LINKS CORPORATE MEDICINE WEB SITE Disclaimer The many extracts on these pages are from copyright material. They are owned by the reference given or its owner. They are reproduced here for educational purposes and to stimulate public debate about the provision of health and aged care. I consider this to be "fair use" in the common interest. They should not be reproduced for commercial purposes. The material is selective and I have not included denials and explanations. I am not claiming that the allegations are true. The intention is to show the general thrust of corporate practices as well as the nature and extent of any allegations made. Any comments made are based on the belief that there is some substance at least to so many allegations. Links to Site Maps Central Initial USA Australian International Corporate Practices (to print) Path to this page Home Australia Markets & aging Nursing homes The Companies overview Health care Hospital Corporatisation   Entry to Privatisation   Privatisation Background   Australian states Pathology & Radiology Gen. Pract. Corporatisation Aged Care Story of corporatisation   Nonprofit dilemma Aging bonanza Banks Nursing homes Home Care Breadth health corporat. Retirement Villages Nursing Homes Government    1985 to 1998    Correspondence    1998 to 2001    2002 to 2005    2006 Accreditation Nurses    People farming Residents & Relatives The Companies Not for profit homes Nursing Hm Comp The Companies overview Listed Companies Milstern DCA    Audit problem Ramsay Hlth Care Aevum Retirement Care Aus. Bigger unlisted Comp. Moran Hlth Care Tricare Regis Grp Unlisted Comp. Vic. A Illawaong Saitta/Neviskia CIS Holdings Unlisted Comp. Vic. B Eildon McKenzie SRS & Marnotta Enhance Peel Street Muskjest Lasalto & Easyplan etc Ellis & Elfam Dampier Bay Hastings Regional Navatha & Locksley Unlisted Comp. Other Aegis Sauve/Craigcare Kennedy Thompson Alchera Park Trans Dominion/Farad Gonzales Bresant Tolega & Karoona Peninsula Introductory page This corporate web site addresses the issues of corporate health care within a broad framework. A web page describing this broad context should be considered as an introduction to each page on the web site. If you have not yet read it then CLICK HERE to open it in another tab or web page. Content An adverse accreditation agency review of one of DCA's nursing home is worrying if it is a predictor of things to come. The company rushed to fix the problems which the press did not report.  Australian section    Amity at Caulfield Accreditation Agency Assessment

We must be fair to DCA, the owner of this home. We only have evidence of problems in one of its homes and when we consider its size it outperforms the many privately run for profit smaller groups when they are grouped. Not for profit local and church groups have also had problem homes.

Church groups have been in the under-funded nursing home sector for a long time. They have treated the poorer sections of the population. The wealthier citizens who paid more and who made bequests when they died are being taken away by for profit entities so cutting into revenue. Church owned nursing homes are aged and they do not have a ready source of capital to meet the demands of government and accreditation. They are stretched and struggling.

Country community nursing homes run by local counsels or church groups, and ethnic community services are also stretched. They often do not have the expertise to rapidly meet accreditation requirements. They need help.

DCA in contrast is wealthy. It raises capital from the share market and from its other businesses. It is buying selectively and renovating or rebuilding. It targets the wealthy. It has the resources and the expertise. As a new company it should still be in the first flush of enthusiasm. Failures in accreditation are consequently of far greater concern and raise the spectre of an excess of commercialism and efficiency at the expense of care. Commercialism impacts negatively on the morale of staff. The report and the attitudes of staff documented in their nursing home in Caulfield in Victoria reflect disillusionment. This report was not picked up by the press but deserves attention, analysis and debate. This web site is primarily about for profit market listed companies.

Assessors found that Amity at Caulfield was compliant in only 28 of 44 criteria. It failed 16. The overseeing manager of the agency ruled seven of these as compliant leaving 9 which is still very poor. The majority of nursing homes found to be acceptable pass all criteria or fail in only one or two criteria. The manager seldom over-rules more than one or two assessments. It is worth noting that the home was making no attempt to improve its services scoring a non-compliance in all four areas.

