Desk & Site Audit Report 2022 Level 1,2 and 3

Role

Updated Policy and Procedures <br><br> Abuse and Neglect <br> Complaints/ Incidents <br> Home Rules <br>

Registers<br><br> Complaints/ Incidents<br> Residents ( Including contacts of NOK)<br>

The Service has a clear, simple statement outlining the policies relating to privacy, dignity and confidentiality.

The Service demonstrates it keeps records in accordance with requirements set out in sections 77 – 79 of the Residential Services (Accreditation) Act 2002 and Regulation 11 of the Residential Services (Accreditation) Regulation 2018 and these are kept current.

The service provider holds copies of agreements with residents.

If a resident refuses to sign an agreement, this is noted by the service provider on the agreement.

The service provider gives information (written and / or verbal), to prospective residents before the agreement is signed.

Policies and procedures in place that demonstrate a commitment to the prevention of neglect and abuse, financial, verbal, emotional, sexual or physical abuse.

All staff and residents are made aware of the Service’s policies and procedures.

Records of any incidents and action taken are maintained.

All staff and residents are made aware of the Service’s policies and procedures.

Records are maintained in accordance with section 11 of the Residential Services (Accreditation) Regulation 2018.

Residents are aware of complaints and appeals procedures, including access to external agencies.

The Service has a policy and/or procedures and / or strategies dealing with the needs of residents who may have complex or difficult behaviours, while respecting the dignity of residents.

The Service provides evidence outlining the rights of: residents to use external service providers

External service providers have access to the premises

The Service has a document recognising the rights of residents to independence and freedom of choice (e.g. House Rules or Statement).

Observations during site inspection that premises is clean and in good repair.

Laundries Elements and Prompts - Service demonstrates that regular cleaning and repairs are undertaken.

Common Rooms and Areas -Elements and Prompts - Observations during site inspection that furniture and equipment is clean and in good repair.

Bedrooms - Elements and Prompts - Fire Safety Management Plan behind the bedroom door.

Bathrooms and Toilets are private and lockable.

Service demonstrates that rubbish is removed regularly.

Pest control records are up to date.

The Service maintains records of cleaning and maintenance work conducted.

The Service demonstrates that it monitors and maintains the inventory list.

Premises is overall maintained to a:

Elements and Prompts - The Service has a safety and emergency plan that includes procedures and an up to date Fire Safety Management Plan. <br>Policy and Procedure in place?

Elements and Prompts - Emergency exits are marked.

Elements and Prompts - Staff and residents are trained in emergency evacuation.

Is the FSMP displayed? (Obtain up to date copy if not already on file)

Has a fire drill been performed in the last 12 months? (View records)

Does each bedroom have an evacuation plan displayed?

Has service provider provided sufficient fire safety testing and maintenance records?<br>o Early Warning Systems (smoke alarms) <br>o Emergency Lighting<br>o Exit Signage

Insurance policy

WorkCover documents (for staff only).

Registration / Accreditation certificates are displayed for residents to view? (It is an offence if not displayed in a common area of the service.)

Are there caution signs when cleaning the service?

Elements and Prompts - Staff position descriptions / duty statements on file.

Elements and Prompts - Advertisements of vacancies.

Menus and dietary requirements for residents are recorded.

Check the Complaints process – records of complaints regarding meals.

The kitchen has documentation from local council confirming inspection or notification of the operation of a food business.

Check the Complaints process – records of complaints regarding meals. <br>Any complaint received has been investigated and resolved.

The Service has written procedures dealing with food storage and pest control.

The department has not received any complaints about food delivery and storage of food.

Is food checked for signs of deterioration / contamination upon delivery?

Is food checked for signs of deterioration / contamination before use?

Is food properly packed / labelled / dated?

Is there a stock rotation system in place?

Are food storage areas clean and free from vermin?

Is food stored away from hazardous materials / substances?

Does the Service Provider, Associate or Staff have current qualifications in administration of first aid and cardiopulmonary resuscitation?

The service provider facilitates access to external service providers (e.g. ensuring brochures / information is available to the residents).

The Service provides assistance and actively encourages external providers to visit the Service.

The Service has a document outlining procedures for financial and clerical support

Elements and Prompts - Written agreements in the approved form are in place (e.g. Rooming Accommodation Agreement - Form R18 used, unless premises is an aged rental accommodation when the General Tenancy Agreement – Form 18a should be used).

Detailed financial records, available to residents or their representative on request, are maintained clearly identifying what the resident has received and what has been paid

Transparent book keeping practices should be in place for residents, whose finances are managed by the Service, including at least an income and expense statement which provides balances.

Note: The practice of the service provider having authority to access or to deal with resident funds is unacceptable, unless the Public Trust is involved.<br><br>Note: The practice of charging fees for sundry services not listed on the agreement or signed by the resident or their representative is unacceptable.<br><br>Note: The practice of service provider keeping residents ATM cards, PINs, credit cards, store cards etc is unacceptable. However, sometimes the residents may give consent for cards to be held by the service provider, but under no circumstances would PINS be provided.

Does the service provider keep transparent records for all transactions involving a resident’s finances?<br>(Audit financial information for 10% residents)

Consent form signed by resident or appointed decision maker?

Does the service provider purchase items for resident (i.e. cigarettes)?

Ledger showing monies in and out is correct?

Is money held for resident equal to amount displayed on ledger?

Are detailed financial records available to residents and / or their decision makers?

Does the service provider or agent keep resident’s passbooks, PIN numbers, ATM / Credit / Store cards?<br>Reminder: The practice of service provider keeping residents ATM cards, PINs, credit cards, store cards etc is unacceptable. However, sometimes the residents may give consent for cards to be held by the service provider, but under no circumstances would PINS be provided.

Reminder: The practice of service provider keeping residents ATM cards, PINs, credit cards, store cards etc is unacceptable. However, sometimes the residents may give consent for cards to be held by the service provider, but under no circumstances would PINS be provided.

Does the service provider handle and distribute residents’ mail?

Does the service provider give assistance to residents who can’t open / read / understand or respond to their own mail?

Written requests from resident to the service provider seeking assistance with their medication management.

Has the service provider developed internal policies and procedures for medication assistance?

The Service maintains records in accordance with the regulation of all instances where medication is provided or refused.

Are Medication Distribution Records checked regularly to ensure that doses have not been missed?

Is there a written incident reporting procedure for staff to follow?

Are Medication Incident Reports reviewed to identify potential areas that need to be addressed?

Are medications stored in a secure, lockable location, in original packaging or dispensed medications repackaged in a Dose Administration Aid (DAA) and in accordance with pharmaceutical storage requirements?

Are all non-prescription medications ordered by a medical practitioner?

Does the service have a procedure for disposal of ceased, expired or unwanted medications?

Are medications for disposal stored separately to medications in use, and returned promptly to the pharmacy?

Records of each resident’s daily living and medical or health supports.

Does the service provider or agent organise visits to the premises by GP’s and other professionals?

Do health care providers have easy access to residents?

Does the service provider or agent assist residents with transport to appointments?

Residents are appropriately clothed and the service provider assists the resident in purchasing their own clothing as / if required.

The Service has written permission to attend to resident’s personal hygiene functions.

Service demonstrates that policy is implemented and personal hygiene needs of residents are addressed.

That the documentation reflects and recognises the importance of preserving external social networks and that friends and family of the resident are welcomed and encouraged to visit the resident.<br>What tools do residents have to preserve social /family networks (i.e. telephone or email facilities)?

Consent forms for services requested.

Service demonstrates that residents do participate in decisions on their lifestyle.