28 AUGUST 2015


Matt Kowald, Barrosa Village


Marlene Durdin, Wheatfields;
Lesley Hauter, West Wimera Health Service;
Dawn Hilditch, Hamley Bridge Memorial Hosp;
Amrik Pal, Barmera Aged Care;
Cindy Waples, Mt Pleasant and G/umeracha Hosp;
Ronnie Leng, Jallarah Homes;
Bridgette Van Den Brink, Jallarah Homes;
Gail Harding, Wheatfields;
Aileen Robertson, Let’s Manage


After discussions with Steve Charman at Intelligent Developments and with Kat Carol from CHSA, ACQA has determined to alter the audit tools to allow drop down menus where you can enter/attach evidence that you meet standards – e.g. policy documents, checklists etc.

Secondly, where there is a question on an audit ACQA will include information that act as prompts as to what would be considered examples of meeting that criteria. The assessors’ tools have those prompts but not everyone has access to these all the time. This will be of most use to new employees who are involved in auditing.

Where a question asks “do you have a policy on this” there will be additional questions about relevance, when last reviewed and does it include everything it needs.
Ultimately this will increase the educational and staff development potential of ACQA audit tools.

The afternoon will be spent presenting and discussing initiatives that ACQA is pursuing to increase the educational components on the site including tutorials on completing audits.
ACQA is also pursuing better whole of system reporting that allows us to identify sites that are achieving in particular areas so we can link them up with sites needing assistance.
ACQA’s goal is to fully realise the two components of our Association’s objects – to build a stronger Network and showcasing quality in aged resident care.


Care Recipient Living Environment Audit

Cindy Waples advised the Network that she has already raised the issue of some of the drop down menus not working. Specifically, if you answer ‘yes’ and there are more questions – these aren’t showing up. This functionality was working 8 months ago but now is not. This makes it difficult to print off the audit to give to a staff member for completion. This request was acknowledged by ID but not yet addressed.

ACTION: Gail Harding to email to Network Members the list of system improvements/upgrades and she will follow up on this straight away.

Positive Performance Measures

Discussion on items 1,2,3 of this section. Suggested new items in this section:

1 Satisfaction with the living environment evidenced through residents surveys, residents meetings and hazards and incidents related to environmental issues
2 Positive feedback on the living environment
3 Timely response and attention to complaints
4 As worded in current item 3


1 Tools – the link doesn’t link

2 Exclusions – change nil to audit applies to all residents

3 Provides Evidence and Results for Aged Care Accreditation Expected Outcomes – goal is for audits to facilitate self-assessment so it needs to allow for the addition of evidence then the audit tool can be saved in the self-assessment with hyperlinks to documents

4 Documents to be reviewed to ensure that it is relevant and current– include prompts for particular policies and documents – e.g. smoking, bed stick, restraint, bed rails, worksite inspections, waste, cleaning, work instructions and duty statements for cleaners, infection control, food safety program. Risk Assessment for equipment, activities and manual handling. Restraint authorisation – no change. Food safety records – no change. Complaints and compliments to living environment. Hazard reports related to environment (need to be able to identify hazards that are related to the environment). WHS policy. Discussion on the idea to include a section where the tool contains a reference to quantitative data on incidents, hazards, complaints, compliments. Network Members feedback is that this might be doubling up when this info is in other documents/evidence.

ACTION: Gail Harding will review Wheatfields’ policy list and identify any other policies that need to be added to this list.

ACTION: Leisure and Lifestyle Audit – to say policy reviewed as per policy (this is to address policy documents that say policies are reviewed for periods of time other than every 12 months).

5 Other National Standards – no changes

Update review date

1 and 2 need to be October 2014
3,4,5,6 links don’t work due to Dept name change – need to restore

Audit criteria

1 Observation of bed and bed height, assess correct height from a safety perspective, stick to stand tags in place

New criteria 2 Where required, have all care recipients been assessed for stick to stand (then change numbering thereafter)

Current criteria 2 Is the seating used by the care recipient set at the correct height to optimise mobility and transfers

Current criteria 3 prompts to include the need to have a policy that includes reference to this, the introduction of a food register that records the date when the food arrived, risk form for residents that have fridges, notices and flyers directed to family members.

