 As part of the continuous improvement process, Hospitality Services have been
outsourced to an external supplier who utilises Canossa staff and on site facilities.
This change has been carried out with evidence of a great deal of consultation with
residents and staff and consistent monitoring of the effects of the change on resident
outcomes.
Canossa is currently working with the Environment Protection Authority of Brisbane
City Council to develop a waste management program which will reduce the amount
of waste and utilise principles of recycling and reduced environmental impact. The
Team viewed documentation in relation to this project and amounts of waste
produced have been documented and significantly reduced.
An audit carried out in December 2003 identified that temperatures were not being
checked on food items because the probes were not reading accurately. The
existing equipment was calibrated and new additional probes were purchased.
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".

Finding: compliant

Canossa’s management has systems in place to identify and ensure compliance with
relevant legislation, regulatory requirements, professional standards and guidelines.
The Team observed a library in the Education Center containing copies of the Aged
Care Act and related Principles, the Commonwealth Aged Care Standards, the
Workplace Health and Safety Act and the Privacy Act as well as a range of best
practice texts and videos. The Deputy Director stated that Canossa is a member of
Aged Care Queensland and receives regular updates about legislative change from
the weekly newsfax as well as from an external provider commissioned to provide
regulatory information. The Deputy Director stated that legislative change is tabled at
management meetings and other appropriate work team meetings.
Staff interviewed stated that they are informed about changes in legislation relating to
their practice through staff meetings and through staff training. Training records
confirm that information about changes to the Privacy legislation in 2002 were
covered in a training session on the topic.
The Team observed that staff in the hospitality areas carried out tasks in a manner
that indicated knowledge of relevant legislation and regulations. Documentation
reviewed indicated knowledge of residents’ rights and responsibilities and the Privacy
Legislation and processes reviewed in relation to human resource management
indicated compliance with industrial relations legislation. There were however some
discrepancies noted by the Team in relation to legislation regulating medication
management (refer to 2.7).
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 1.3 Education and Staff Development
This Expected Outcome requires that "management and staff have
appropriate knowledge and skills to perform their roles effectively".

Finding: compliant

Management and staff working in the areas relating to standards one, three and four
outcomes have the knowledge and skills to perform their roles effectively.
Education and staff development is promoted and supported by management and a
training program covering all standards is provided. The education committee meets
monthly and assists in the development of the annual training program. The staff
development officer stated, and document review confirmed, that education sessions
are planned on the basis of an annual needs analysis, staff satisfaction survey and
performance management processes. An annual training plan is developed covering
stable sessions and extra sessions are added as need arises. The Staff
development officer stated examples such as changes to legislation, the introduction
of new equipment or the introduction of new processes. A monthly planner is made
available to staff with all sessions indicated. Lesson plans with learning objectives
and attendance records were sighted by the Team.
The staff development officer stated that each education session is evaluated,
sometimes formally, and in other cases in terms of outcomes demonstrated on the
floor. The Team reviewed the formal evaluations. The staff development officer
stated that class times are scheduled flexibly to meet student need, for example
some sessions are held at 9.30 in the evening in response to staff requests.
Document review indicated that core competencies are assessed in manual
handling, CPR, handwashing, fire and evacuation and medication administration.
Canossa has partnerships with several TAFE colleges and universities throughout
Queensland and regularly support work placement students in nursing, pharmacy
and physiotherapy. There are currently three employees who are Certificate III in
Aged Care trainees and one additional trainee is fully funded by Canossa.
Records indicate that in November 2001-November 2002, there were 52 topics
covered excluding mandatory training and orientation. Participant attendance hours
were 1140.25, and 56% of these hours were in the employees own time. This was
an increase of 566% on the previous year. From November 2002 – August 2003, 51
topics had been covered with 1150.5 participation hours. Topics offered covered all
standards of management, clinical care, lifestyle and physical environment.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 1.4 Comments
Complaints
This Expected Outcome requires that "each resident (or his or her
representative) and other interested parties have access to internal and
external complaints mechanisms".

Finding: compliant

Each resident (or their representative) and other interested parties have access to
internal and external complaint mechanisms, as shown by:
The Director of Nursing and Deputy Director of Nursing described Canossa Care’s process for ensuring that residents, their representatives and other interested parties have access to internal and external complaint mechanisms. The same process is in place for the Nursing Home, Verona Villa Hostel and Ethnic Hostel and includes: Providing written and verbal information about the internal and external complaint mechanisms in the resident agreement and residents’ and relatives’ handbook, which are provided to each resident and/or their representative prior to admission; Discussing how verbal and written complaints may be made during the admission process; Displaying information about complaint mechanisms throughout the each of the facilities; and Providing complaint forms and a suggestion box in each facility, and a complaint form in the handbook. The assessment team reviewed the residents’ and relatives’ handbook, which included information about the verbal complaints process and the written complaints process. This information also identified timeframes for the follow-up of complaints. The Deputy Director of Nursing stated that complaints are investigated, actions taken and outcomes followed up with the complainant if known. Eleven residents and/or representatives interviewed stated that they were aware of how to make a complaint and felt they could address a complaint to staff and /or management. The Deputy Director of Nursing stated that resident meeting/forum minutes have recently been recorded in an ‘action’ format to assist in tracking comments and following these issues up. Review of resident meeting minutes identified that comments, complaints and suggestions were recorded from residents. The assessment team observed that information about complaint mechanisms is on
display in each of the faculties.

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".

Finding: compliant

Canossa has a documented vision, values, philosophy and objectives as sighted by
the Team in the Quality Manual, the staff and resident handbooks and posters
displayed in public areas of the facility.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
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".