I must confess to being more than a little jaundiced about the plethora of processes, procedures and documents and the emphasis on them in the accreditation process. I accept that in a competitive marketplace where the pressures are away from care this is essential.

The complexity and the emphasis placed on procedural documentation seems to draw the focus away from care and place it on process. I am not questioning the intention behind this but worry that this is so intrusive that it further dehumanises and depersonalises care. Perhaps in a more appropriate context these things would simply be natural and normal - and glaringly obvious when omissions occur. Documentation and process would be an aid to care and not an end in themselves.

On the DCA page I commented on DCA’s position in regard to government policy, credibility and the way in which accreditation in the USA had largely whitewashed problems in facilities owned by rich and powerful groups. I also indicated that staff from Sydney rushed to the hospital and rapidly fixed all of the measurable problems. The agency then awarded it a perfect score - the results of which were included on the assessment put on the www. It will take more than this to change the attitudes of staff.

One of the key pointers to a dysfunctional nursing home corporation is the rapid turnover of senior staff in the homes. All too often this is because they are being pressured to take actions which they find unacceptable. They may be unable to respond to reasonable complaints from staff. Two key problems for staff are pressure on staffing levels and skills, and the rationing of essential supplies and services needed for the proper care of residents. Inadequate cleaning services and unsanitary conditions also drive staff away. The assessment points to a situation like this.

Dedicated staff depart and are replaced by people who are not interested in the residents and who are willing to clean bottoms simply because they need the money. A culture of indifference develops.

There are many allegations which indicate that nursing homes are either told of impending inspections or learn of these on the grapevine and so are able to quickly fix problems and pass inspections. Several comments in the report on this nursing home indicate a poorly coordinated last minute scramble to make the home more presentable occurred in the weeks before the assessment.

A selection of the comments made by the assessors are provided on this web page. They give an indication of the nature of the problems and their severity. The many different explanations and promises made by management in response are not included here.

The explanations given suggest that much of the management and decision making was centralised in headquarters in Sydney and that (as occurred in Mayne Health when it was reorganised by Peter Smedley) this may be at the heart of the problem. One can only hope that the explanation that the problems and central "support" were needed because of staffing difficulties do not hide a policy of centralised cost cutting and a one size fits all model in pursuit of "efficiency". This has resulted in inhumane ware housing in the USA.

My impression on reading this report was not only of dissillusionment, disinterest and ware housing but of the absence of "caring" from the care. There is no sign of intimacy or attention to personal wishes and interests - no attempt to make life livable. The elderly are being processed and it seems likely that many staff don't even know their names - they are too stressed by the pressures under which they work. Are these pressures the consequence a drive for commercial efficiency and productivity - to increase profitability.

Standard 1: Management Systems, Staffing and Organisational Development

Continuous Improvement Non Comp Non-Comp

Staffing problems are the first criticisms made by the assessors. Without leadership and commitment by staff care languishes and improvements do not occur.

Amity at Caulfield does not have a framework that assists it to actively pursue continuous improvement. While audits are conducted for expected outcomes across all of the Accreditation Standards, actions taken to address identified issues are not always effective in correcting areas of non-compliance. Suggestions and complaints have not been actioned or responded to. Results of continuous improvement activities do not show improvements for residents and other stakeholders. Staff, residents and representatives expressed concerns regarding:

• Management’s willingness or ability to respond to identified issues.
• The frequent changes in management and staff and the instability that this causes.
• New managers implementing new systems and ignoring any previously established systems.
• How information does not appear to be conveyed from one manager to the next.

A log book is kept in which staff and residents report problems needing attention and when the matters are dealt with. Here are just a few of the comments about this.