ACTION: Lesley Hauter to send a copy of a food register template for sharing.
Current criteria 4 change to on the day of audit were all products in care recipients’ rooms stored appropriately. Then, include examples of medications (prescribed and non-prescribed, topical ointments/creams, razorblades, toiletries, fly spray, air fresheners (things that you don’t have SDSs for) and items generally in shared bathrooms.

Current criteria 5 Is the living environmental temperature in care recipients’ rooms appropriate to the current climate and weather conditions.

Current criteria 6 Is the temperature in communal areas appropriate to the current climate and weather conditions.

Current criteria 7 add prompt to check the conditioners in bedrooms, AC contractors’ reports, maintenance logs ad reports

Current criteria 8 Are all call bells/personal alert systems working

New criteria 10 When alone, do care recipients have access to call bells that can be reached and operated. Prompts – correct length of cords, ease of use, consideration of wireless, bracelet or alternative personal alert system.

Current criteria 9 – delete ‘safe’

Current criteria 10 – no changes

Current criteria 11 – use Australian spelling of odour

Current criteria 12 – prompts – electric shavers, shower chairs

Current criteria 13 – prompt – wheelchairs, walkers

Current criteria 14 – prompts – anti-social behaviour is managed, non-clinical eating areas that promote normalisation e.g. medication dispensing at non-meals times, medication trolley not in dining room at meals times, music, tablecloths, conversation starters (cards, photos)

Are any Care Recipients using bed poles?

Drop down questions – if yes, have all Care Recipients using bed poles been assessment by properly qualified staff?

Have reviews been completed on all Care Recipients using by properly qualified staff?

Next drop down box – if Care Recipient is using bed poles, are they fitted correctly?
Are any Care Recipients restrained?

Drop down questions – behaviour management plan in place, reviewed by appropriately qualified staff

Do you have any Care Recipients that smoke?

Drop down questions – fire blankets, observed, monitored, separate smoking area

Do you have any Care Recipients with refrigerators in their rooms?

Drop down questions – no change


Ronnie and Bridgette (Jallarah Homes) reported the addition of a kitten “Clawd” and said goodbye to the turtle.

Amrik reported that Barmera has recently gone through accreditation – stressful in the lead up but the actual day went well.

Wireless internet has been introduced on a fee for use basis for residents and family. Are conducting a fundraising drive at the moment. Took on 5 new licences in the aftermath of Mallala. Occupancy high. Morale could improve. Gail talked about healthy workers champions training through ACS (Aged and Community Services) – has been well received and integrated in the workplace. Also talked about the introduction of the philosophy of “we will never be accused of caring for our residents more than we care for our staff”, which she picked up from a Return to Work seminar.

Lesley from West Wimmera Health Service reported on Montissori – 2 day on site training for staff – Tasmania services are spearheading the promotion of this model of activity care for dementia care residents. Significant take up rate throughout Victoria. Philosophy has application beyond just dementia care residents. Recommends this training highly and is seeing significant improvements in the facility.

Cindy from Mt Pleasant and Gumeracha Hospitals reported on the success of dealing with a care recipient who entered other’s rooms – they put in a rope across and open doorway that stopped the resident from entering but allowed the others to not have to be shut in their rooms.


Reports not fully printing out – columns are missing in incidents reports. This used to work by highlighting and printing but this no longer works.

Gail reported that the ‘back’ button issue previously discussed can not be remedied as this is just how computers work.

Can we sort by different staff member ID, sort by fractured leg, burns etc – a filter? When exported to excel some info may not appear in columns – one solution is to highlight all and then click on ‘wrap text’ on the status bar so that info can be contained in the columns. This may help. Not all columns and parameters on register print off the same as on the screen. Another approach is to use the ‘filter’ button. It seems that this happened automatically in a previous version but isn’t working now.