Finding: compliant

Canossa has processes in place to ensure that appropriately skilled and qualified
staff are recruited and employed. These processes include:
The Deputy Director stated that recruitment takes place through review of
expressions of interest on file and through advertisements. Applicants are asked to
respond to a set of selection criteria and to participate in a panel interview.
Questions and responses are documented and kept on the successful applicants’
file. References are checked and a record of referees, questions asked and
responses are kept on file. In addition, copies of registration, certificates and awards
are kept on file. Review of eight personnel files confirmed this.
The Staff Development Officer stated that new staff participate in an orientation
program which includes information about the organisational structure, mission and
values, workplace health and safety and fire safety, infection control and competency
assessment relating to their specific area of work. Review of the orientation program
folder confirmed this. New staff complete a checklist of tasks and competencies
within their first three months probationary period. These checklists were sighted in
the personnel files.
Canossa has processes in place to ensure that staff are monitored in their tasks,
such as:
The Team viewed performance development appraisals signed by staff members
covering performance, professional and ethical practice, critical thinking, core
competencies and opportunities for training. The Deputy Director stated that area
supervisors monitor competency timeframes and follow up if competencies are due.
The Deputy Director stated that Canossa has 24 hour registered nurse coverage and
that benchmarking against other similar facilities indicates that the ratio of staff hours
to beds is high at Canossa. Staff were observed carrying out tasks in accordance
with appropriate skills and knowledge in most areas, however there are some
deficiencies evident in skill level relating to standard two. Refer to expected
outcomes: 2.4; 2.7; 2:12 and 2.13.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 1.7 Inventory
Equipment
This Expected Outcome requires that "stocks of appropriate goods and equipment for
quality service delivery are available".

Finding: compliant

Equipment is trialled by staff before purchase and training provided in the use of new
equipment. For example, four new hoists were purchased in July 2003 and the
Team viewed evaluations and recommendations documented by eleven staff in
relation to this equipment.
Document review indicated that Canossa has a monthly, quarterly and yearly
maintenance plan covering all equipment. A computer program prompts the
maintenance supervisor daily in relation to equipment due for planned maintenance.
When maintenance tasks are carried out they are signed off. A list of approved
contractors is kept on site and copies of registration and license numbers for
tradespeople were sighted by the Team.
Each floor has a maintenance book in which staff enter daily maintenance tasks and
these books are checked daily. The Team viewed the maintenance books and tasks
were signed off as completed within 24 hours. The maintenance supervisor is on-call
twenty-four hours and can be contacted at night if emergency maintenance is
required.
Care staff and hospitality services staff interviewed indicated that maintenance is
carried out promptly when requested.
Supplies of goods are co-ordinated by a purchasing officer and day to day
purchasing is carried out by area managers. Registered nurses, care staff and
hospitality staff interviewed stated that they have access to adequate supplies of
stock to carry out their work.
The Team observed evidence of stock rotation in the kitchen and an abundant supply
of chemicals for laundry and cleaning.
1.8 Information
This Expected Outcome requires that "effective information management systems
are in place".

Finding: compliant

Effective information management systems are in place at Canossa.
The continuous improvement system can be seen to follow through from source of
issue to discussion, action and follow-up in minutes of meetings, hazard and incident
reports and action plans.
The staff development officer stated that staff have access to information through
staff meetings, minutes of meetings, memos and training. Residents have access to
information through residents’ meetings, the newsletter and an open door policy by
staff and management.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
Care staff, maintenance staff, hospitality staff and administration staff confirmed that
they have access to information about their work and that they have opportunities to
give feedback about improvements. One care staff member indicated that
management did not always respond to ideas put forward, and a number of staff
members across all areas indicated that they did not always hear back about ideas
put forward.
Canossa has a number of staff members who are bi-lingual and these individuals are
able to assist in communication with the multi-cultural resident mix. The Team
sighted a number of policies and work instructions printed in several languages to
ease communication with staff. The Team sighted confidentiality agreements signed
by staff members in eight out of eight personnel files. Personnel files and resident
files were stored securely and there is a contract with an external provider to retrieve
and destroy archived documents.
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".

Finding: compliant

Canossa has service agreements with external providers. Service agreements cover
details of the service to be provided; regulatory requirements; service review
processes; complaints mechanisms; finance arrangements; and termination
processes.
License numbers and registration numbers were sighted on file for qualified
tradespeople.
A checklist evaluation form was sighted for staff to comment on goods or services
provided. Contracts are renewed according to a set timeframe, and on the basis of a
review of evaluations and communications between management, staff and the
provider. The Team also viewed purchase comparisons carried out on service
providers, comparing cost and value for money.
The Team viewed documentation confirming that the Hospitality Services Provider,
for example, meets regularly with management to discuss issues arising in the
cleaning, kitchen and laundry areas. Minutes from these meetings indicate that the
external provider responds promptly to any concerns raised.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Standard 2: Health and Personal Care

2.1 Continuous
Improvement
This Expected Outcome requires that "the organisation actively pursues continuous
improvement".

Finding: compliant

Refer to 1.1
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".

Finding: compliant
Refer to 1.2
2.3 Education and Staff Development
This Expected Outcome requires that "management and staff have appropriate
knowledge and skills to perform their roles effectively".

Finding: non-compliant

The team found that management and staff do not have appropriate knowledge and
skills to perform their roles effectively. In particular the team found significant
deficiencies in the knowledge and skills of registered nurses in relation to:
- the resident care system used by the service
- the role of assessment in providing appropriate clinical care
- assessment and management of residents with constipation
- continence assessment
Registered nurses interviewed (two):
- were unaware of Canossa’s policies in relation to resident assessment processes - one registered nurse interviewed identified a resident assessment reference manual, however this reference did not relate to the care system currently in use at the Service - were unaware of the availability of comprehensive assessment tools for where significant care needs are identified, and could not locate them - were unaware of the requirement to conduct comprehensive assessments where significant care needs are identified, despite clear prompts on baseline the baseline assessment form such as “see comprehensive assessment” (where a significant care need is identified) - advised that they transcribe medication orders for medications not packed in the Webster system onto “signing sheets” When asked why medication orders transcribed onto “signing sheets” were different to medication orders, one registered nurse advised that the transcribed order reflected what registered nurses had found to be best for the resident. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 When asked about the correctness of the practice of transcribing medication orders, both registered nursed interviewed advised that they believed that the practice was not correct practice (see also 2.7 Medication Management). One registered nurse advised: - that her morning shift duties includes the routine administration of enemas and - that a list of residents requiring regular suppositories and enemas was held in the front of the medication charts and that she used this list as a reference
When asked about other strategies used to manage constipation for the residents
listed on the “suppository list”, one registered nurse advised that oral aperients had
been found not to be effective (see also 2.12 Continence Management).