Examples of unresolved logs include:

• 13 July 2004: Staff numbers had not increased with the increase in resident numbers.
• 21 July 2004: A resident’s recliner chair had been ‘out of action’ for several months and had been reported to maintenance but had not been repaired.
• 4 August 2004: A heater in a resident’s room was not working, despite being reported four and a half months previously. The resident complained of feeling cold on a daily basis. An action on the log stated ‘Staff encouraged to seat resident in lounge and ensure adequate clothing worn’.
• 11 August 2004: Insufficient shower chairs for high care residents since residents had been moved from the second floor (Balmoral).
• 12 August 2004: Only one staff member in Windsor from 1pm to 3pm. ‘Due to the increase of high level care residents they are requiring more assistance therefore with x1 staff member on the floor it is difficult to attend to all resident needs’.
• 28 August 2004: A relative had to wait a ‘considerable time’ to get a staff member for their mother, after having problems contacting the registered nurse due to phone malfunction.

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Unactioned hazard alert forms dating back to 22 July 2004 were found in improvement log folders, available at reception. Issues included:

• 24 July 2004: A complaint by staff that there are too many residents for the kitchen staff to be able to handle. ‘There needs to be 2 of us, especially with the hours given...The dishwasher on Ascot is not working properly and there are no tea towels thus dirt and grime is being wiped off with paper towel and not disinfecting plates or cutlery. There is no soap dispenser in Windsor to clean hands properly’.
• 28 August 2004: A request for more tea towels, dish rags, wiping cloths and an apron, as there was only one wiping cloth in the Windsor kitchen for seven hours of wiping and only two dish rags for seven hours of drying dishes.

The failure of the home to audit its own processes and procedures was blamed on the staffing problems

The aged care services manager said that audits had fallen behind schedule. The quality and education manager, who left the service on 3 September 2004, was conducting audits. Management stated that the group manager education and quality will arrive from Sydney in two weeks’ time to train and monitor the weekend supervisor (who commenced on 6 September 2004) in conducting audits. The weekend supervisor stated that she is at the service for a three-month period.
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Audits are not always conducted according to documented instructions. For example, an audit of progress notes conducted on 18 May 2004 should have included a 10 percent sampling but only three residents’ files were audited.
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The staff communication folder is available at reception and this contains memos regarding various issues. Staff are required to sign memos to acknowledge that they have read the information. However, of eight memos viewed by the team, numbers of signatures varied between 20 to 25 out of approximately 73 staff.

There is a schedule for meetings; however, this ceases at June 2004. Minutes of meetings do not address issues raised in previous meetings and ‘business arising’ is always blank.
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A resident and representative satisfaction survey was conducted in June 2004 and the results were made available in the residents’ and representatives’ communication folder, available at ground floor reception. The survey was in eight-point type and difficult to read. Seventy-nine surveys were sent out and 21 were returned, a response rate of 27 percent. Respondents identified the following issues:

• Inadequate staff are available on Ascot.
• Two responses indicated that there are insufficient wheelchairs and that those available are lacking footrests.
• "I am particularly concerned regarding what seem to be continual management and nursing staff changes. Furthermore these changes are NEVER communicated to the families of the resident".
• Meetings lack a ‘clear agenda or statement of purpose.’ The relative questioned why they should "be interested in attending’ the residents’ and representatives’ meeting in May 2004 when they had ‘no idea’ what the meeting was about".
• The residents’ and representatives’ communication folder does not contain useful information and is only available on the ground floor. Residents and relatives have not been consulted as to the type of information they would like to see in the folder. The newsletter listed new staff appointments and job titles but gave no idea about the tasks that these staff would be performing.

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A survey was distributed to medical officers. Of five responses, only one included a date, which was 13 August 2004. The results of this survey had not been collated or acted upon. Identified issues included doctors’ difficulty in locating staff
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Residents’ and representatives committee minutes dated 1 June 2004 were available in the residents’ and representatives’ communication folder, in eight-point type. Issues were raised at the meeting, including:

• The standard of cleaning.
• Not all carers greet residents when they come on duty.
• Not enough serviettes.
• Not enough face washers and towels on Ascot. An action to address this stated that a stocktake was to be conducted on all floors and orders were to be placed to ensure adequate supplies.