Question – do other sites credential their RN’s annually – or conduct a skills assessment? This has come from the amount of medication errors results. Ideas – use Lee Care to manage medication, send a notice for each discrepancy, medication checks at the end of each shift/start of every shift, training and education, attend RN and EN meeting to seek their input on how to address this, introduce guidelines for safe and effective medication rounds –


Question – do other sites use the National Diabetic Scheme for clients? Individuals must apply in their own names, the facility orders the products on the resident’s behalf at no charge. The individual is responsible for specific products purchased just for them outside of the basic supplies for which they are financially responsible. Lee Care can record and summarise this information for billing purposes. If families fail to positively respond you could approach the Guardianship Board.

Question – medication aprons – are these mandatory? No.

Question – we have 2 toilets for staff that clients have been using and messing. Others suggest – lock it, install a key pad.

Question – Leisure and lifestyle volunteers – are they allowed to take residents off-site on their own? Yes, but make sure they have own phone. Ensure volunteer policy includes all information about training, insurance, vehicle use etc just as you would for an employee.

Question – students on work placements – in guidelines it says that sign off must be by a person with Cert IV in Workplace Training and Assessment.

Question – immunisation – its not compulsory so should we get the employee to sign an exemption form? Some sites do require this, yes. Guidelines suggest that a register is kept on status.


Complaints Management Audit

Change the name and thrust of this audit tool to be about feedback generally

Rationale – Reword the rationale with better grammar.

Performance Measures

1 Response time to complaints and feedback (this can be informed by complaint/ concerns/ compliments/ feedback electronic systems that sites may have)

2 Identifying, managing and responding to trends in internal and external complaints and feedback.

3 include ‘and feedback’

4 Continuous improvements that have been identified from addressing or resolving complaints and feedback.


Exclusions: all feedback to be included in audit

Documents – include orientation records, correct spelling of register, remove the stand alone ‘complaints’ (NOTE – this is repeated at number 5 – take out number five)
National standards – insert link to ‘complaints alerts’

Include link to new resource box
4,5,6 didn’t load – new links need to be included
Add reference and link to Act and provider principles

Audit Criteria – complaints management system process
Criterion 1 – add ‘and feedback’
Criterion 2 – update the new date
Criterion 3 – update to new legislation and date
Criterion 4 – have care recipients and their families been provided with information about lodging complaints and the complaints management process?
Criterion 5 – no change

Audit Criteria – Staffing and Culture
Check the link and page number
Criterion 1 – no change
Criterion 2 – no change
Criterion 3 – no change
Audit criteria – staffing add process
Criterion 1 – add ‘and feedback’ and take out ‘special needs’
Criterion 2 – remove
Criterion 3 – no change
Criterion 4 – add in prompts – give consideration to suggestion boxes

Audit Criteria – Review of Complaints
Criterion 1 – add prompts
Criterion 2 – add prompts
Criterion 3 – add in examples of evidence – board minutes, complaints forms
Criterion 4 – is there evidence that the service has in at least 80% of cases responded to high risk complaints within 48 hours.
Criterion 5 – no change
Criterion 6 – Have you capturing any verbal complaints during the audit period yes/no
Criterion 7 – no change
Criterion 8 – Are there mechanisms in place to report complaints and feedback to the staff team.
Criterion 9 – have all relevant complaints
Criterion 10 – Are serious/high risk complaints reported and discussed with approved providers urgently and provided with statistical data on complaint and feedback trends.

Evaluation of complaints
Criterion 1
Criterion 2 change mentally competent to ‘cognitively aware’
Criteria 3 – consideration given to risk matrix, Board/Executive reports
Analysis and improvement
No change

Actioning the Audit
No change

Medication audit tool

Gail reported on the follow up to a previous issues about doctors doing medication chart review – Gail rang Pharmacy Board and PBS who confirmed there is no legislation that doctors have to review medication chart or how frequently. This is entirely a matter for facilities to determine as a matter of policy. Therefore the accreditation agency might say that they want to see this however, there is no legislative requirement.

This question was then taken out of the audit for medications.

Lee Care Work Instructions

Work Instructions have been issued by Lee Care on clinical audits. Gail is happy to distribute these if you want to ask her.
Education through ACQA

We are about to begin developing YouTube style clips attached to the audit tools for staff to access about quality practice and auditing.

Ideas from Network Members:

How to do a successful medication round
Normalisation of mealtimes
Staff dismissal due to resident abuse
Question – is this a one strike you’re out situation.

Meeting closed 3.15pm

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