2.4 Clinical
This Expected Outcome requires that "residents receive appropriate clinical care".

Finding: non-compliant

The service’s philosophy of care is as follows:
Sisters and lay staff are committed to bringing healing, hope, comfort and serenity to
the sick, the aged, the most needy and most dispossessed.
However, the team found that residents do not receive appropriate clinical care. In
particular the team found that:
- health assessment for some important areas of resident care such as continence management, bowel management and behavior management is not effective in that the cause, history and contributing factors of significant care needs are frequently not investigated to ensure that care strategies are appropriate - health assessment data that is collected does not result in the development of - registered nurses do not use the resident care system in place at the Service as - registered nurse’s knowledge and skills in relation to effective management of continence and constipation is not adequate (see Expected Outcomes 2.3 Education and Staff Development) - evaluation of care strategies does not occur with adequate frequency for residents with significant and changing care needs The Director of Residential Services, Deputy Director of Residential Services and Level III Registered Nurse advised that the resident care system in place at the service involves: - a seven day settling in period on admission, during which time care staff document resident patterns and care needs in the progress notes - a series of baseline assessments are conducted for all residents, and comprehensive assessments where significant care needs are identified (at the discretion of the case manager) - progressive assessment and care planning over a six week period which is overseen by an allocated registered nurse case manager Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 - case conference with family allied health staff and other care staff after four - resident classification assessment approximately eight weeks after admission - care plan evaluation at least three monthly and as need arises conducted by the - annual re-assessment and case conference prior to classification For all (fourteen) residents clinical records reviewed, comprehensive assessment had not been conducted (as required by the Service’s resident care system) where significant care needs had been identified (see also Expected Outcomes 2.12 Continence Management and 2.13 Behavioral Management). A review of assessment documentation also showed that care strategies had been determined in isolation of investigation of the cause, history and contributing care factors in relation to these areas. For five of the thirteen residents clinical files reviewed, evaluation of care strategies had been reviewed two weeks prior to the audit and then not for approximately ten months prior to that review. Review of the care strategies for three of these residents identified substantial changes in care that had occurred throughout the ten- month period. Oral and dental care needs were noted not to have been assessed for four of the fourteen residents clinical files reviewed (that section of the assessment had not been completed). For nine of the fourteen residents reviewed care strategies were not evident on the care plan in relation to oral and dental care needs (where a care need had been identified). When asked about oral and dental care needs, two assistants in nursing identified a second ’24 hour care plan’ they used to identify oral and dental care needs. Two of these secondary care plans were noted to contain information about the degree of assistance required (for example full assistance, supervision only etc) and not information of resident status, that is, whether the resident had dentures, required oral toilets etc. Ten of the fourteen residents reviewed were noted to have pain. For eight of the these ten residents, the cause of the pain was not identified and care strategies noted primarily involved the use of analgesia, including where pain triggers identified the need for other nursing strategies such as repositioning, massage, particular care routines and particular continence care routines. Three of the ten residents with identified pain management needs had non-pharmaceutical care strategies identified. The Services’ policy regarding management of residents with significant weight loss states they review by a Dietician is to occur where there is 5% loss of body weight over a one month period or 10% loss of body weight over a three month period). Three residents were noted to have had significant weight loss within the past twelve months period. For two of the three residents with weight loss referral had not occurred in accordance with the service’s policy. One resident had lost seventeen kilograms before dietetic assessment occurred another resident had lost six kilograms before dietetic assessment occurred. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 2.5 Specialised Nursing Care Needs
This Expected Outcome requires that "residents’ specialised nursing care needs are
identified and met by appropriately qualified nursing staff".

Finding: compliant

The team found that residents’ specialised nursing care needs are identified and met
by appropriately qualified nursing staff.
Specialised nursing care needs were identified in assessments and care plans for
seven of the thirteen residents clinical files reviewed, including:
- prescribed skin creams X 3
- nebulised ventolin X 1
- indwelling catheter care X 1
- wound care X 2
- eye drops and X 2
- gastric feeding X 1
For each of the above specialised nursing care needs, care plans reflected medical
directions and/or nursing assessment.
Registered nurses were noted, in all cases to deliver specialised nursing care needs.
One resident receiving complex wound care and prescribed eye drops advised that
her treatments were completed as required by a registered nurse.
Two registered nurses were able to identify a 'treatments folder' used to record
resident treatment.
2.6 Other Health and Related Services
This Expected Outcome requires that "residents are referred to appropriate health
specialists in accordance with the resident’s needs and preferences".

Finding: compliant

The team found that residents are referred to appropriate health specialists in
accordance with the resident’s needs and preferences.
The Director of Residential Services, Deputy Director of Residential Services and
Level III Registered Nurse advised that referral for specialist medical consultation is
arranged by medical officers and that by registered nurses for other needs such as:
- palliative care assessment (available at the collocated Canossa Private Hospital)
- Physiotherapy
- Occupational Therapy
- Dietetic review
- Mental Health Team (accessed from a local public hospital)
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 However, when asked about the availability of specialist medical resources for assessment of residents with cognitive impairment, mental illnesses and challenging behaviors, the Director of Residential Services, Deputy Director of Residential Services and Level III Registered Nurse advised that such a resource was not readily available or in use. Referral was noted to have occurred for two residents reviewed. For example: - one resident was noted to have been referred internally to the dietician resulting - one resident was noted to have been referred for specialist medical oncology
2.7 Medication
Management
This Expected Outcome requires that "residents’ medication is managed safely and
correctly".