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A relative said that they had not received minutes from a meeting held on 10 August 2004, but that they have never had so many meetings with management as they have during the past couple of weeks.

One entry suggests that purchases are controlled centrally. This is one reason why there were so many complaints about equipment and why management changed so frequently.

On the second day of the audit, management showed the team some improvement logs that had received approval from Sydney for the raising of purchase orders.

Human Resource Management Non Comp-Comp

Staff and management were both problem areas. Were low staff levels willingly accepted to keep costs down? Could it be that this was somewhere people did not want to work? Much of the management seems to have been done indirectly from Sydney.

There are not sufficient and appropriately skilled and qualified staff to ensure that services are delivered in accordance with the Accreditation Standards.

Amity has had difficulty recruiting and retaining aged care services managers. The current aged care services manager is from Sydney and has been in the position for five weeks. Management said that she will stay until November or until a new aged care services manager is appointed.
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An operations manager from Sydney said that she would be based at the service until the appointment of an aged care services manager and for at least six months.
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At the time of the review audit there were 75 high care residents (three in hospital) and three low care residents. The current staffing levels are that a registered nurse division one is on duty for each of the two floors on morning and afternoon shifts seven days a week. One registered nurse division one is on duty at night. Registered nurses division one have responsibility for medication rounds, liaison with doctors, relatives and residents, responding to telephone inquiries, assessing and documenting high care residents needs, specialised nursing care such as wound management, enteral feeding, supervision and direction of personal carers and administration of schedule eight drugs. The team observed that the medication rounds took until 10:30 or 11:30 am due to interruptions from telephone calls, doctors’ rounds and clinical events such as falls. Staff said that the medication rounds commenced at 7:15 am and that the midday round began at 12 midday. The team noted that the registered nurses division one were not always able to take their meal breaks on time, one working up to seven hours before they could take a break.
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A relative said that there were two staff for 39 residents two weekends ago and there are insufficient staff to undertake activities properly. The relative said that agency staff are not well trained.

Relatives said that there are not enough personal care assistants to answer call bells, feed residents and to provide continence care and hygiene when residents have been incontinent. Management said that the computerised call bell print out showed that there are no undue delays in answering bells. Relatives said that staff answer the call bell and say to residents that they will be back soon and disappear for up to half an hour. Improvement logs document that relatives have complained about residents waiting for attention, to be fed and for hygiene. Management said that all staff, the diversional therapists, carers and the whole management team would assist with feeding residents at meal times. However, this did not happen for the four days of the review audit. Carers and the diversional therapy staff assisted residents with their meals and the team noted that residents in their rooms and small lounges waited for up to half an hour before being fed by carers.
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The team asked management for copies of the rosters for the past six months and was not able to sight them. The team was told that the service does not keep past rosters and that any query about who worked on which shift would have to be followed manually.

Inventory and Equipment Non Comp Comp

One way to keep costs down is to tightly control and limit the commodities which residents use and need for comfort and basic nursing. Families will bring their own supplies or pay rather than antagonise staff on whom their relative depends.

There is no effective system to ensure that stocks of goods are maintained or that equipment for quality service delivery is available.

Residents who require pressure relieving devices, such as air mattresses, are required to pay for them, contrary to the schedule of specified care and services in the Quality of Care Principles 1997. One relative said that they had bought an air mattress and another relative said that they had been told to buy or hire an air mattress. The team sighted evidence in a third resident’s file that the resident would be responsible for the cost of hiring an air mattress. Management acknowledged the need to determine which residents had been charged for these devices and to reimburse them.