Finding: non-compliant
The team found that residents’ medication is not managed safely and correctly.
The Director of Residential Services, Deputy Director of Residential Services and
Level III Registered Nurse advised the medication management system was currently
under review and that an improved system of medication charting and administration
was to be implemented in the near future.
Only registered nurses administer medication. Medications are packed in multi-dose
administration aids. Registered nurses sign once for all medications administered
from the multi-does blister packs.
Medications that are not supplied packed in multi-dose blister pack are transcribed
onto “signing sheets” by registered nurses, creating a systemic risk of transcription
error. The majority of residents have one or more medication that is not packed and
therefore needs to be transcribed onto a signing sheet, and for each medication that
is to be transcribed, it is routinely transcribed multiple (up to nine) times (as the
signing sheet requires separate transcription for each week. Exposure to the risk of
transcription error is continuous, as transcription is a system requirement for all non-
packed medications for all residents in all areas of the nursing home. Further to this,
registered nurses routinely transcribe and administer medications differently to the
original medical order.
Review of one medication folder found:
- more than forty medications had been transcribed onto ‘signing sheets’ by more - the majority of the forty transcribed medications had been transcribed nine times, - eleven of the forty medication transcriptions were observed not to have been transcribed in accordance with the medical order Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Medication observed not to have been transcribed in accordance with the medical order included: - Medical order for Temaze 10mg nocte transcribed as Temazepam 10mg nocte - Medical order for Ventolin neb QID transcribed as Asmol 5mg QID. - Medical order for Valium 5mg PRN transcribed as Valium 5mg Tuesday, - Medical order for Senna 1 – 2 PRN transcribed as Senna X2 nocte - Medical order for Neocytamin 1000 3/12 transcribed as Neocycatmin amp 3/12 - Medical order for Dilantin 30mg susp. nocte transcribed as Phenytoin 5gm/2ml - Medical order for Zyprexa 5mg at 4pm transcribed as Zyprexa at 5pm - Medical order for Durolax supp. X1 daily at 6pm transcribed as Durolax supp. - Medical order for Normocol 1tsp with lunch transcribed as Normocol 1tsp mane at - Medical order for Capadex 1 – 2 QID PRN transcribed as Capadex X2 QID - Two separate medical orders for Endone, one for Endone 5mg BD and one for Endone 5mg PRN transcribed as one order, Endone 5mg BD + TDS PRN Two registered nurses questioned about why some transcriptions were different to the original medication order advised that orders are transcribed to best meet the needs of residents. The above list of medications were observed in all cases to be signed for as administered in accordance with the transcribed order rather than the medical orders. In three cases of incorrect transcription, the Team noted that the transcription had been made from a previous transcription rather than from the original order, that is, transcription of an incorrect transcription. The Service does not have policies are procedures regarding the practice of nurse initiated medication. Two registered nurses interviewed advised that they used their professional judgement in deciding what medications to initiate without a medical order. Twenty-two examples of registered nurse initiated medications were noted to be recorded throughout residents’ medication charts. In three cases, nurse initiated medications for aperients were noted to have been administered despite other existing regular orders for aperients. In one case the resident had a medical order for a regular aperients, the resident was receiving suppositories on a regular basis (without a medical order) and another nurse initiated aperient medication had been ordered and administered. The Service’s policy regarding verbal medication orders requires that staff record the verbal order on a ‘phone order’ form and that the medical officer sign the phone order on their next visit. Seven phone orders for medications were noted not to have been signed by a medical officer. In each case, periods of time between one week to four months were noted to have elapsed since the phone orders were given. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
Phone orders were noted to be for antibiotics, insulin, sedatives, aperients,
analgesics, including schedule 8 narcotics and once only anti-psychotic medications.
In one case, a phone order for Haldol PRN (an anti-psychotic medication) was
transcribed from the verbal order form onto a ‘signing sheet’ as an on-going PRN
medication. This medication continued to be administered although no medical order
was evident. Phone orders were evident for simple analgesia, various aperients,
suppositories and enemas (see also 2.12 Continence Management), nutritional
supplements, and oral anti-fungal agents.
On 4 September 2003, the team reviewed Canossa’s submission in response to the
team’s initial findings of serious risk in this Expected Outcome. The submission
provides information about immediate corrective action taken to immediately cease
the practice of transcribing administration orders for medication, communicate this
decision to relevant staff and provide training in relation to medication management.

On 4 September 2003 a member of the assessment team conducted a support
contact with the above service and verified that the actions outlined in the submission
had been implemented for all residents.
The actions taken will take some time to have full effect. Further to this, the service
has not completely eliminated the practice of transcribing medication orders.
However, on balance, the team considers the non-compliance in relation to
medication management practices not longer represents serious risk.
2.8 Pain
Management
This Expected Outcome requires that "all residents are as free as possible from
pain".

Finding: compliant

The team found that all residents are as free as possible from pain.
All (five) residents interviewed about pain stated that they did not have pain or had
pain that was relieved via medication or other strategies.
Two residents interviewed stated that the physiotherapy they received helped relived
their pain. Physiotherapy was noted to play an integral role in pain management at
the Service, four of the residents’ files reviewed were noted to have interventions for
pain planned and delivered by the internal physiotherapy service.
Ten of the fourteen residents reviewed were noted to have pain. For eight of the
these ten residents, the cause of the pain was not identified and care strategies
noted primarily involved the use of analgesia, including where pain triggers identified
the need for other nursing strategies such as repositioning, massage, particular care
routines and particular continence care routines. Three of the ten residents with
identified pain management needs had non-pharmaceutical care strategies identified.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 2.9 Palliative
This Expected Outcome requires that "the comfort and dignity of terminally ill
residents is maintained".

Finding: compliant

The team found that the comfort and dignity of terminally ill residents is maintained.
Eleven of the fourteen residents clinical records reviewed showed evidence of
assessment of end-of-life and after-life wishes.
Specialist palliative care medical and allied health resources are available at the
collocated Canossa Private Hospital. The Service accesses these resources as
required to assist with palliation.
Palliative Care Volunteers form part of the Services palliative care support systems
for residents and their families and staff. Palliative Care Volunteers are provided with
a palliative care volunteer’s handbook to assist in preparing them for their role and a
workshop on ‘Grief, Loss and Bereavement’ has also been attended by volunteers.
Interviews with the Palliative Care Coordinator and the Staff Development Officer
confirmed this.
2.10 Nutrition and Hydration
This Expected Outcome requires that "residents receive adequate nourishment and
hydration".

Finding: compliant

The team found that residents receive adequate nourishment and hydration.
All (fourteen) residents reviewed had a current diet assessment in their clinical record
and strategies listed on their care plan in relation to diet, nutrition and hydration,
including special needs and diets and aids to eating and drinking.
Information from the diet assessment form is transferred to a ‘diet book’, which is
used by care staff to complete daily menus. For resident who are unable to complete
menu forms independently, care staff use the diet book to complete the menu forms.
The catering service depends on information provided daily on ‘menu forms’ to
determine what meals and drinks to provide.
Three entries in the resident’s ‘diet book’ reviewed were noted to be consistent with
needs identified during assessment.
Five of seven residents interviewed about meals and drinks stated that they were
happy with the quality, quantity, type and variety of meals. Two residents stated that
not all meals were to their liking. However one of these residents stated that they
considered themself to be a ‘fussy eater’.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Three residents were noted to have had significant weight loss within the past twelve
months period. For each resident, referral to a Dietician had occurred, in two cases
however referral had not occurred in accordance with the Service’s policy (5% loss of
body weight over a one month period or 10% loss of body weight over a three month
period). See also 2.4 Clinical Care.
2.11 Skin Care
This Expected Outcome requires that "residents’ skin integrity is consistent with their
general health".

Finding: compliant

The team found that residents’ skin integrity is consistent with their general health.
All (fourteen) residents’ clinical records reviewed showed baseline assessment of
skin condition on admission to the service and Norton Scale pressure risk
assessment where indicated on admission to the service. For each resident with skin
care needs, a skin care plan was in place.
Registered nurses interviewed about skin care (two) identified the medication charts
as the source of information about prescribed skin care treatments and the
treatments folder as the source of information about wounds.
Assistants in Nursing interviewed about skin care (two) were able to describe
residents’ skin care needs and identified a secondary ’24 hour care plan’ as their
main source of information about residents skin care needs.
2.12 Continence Management
This Expected Outcome requires that "residents’ continence is managed effectively".

Finding: non-compliant
The team found that residents’ continence is not managed effectively. In particular
the team found:
-
assessment of the cause, history and contributing factors of incontinence does not routinely occur; and management of constipation is not effective and results in negative health outcomes for residents Twelve of the fourteen resident’s clinical records reviewed had identified residents with incontinence care needs - either urinary incontinence, feacal incontinence or both. For all (twelve) residents with an identified continence care needs, continence patterns had been recorded via a flowchart. However, assessment of the cause, history and contributing factors had not occurred in all cases (as required by the resident assessment system in place at Canossa). The baseline continence assessment includes the prompt “see comprehensive continence assessment”, where the resident has been identified as incontinent. When asked why comprehensive assessments had not been completed, one registered nurse advised that comprehensive assessment was no longer undertaken. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 The clinical management team advised that continence assessments had previously (about eighteen months ago) been the responsibility of a ‘continence nurse’, and that since the cessation of this position, continence assessment was now the responsibility of registered nurses. It was noted that a comprehensive continence assessment was not included in the clinical system manual provided to the team as a guide to resident care processes and that registered nurses interviewed about continence (two) were unable to locate the assessment. During discussion about daily routines for registered nurses, one registered nurse advised that morning shift commences with administration of routine suppositories and enemas. A list of residents who have regular suppositories and enemas was noted to be located at the front of the medication charts. The list was noted to contain thirteen residents who have routine ‘as required ‘ and regular suppositories and enemas: - for all thirteen of the residents, assessment of bowel function or assessment of the cause, history or contributing factors of the constipation had not been conducted - for nine of the thirteen residents, dietary interventions were not in place, nor had - for seven residents, two or more aperient medications were being used in conjunction with suppositories and enemas - for one resident, constipation and the need to use the toilet was identified as a - for two residents there was evidence in the progress notes of abdominal pain - for one resident there was evidence of recurrent severe faecal incontinence following administration of suppositories and causing distress and discomfort. Disposable continence aids are provided to residents who need them at the
registered nurses’ discretion. A list of incontinence products used by each resident is
available in each area of the nursing home and three assistants in nursing
interviewed were able to locate the list as the source of information about which
product to use.

2.13 Behavioural Management
This Expected Outcome requires that "the needs of residents with challenging
behaviours are managed effectively".

Finding: Non-compliant
The team found that the needs of residents with challenging behaviours are not
managed effectively. In particular the team found:
-
assessment of the cause, history and contributing factors of challenging behaviors does not routinely occur; and management of challenging behaviors does not include programs designed for residents with dementia related disorders Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Six of the fourteen residents clinical records reviewed had identified challenging
behaviors requiring specific care, from benign wandering behaviours or aberrant
behaviors such as physical and verbal aggression. For all six residents with special
care needs related to challenging behaviors, assessment of the behavior patterns
had been recorded via a flowchart. However, assessment of the cause, history and
contributing factors had not occurred (as required by the resident assessment system
in place at Canossa).
The baseline behavior assessment includes the prompt “see comprehensive
behavior assessment”, where the resident has been identified as having challenging
behaviors.
The clinical management team advised that the comprehensive behavior assessment
was no longer included in the resident care system.
Resident -specific behavior management programs were not in place beyond
symptom control.
2.14 Mobility, Dexterity and Rehabilitation
This Expected Outcome requires that "optimum levels of mobility and dexterity are
achieved for all residents".

Finding: compliant

The team found that optimum levels of mobility and dexterity are achieved for all
residents.
All (fourteen) residents’ clinical files reviewed showed nursing assessment of mobility
and dexterity, physiotherapy assessment and program development, occupational
therapy assessment had occurred on admission.
An extensive program of physiotherapy is available for residents, including a
physiotherapy clinic that provides for slow-stream rehabilitation. Mobility, dexterity
and rehabilitation programs are delivered primarily by Physiotherapists and
physiotherapy aids.
A range of aids and assistive devices such as basic wheelchairs, walkers, walking
sticks etc are provided to residents as indicated by assessed need. Aids are
provided for high care residents.
Two residents interviewed spoke positively about the physiotherapy program.
2.15 Oral and Dental Care
This Expected Outcome requires that "residents’ oral and dental health is
maintained".

Finding: compliant

The team found that residents’ oral and dental health is maintained.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Nine of the fourteen resident’s clinical files reviewed had assessment of residents
oral and dental care needs, five either did not have that aspect of the assessment
completed or had part of the assessment completed.
Care strategies related to oral and dental care needs were not recorded on resident’s
care plans for ten of the fourteen residents. However all (three) Assistants in Nursing
interviewed identified secondary ’24 hour care plans’ which described the oral and
dental care strategies.
A visiting dental service is available as required. High-care residents are provided
toothbrushes, toothpaste, denture containers, mouth-wash and denture solution as
required. Low-care residents are assisted to obtain these items.
2.16 Sensory Loss
This Expected Outcome requires that "residents’ sensory losses are identified and
managed effectively".