One resident reported that they were unaware that Amity supplied toothpaste or combs and had been providing their own. The resident was also not aware that Amity would supply clothing protectors, these had been requested some months ago and were in circulation on the second day of the review audit. The resident had paid to have protectors made.
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Issues were raised at the meeting, including:

• Not enough face washers and towels on Ascot. An action to address this stated that a stocktake was to be conducted on all floors and orders were to be placed to ensure adequate supplies.
• Not enough serviettes.

Despite documentation in the minutes of a meeting in June 2004 of the implementation of a stocktake system, improvement logs continued to be raised by relatives regarding the lack of linen available to residents, specifically towels and face washers on 19 and 20 August 2004. An action on 21 August 2004 recorded that towels had been placed in Windsor from Balmoral (the now-unused second floor).
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The support contact of 1 September 2004 states that residents, relatives and staff confirmed that there continued to be ongoing problems obtaining sufficient supplies of linen and towels.
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Staff stated that large numbers of towels and facewashers have been purchased within the last week or two and that there are now sufficient stocks of linen; however, a relative said that they continue to have concerns regarding the availability of towels. A staff member said that clean linen, such as serviettes and facewashers, is stockpiled in residents’ rooms, resulting in a lack of supplies for the following day. The team noted that the cupboard in one resident’s room contained a large number of serviettes, facewashers and towels.

A relative showed the team their loved one’s bed, commenting that the flowered bedspread was not usually in place and that the pillowcase was often missing. The relative stated that the appearance of the bedspread and pillowcase coincided with the team’s arrival on 7 September 2004. The relative also said that the overbed table is often missing from the resident’s room.
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The resident agreement states that microwaves, refrigerators and electric kettles are available in each resident’s room and that nursing staff will make an assessment based on safety to the resident before permitting use of the items. However, management and the maintenance man said that all microwaves and kettles have been removed for safety reasons.

Information Systems Non Comp Non-Comp

Among the first things to fail when staff lose heart or when under-staffing occurs are note keeping and communication between staff and with residents and their relatives. Attention to detail suffers.

Residents and relatives do not have access to information appropriate to their needs and staff do not have access to accurate information to assist with the delivery of appropriate care to residents.

Review of residents’ files showed that every one had gaps in documentation such as: missing care plans, care plans not reviewed, or reviewed only once since December 2003, illegible entries, signatures illegible (some with missing designations), information on the assessments not transferred to the care plans and no clinical care entries in the progress notes for up to a month.
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The survey was in eight-point type and difficult to read. A respondent to the survey stated that: The residents’ and representatives’ communication folder does not contain useful information.
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Residents’ files are not securely stored. Files in one unit were in a cupboard labelled ‘resident historys’ [sic]. The cupboard was unlockable and the team noted that the room was not consistently locked.

Incident forms are incomplete and not always filed appropriately. For example, of three incident forms relating to residents located in a folder at reception:

• None indicated that notification was provided to the medical officer or next of kin.
• Two were filed under the section relating to staff incidents as opposed to residents’ incidents.
• None were correctly completed:

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Management said that a resident list is printed daily and issued to staff to let them know which residents are in the service or in hospital. - - - - - - Staff said that the list is not accurate, is rarely updated and that they have to ask the registered nurses division one on each floor who is in hospital on a daily basis.
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The visitor sign in/out log is held at reception and is used to record who is in the facility in the event of fire or other emergency. However, the team noted that there were no entries in this log (apart from the team) between 3 September 2004 and 10 September 2004, despite there being numerous visitors to the facility within this time.

Standard 2: Health and Personal Care

One of the things which emerges from within the many problems in this section is a one size fits all approach. There is little attempt to attend to the individual needs, likes and dislikes of the residents. Decisions about diet are made by a dietician in Sydney who has never seen the resident. Surely this is ware-housing!

Continuous improvement Non Comp Non-Comp

The organisation does not actively pursue continuous improvement. Care staff are not involved in auditing clinical systems or care. Clinical audits conducted since October 2003 identified gaps in clinical documentation and actions have not addressed the cause of the systemic non-compliance. The team identified areas of non-compliance that had not been identified by the service or a ‘peer review’ team.