Finding: compliant
The team found that residents’ sensory losses are identified and managed
effectively.
All (fourteen) residents clinical files had comprehensive assessment of vision,
hearing and communication assessment conducted by an internal Occupational
Therapist, and care plans linked to the findings of assessment.
Residents have access to specialist optometic and audiometic services as required.
2.17 Sleep
This Expected Outcome requires that "residents are able to achieve natural sleep
patterns".

Finding: compliant

The team found that residents are able to achieve natural sleep patterns.
Twelve of the fourteen residents clinical files reviewed showed that residents sleep
patterns had been assessed on admission to the service and that sleep care plans
were in place where are care need was evident.
Sleep care plans contained a range of strategies for promoting natural sleep patterns
including environmental strategies, provision of food and fluids at specific times,
music, specific retiring times and pharmaceutical intervention as required.
All (eight) resident interviewed about sleep stated that they slept well or were
assisted to sleep well.


Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Standard 3: Resident Lifestyle

3.1 Continuous Improvement
This Expected Outcome requires that "the organisation actively pursues continuous
improvement".

Finding: compliant
Refer to 1.1
3.2 Regulatory
Compliance
This Expected Outcome requires that "the organisation’s management has systems
in place to identify and ensure compliance with all relevant legislation, regulatory
requirements, professional standards and guidelines, about resident lifestyle".

Finding: compliant

Refer to 1.2
3.3 Education and Staff Development
This Expected Outcome requires that "management and staff have appropriate
knowledge and skills to perform their roles effectively".

Finding: compliant

Refer to 1.3
3.4 Emotional
This Expected Outcome requires that "each resident receives support in adjusting to
life in the new environment and on an ongoing basis".

Finding: compliant

Each resident receives support in adjusting to life in the new environment and on an
ongoing basis, as shown by:

In an Interview, the Admission Officer, Director of Nursing and Deputy Director of
Nursing stated that support is provided to the resident and their representative as
early as the pre-admission process, as well as throughout the admission and settling-
in process by providing information and access to staff such as care staff, diversional
therapy staff and pastoral care staff and volunteers.
Eleven residents and their relatives interviewed stated that they felt supported
throughout the admission and settling- in process and that ongoing communication
with staff is timely and effective.
Review of eleven resident records and care plans identified that, where appropriate,
residents are provided support in the form of pastoral care visits, one-on-one
visits/activities with diversional therapy staff and specific strategies to support
residents emotional needs.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
Families are sent a condolence card from the Pastoral Care Coordinator six weeks
after the death of the resident and on the anniversary of the residents’ death. The
Palliative Care Coordinator confirmed this process on interview and also stated that a
yearly memorial service was conducted for those residents who have died and that
family, other residents and staff were invited to attend.
3.5 Independence
This Expected Outcome requires that "residents are assisted to achieve maximum
independence, maintain friendships and participate in the life of the community within
and outside the residential care service".

Finding: compliant

Residents are assisted to achieve maximum independence and participate in the life
of the community, as shown by:
An independence, privacy and dignity care plan is formulated from information gathered on admission and on assessment/re-assessment of residents’ needs. Review of resident record and care plans identified individual strategies are documented to support residents’ independence, such as the use of mobility aids, and support residents in their activities of daily living. The Activities staff assist residents in maintaining links with the community by assisting residents to participate in outings such as to the Italian Club, inviting community groups like schools to the facilities and providing opportunities for families to participate in special functions such as B-B-Q’s and a recent international food day. The assessment team confirmed this on review of activities programs and of resident interviews. A newsletter is published monthly to provide information to residents and their families and residents are encouraged to contribute to the contents of the newsletter. One resident does so on a monthly basis. Eleven residents and their representatives interviewed stated that they were involved in making decisions about their cares to maintain their independence.
3.6 Privacy
This Expected Outcome requires that "each resident’s right to privacy, dignity and
confidentiality is recognised and respected".

Finding:
compliant
Each resident’s right to privacy, dignity and confidentiality is recognised and respected, as shown by: Residents’ individual needs are documented on an independence, privacy and dignity care plan formulated from information gathered on admission and on assessment/reassessment of residents needs. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Residents each have a single room with a shared bathroom and staff were observed
by the assessment team to respect residents' privacy, dignity and confidentiality
through knocking before entering and closing doors while carrying out care. Eleven
residents interviewed stated that they felt their privacy and dignity was maintained.
The Admissions Officer stated that information related to residents’ privacy and
confidentiality is included in the residents’ and relatives’ handbook and these were
sighted by the assessment team.
Residents’ information was observed to be stored in a secured area for staff only to
access.
The assessment team observed that information related to resident rights is
displayed within the facilities.
3.7 Leisure Interests and Activities
This Expected Outcome requires that "residents are encouraged and supported to
participate in a wide range of interests and activities of interest to them".

Finding: compliant

Residents are encouraged and supported to participate in a wide range of interests
and activities of interest to them, as shown by:
The assessment team interviewed three Diversional Therapists and one Recreation Officer who plan and implement the activities program across the three residential facilities. The assessment, care planning review and resident needs evaluation processes are documented on the same forms used by the activities staff in each facility. Assessment of residents’ activity and leisure needs and preferences are assessed on admission and relatives are encouraged to complete a ‘getting to know me’ form for new residents. Individual and group care plans are developed and the Activities officers document the evaluation of the activities program. Review of eleven residents records confirmed this. Residents, staff and Activities staff stated that residents may attend activities in any of the facilities at any time. Outings are also undertaken on a rotational basis throughout the facilities. Review of resident records identified that the Activities staff are evaluating resident care plans and modifying residents’ individual and group activity care plans on a three monthly basis as well as when residents’ care needs change. Residents and relatives interviewed stated that they were satisfied with the activities program offered and were provided with the opportunity to provide input in to the programs if they chose to. Two residents and their representatives in the Nursing Home expressed the wish for more activities as they attend all the activities available and one relative stated their preference for activities on the weekend and in the late afternoon. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 The therapy team, in explaining the use of the assessment process and forms used and the care plan development and evaluation of the care plan, the following inconsistencies were identified: • Each Activities staff member identified a different use for the Care Plan: Lifestyle - Individualised Program and Group Program areas of the care planning document used in each Service; • The Activities staff stated that the Action/Strategies page was used for evaluation of the residents needs and additional strategies were documented on the group or individualised program areas of the documentation. Discussion with one Registered Nurse and Staff Development Officer identified that the Action/Strategy is the area staff should record individualised interventions and evaluation of the care plan should be undertaken of the on the Care Plan Review page; • The assessment team reviewed resident records in each Service and identified that the ‘support to get to activities’ and the ‘support during activities’ areas of the Care Plan: Lifestyle are not at all consistently completed; and • The identified ‘Getting to Know me’ assessment/information forms have not been completed for current residents although previous assessment information is available in secondary records.
These inconsistencies are likely to create a barrier to effective communication
between staff members about resident need.
3.8 Cultural and Spiritual Life
This Expected Outcome requires that "individual interests, customs, beliefs and
cultural and ethnic backgrounds are valued and fostered".

Finding: compliant

The individual interests, customs, beliefs and cultural and ethnic backgrounds are
valued and fostered, as shown by:
The assessment team interviewed the Pastoral Care Coordinator and the Director of Nursing who identified that the Service has a volunteer program in place that provides volunteers in the areas of pastoral care, palliative care and volunteers to support general activities such as transporting residents between Services for therapy and activities. A volunteer orientation and training program is in place that includes a Volunteer Handbook, role descriptions and training in areas such as manual handling, rights and responsibilities, fire safety and infection control. Interviews with the Pastoral Care Coordinator and Staff Development Officer confirmed this program was in place and that the Pastoral Care Coordinator stated that strategies were being developed to ensure all volunteers are current and new volunteers completed the training programs. Review of eleven resident records identified that regular contacts by Pastoral Care Volunteers were recorded in the residents progress notes and the Individualised Care Plans identified the individual frequency and type of contact preferred. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
Eleven residents and their representatives interviewed expressed that the pastoral
care staff and volunteers provided continuous support for them on an individual
basis. Residents from various religious backgrounds identified that they had frequent
access to religious services and pastoral activities to meet their needs and
preferences.
3.9 Choice
Decision-making
This Expected Outcome requires that "each resident (or his or her representative)
participates in decisions about the services the resident receives, and is enabled to
exercise choice and control over his or her lifestyle while not infringing on the rights
of other people".

Finding: compliant

Each resident (or their representative) participates in decisions about the services the
resident receives, and are enabled to exercise choice and control over their lifestyle,
as shown by:
A second monthly Residents meeting/forum provides a forum for residents and their representatives to provide feedback to the staff and management about service provision such as meals and activities. Review of Resident meeting/forum minutes confirmed that issues such as changes to the menu and catering service have been discussed with residents. The Team noted that information provided in the residents’ and relatives’ handbook outlines information related to how residents and their relatives can exercise their choices and make decisions related to their care. Residents and their representatives are provided with other opportunities to input into the decision making processes within the facilities such as through the suggestion/complaint process; case conferences; satisfaction surveys; and resident education; in addition to the Resident Forums. Management indicated that resident and relative feedback and input is very welcome. Interviews with eleven residents and/or their representatives indicated that they felt
they could participate in decisions relating to their care and the services provided.

3.10 Resident Security of Tenure and Responsibilities
This Expected Outcome requires that "residents have secure tenure within the
residential care service, and understand their rights and responsibilities".

Finding: compliant

Residents have secure tenure within Canossa Care, and understand their rights and
responsibilities, as shown by:
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 The Admission Officer reported that, prior to admission, prospective residents and/or their representatives tour the facility and are provided with an explanation of the Resident Agreement, including tenure, and the rights and responsibilities of both parties as well as fees and services provided. Residents are encouraged to seek legal advice about the Resident Agreement prior to signing and returning it. All residents/representatives are also provided with a residents’ and relatives’ handbook and a verbal explanation of the handbook. The assessment team sighted both the resident agreement and the residents’ and relatives’ handbook. The Admission Officer, Director of Nursing and Deputy Director of Nursing reported that if it is necessary to move a resident, for example when a low care resident needs to be provided cares in a high care area, consultation with staff, the resident and their representatives, and General Practitioner is undertaken. A new resident agreement may also be signed in some instances. Information related to resident’s rights and responsibilities is provided in the Residents’ and relatives’ handbook and is displayed within the facilities. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Standard 4: Physical Environment and Safe Systems

4.1 Continuous Improvement
This Expected Outcome requires that "the organisation actively pursues continuous
improvement".

Finding: compliant

Refer to 1.1
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”.

Finding: compliant

Refer to 1.2
4.3 Education and Staff Development
This Expected Outcome requires that "management and staff have appropriate
knowledge and skills to perform their roles effectively".

Finding: compliant

Refer to 1.3
4.4 Living
Environment
This Expected Outcome requires that "management of the residential care service is
actively working to provide a safe and comfortable environment consistent with
residents’ care needs".

Finding: compliant

Residents of Canossa have single rooms with ensuites. There is room for residents
to have their own belongings and residents interviewed state that this is encouraged.
There are informal areas with sufficient seating for residents to meet with relatives
and families outside their rooms if they wish. There are also kitchenettes provided
for use by residents’ relatives and families.
The grounds are well maintained with gardens and water features and outdoor
seating. Residents were observed by the Team being escorted to and from daily
activities and the dining rooms.
Residents’ accidents are documented and trended with some analysis carried out in
relation to time of accident, type of accident and level of injury. As the most common
type of accident is falls in the trending, a falls prevention program was developed.
Each incident is investigated by the workplace health and safety officer and possible
causes identified and eliminated. The program includes a component of education
for staff and residents.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
There are major building works being carried out on site with the construction of a
retirement village. The building area is fully fenced and separated from the
residential care rooms. The staff working on the building site have had workplace
health and safety training which was attended by the Workplace Health and Safety
Officer at Canossa. The Canossa Workplace Health and Safety Officer stated that
he inspects the building site on a weekly basis.
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".