The audits show that the actions documented to improve documentation have been to review the residents’ files, memos to staff and some education that training attendance records show were poorly attended by the 73 staff.

Staff, residents and relatives use improvement logs and incident forms to identify deficits. However, the team identified a large number of improvement logs and incident forms dating from March 2004 that had not been processed by the project manager, the former and current aged care services managers or the education and systems coordinator.
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Three audits on documentation conducted on 5 December 2003, 18 May 2004 and 11 August 2004 identified the same issues, being:

• Progress note entries are not always in black ink.
• Not all entries include a signature, printed name, time and designation.
• The next of kin is not notified of changes in health status.

Actions taken to address these issues (which variously included reporting findings to management, issuing memos to staff and organising education) have not been effective in addressing non-compliance. Follow-up audits have not been conducted to ensure that issues do not recur, despite the fact that the audits conducted in 2004 both showed a decrease in compliance of five per cent since previous audits.

Clinical care Non Comp Non-Comp

Residents are in a nursing home because they are too old and ill to care for themselves. They are here to receive this care.

Management cannot ensure that all residents receive appropriate clinical care. Residents’ care needs are not consistently assessed and residents and relatives said that residents’ care is not consistent with their care needs. Clinical supervision does not consistently occur to ensure that staff practices are consistent and that staff provide care according to residents assessed needs. Evaluation of residents’ care plans is not consistent.
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Care plans have generic interventions without specific detail of individual needs and preferences. For example, residents’ sleep care plans do not consistently detail preferences that are documented on assessments
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Residents’ nutritional and hydration and cultural and spiritual needs are not consistently documented; a Jewish resident with a ‘dislike’ of pork documented on their diet analysis form was given pork sandwiches.
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Progress notes have not been documented consistently. Gaps in clinical documentation vary from six to 11 to 30 days for high care residents. Management said that staff have been instructed to document in the progress notes every day since the last week of August 2004; however, this is not happening consistently.

Residents and relatives said that residents’ care needs are not always met; clinical supervision does not occur consistently. For example, residents who require assistance with feeding are not always encouraged to eat, those who require nutritional supplements said that they have not always been available and one commented ‘up until two weeks ago I did not get my (nutritional supplement)’. The team observed residents in their rooms and lounges waiting to be fed for up to half an hour at lunchtime. A resident who has a urinary catheter does not always have their catheter bag emptied.
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The relative said that they often have to ask for the bag to be emptied as it is full (the resident has fluid tablets to increase urination). The fluid chart documents that the bag has been emptied once, twice to three times a day since early July 2004. For three single days there is no urine output documented.

Evaluation/review of care plans is not consistent or according to policy. Review of residents’ files showed that care plans had not been evaluated/reviewed regularly.
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An eighth resident’s file shows that they have lost weight and have had infections and dehydration requiring hospitalisation. There are no changes to the above mentioned resident’s care plans and no reviews of the care plans documented.
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Residents’ clinical condition and changes to management or care are not consistently documented.
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Resident B was taken to a local emergency department by relatives because they were not happy with the resident’s condition and management. The resident was found to have both eardrums ruptured and an injury to their ribs on one side. There is no record of how these injuries were sustained and management said that they had not investigated the cause. The resident returned to the service and died nine days later.
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Relatives said that they employ carers for their residents to ensure that the residents’ care needs are met. Some relatives come in to feed residents and attend to their care needs because they are concerned that the resident will not be attended to promptly.

A resident’s relative said that they were still waiting for a prescription for new glasses following the resident having their eyes tested at the service six months ago, despite having asked two ‘unit managers’ for the prescription.

Medication Management Non Comp Comp

Many elderly are dependent on accurate medication - and need to take this at appropriate intervals in order to maintain effective blood levels. Failure is a problem associated with understaffing, deskilling and disinterest.