Finding: compliant

Canossa has four trained Workplace Health and Safety representatives. A monthly
Workplace Health and Safety meeting is held to table and action Workplace Health
and Safety issues and review hazard reports and incidents. Minutes of the meetings
indicate that issues raised lead to actions which are then carried out immediately or
referred to the workplace health and safety action plan. Members of the Workplace
Health and Safety Committee include four management representatives and four
staff representatives. A review of hazard reports indicates that staff identify hazards
and these are then discussed and action taken. For example: A hard reported on the
20th May indicated that a wheelchair was in need of adjustment as a residents’ foot
kept slipping. This was immediately rectified. On the 14th May it was reported that
shampooing the carpet left the floors alongside the carpet slippery. The carpet
cleaning was consequently shifted to a dry clean method.
A review of incident trending indicates that incidents and accidents are collated and
analysed in relation to staff or resident, location, injury and time. Recent trends
indicate a high rate of strain injuries which has led to investigation and purchase of
four new hoists.
Monthly audits on environment and safety are completed by the Workplace Health
and Safety Officer through which issues are identified, risk assessed and acted
upon. A review of audits confirmed that issues are either acted upon immediately or
referred to the workplace health and safety committee.
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".

Finding: compliant

Management and staff are working to provide an environment that minimises fire,
security and emergency risks.
Document review indicates the 100% of staff have attended fire training in the last
twelve months.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Fire equipment is tested and tagged annually (last date April, 03). Exit signs are
illuminated and exit doors are visible from any point in the building. Exit doors are
single latch and clear of obstruction.
There are evacuation plans on each floor and these are accurate.
There is a no smoking in building policy with signs on doors and throughout the
building. There is a designated smoking area outside and away from the building.
Residents were observed by the Team smoking in outside areas.
Three cleaners, two laundry staff, one carer and two kitchen staff were interviewed
about fire procedures and all were able to articulate these clearly.
An external provider provides security services at night and night staff carry mobile
phones.
4.7 Infection
This Expected Outcome requires "an effective infection control program".

Finding: compliant

The team found that there is an effective infection control program.
The Staff Development Coordinator performs of the function of Infection Control
Coordinator. The infection control program in place at the service includes:
- an infection control policy and procedure manual (reviewed)
- an infection control committee (terms of reference and minutes reviewed)
- a role specific induction program in relation to infection control, including for
- training regarding standard precautions (training records viewed) - hand washing competency assessments (competency assessments viewed) - provision of personal protective apparel and training on their use (staff practices - a waste management program including for general and clinical waste - a staff health program including identification of illnesses which require staff not to - an outbreak management program including definition of an outbreak and provision for establishment of an outbreak management workgroup where an outbreak occurs - an infection surveillance program (surveillance data reviewed) Hand washing facilities and solutions were noted to be readily available in all areas All (three) care staff interviewed, described the importance of hand washing in their care routines (without specifically being asked), were aware of the circumstances in which to use personal protective apparel and were aware of waste management procedures, including for clinical waste. Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 4.8 Catering, Cleaning and Laundry Services
This Expected Outcome requires that "hospitality services are provided in a way that
enhances residents’ quality of life and the staff’s working environment".

Finding:
compliant

Canossa outsources catering, cleaning and laundry services to an external provider.
The provider utilises the on-site kitchen for catering and the on-site laundry for
washing residents’ personal clothing. Flatware is sent off site for laundering.
There are systems that include policy and procedures, and work instructions for
specific shifts in all areas. Staff in these areas attend training through Canossa’s in-
service training program as well as through the external provider’s training program.
Staff sign off on work sheets to indicate work carried out in the kitchen, laundry and
cleaning areas and work is monitored by supervisors.
The Team viewed a menu that was reviewed by a dietician and this linked to a
purchase order system. Kitchen staff stated that food orders are checked against the
invoice on arrival and weighed to ensure correct weights are supplied. Damaged or
out of date goods are returned. Kitchen staff indicated that cold foods are
temperature checked on arrival and a review of records confirmed that temperatures
are documented. The Team observed evidence of stock rotation in the dry goods
pantry and appropriate storage practices in the fridge and cold room.
The Team observed kitchen staff preparing foods in line with appropriate infection
control practices, for example wearing hats and gloves, washing hands and using
colour coded chopping boards.
Specialised dietary needs were documented as well as individual preferences.
Residents interviewed stated that if they do not like what is on the menu they can
have something else.
There had been a large number of complaints about the food documented when the
external provider first took over catering services. Minutes of meetings between
residents and management and between management and the external provider
indicate that concerns were acted upon promptly. Monthly graphs have been kept
indicating complaints and the number of issues and the number of complaints has
reduced consistently from the takeover in March until August.
Only personal clothing is laundered at Canossa. Laundry staff were able to
demonstrate to the team the procedures for sorting washing and for handling soiled
clothing which comes to the laundry in sealed bags. Clearly delineated dirty and
clean pathways were demonstrated. Personal items once cleaned, are folded and
placed in named baskets for return to the resident.
Residents stated that they are happy with the laundry service. One relative
commented that some items of clothing do not last when washed by the Service, so
she takes them home to wash herself.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003 Cleaners were able to articulate infection control procedures in relation to their work
as well as the tasks specific to different shifts. The Team observed that trolleys were
well equipped with personal protective equipment and chemicals were kept in a
locked cabinet. Cleaners described the use of different mops and buckets for
different areas.
Eleven residents interviewed stated they are satisfied with cleaning services and the
Team observed that the environment was clean and free of odour.


Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003
Assessment team’s recommendation regarding accreditation

The assessment team recommends that the Aged Care Standards and Accreditation
Agency Ltd accredit Canossa Nursing Home (Italian).

The assessment team recommends that the period of accreditation be 1 year.


Assessment team’s recommendation regarding support contacts
The assessment team recommends that there be frequent support contacts
during the period of accreditation.
Service Name: Canossa Nursing Home (Italian) Dates of audit: 26/08/2003 to 29/08/2003

Source: http://www.accreditation.org.au/upload/documents/pdfs/qld/CanossaNursingHomeItalian02.pdf