While the service does have processes in place to manage residents’ medication, the system does not ensure medication is safely and correctly administered.

Residents do not receive their prescribed medication at the correct time. The team observed 8:00 am medication rounds completed at 10:30 am, 11:00 am and 11:30 am.
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The team spoke to the resident, and the resident stated that their drugs were often given out very late in the mornings. Two other residents confirmed that they did not always get their medication on time.

Some residents are not receiving the full benefit of their medication. The lateness of some medication rounds affects residents having repeated doses throughout the day, for example residents who take medication three times a day. Residents receiving medications three or four times a day have their prescribed medications ordered at regularly spaced intervals to ensure maximum effect.
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The team observed a handwritten A4 size note on the door to a resident’s room stating the resident’s name, prompting staff to give medications (the medications named are used to treat Parkinson’s disease) to the resident, and stating the times that staff needed to give the medication. The aged care services manager stated that the family put the note up.
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The resident had gone 17 hours without the medication, and then received two doses within an hour. The registered nurse division one stated at the end of one 8:00 am medication round (at 11:30 am), that ‘it is now time to do the 12:00 midday medication round’.

The registered nurse division one stated that they have to attend to clinical care needs and ward management activities during medication rounds and this delays residents’ receiving their medication on time. The team observed 12 interruptions in one medication round.
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Staff do not comply with the medication management system and medication is not safely and correctly administered to residents as shown by a sample of 11 medication charts:

Nutrition and Hydration Non Comp Non-Comp

Dehydration due to a failure to offer fluids, to keep water jugs filed or to have them within reach is a common feature of understaffing, deskilled staff and indifference.

Weight loss is due to a failure to offer tasty food, lack of time to eat it, or a failure to help those with difficulty eat. One again understaffing and indifference play their part.

Hydration and nutrition failures are serious problems resulting in weight loss, inanition, immobility, pressure sores and accelerated death.

Residents’ nutritional and hydration needs are not consistently assessed and reviewed. Residents are losing weight and there is no supervision to ensure that additional nutrition is offered. Residents’ assessed needs are not consistently met and preferences are not being respected.

Residents’ files showed that some residents have lost weight and that their weights are not consistently documented according to the service’s policy that residents should be weighed monthly and those with weight loss weighed weekly. Reviews of seven files show that this is not consistent. Residents who lose weight have their details faxed through to a dietitian in Sydney and advice is faxed back. This advice is not consistently documented on residents’ care plans, however it is on file in the resident’s folder. A dietitian does not interview residents.

Residents and relatives said that residents’ care needs are not always met. For example residents who require assistance with feeding are not always encouraged to eat and those who require nutritional supplements said that they have not always been available and one commented ‘up until two weeks ago I did not get my [nutritional supplement]’.
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Resident F had lost weight and was ordered a nutritional supplement. The resident said that this was not consistently available and that until two weeks previously, had often not been given to them.
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One of their care plans documents that the resident is to be weighed monthly and another that the resident is to be weighed weekly. The resident’s progress notes show that the doctor is aware of the weight loss and that the resident has had infections and dehydration requiring hospitalisation. There are no changes to the resident’s care plans and no reviews of the care plans documented.

A relative reported that their mother has ‘lost a lot of weight’. They stated that this has occurred because staff do not have enough time to spend with residents at meal times encouraging them to eat.
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The team observed that residents who have vitamised diets do not have additional nutrition at morning and afternoon tea and at suppertime. The evening meal is served at 5:00pm and the breakfast at 8am; leaving residents who have vitamised meals without food for 15 hours.

Low cost unappetising meals are a common way of keeping costs down. There have been several newspaper reports analysing how little money is spent on meals in some nursing homes

Sometimes the menu is not adhered to. Relatives said that party pies were served as a substitute for a meal when they were not on the menu. During lunch on the first day of the review audit, one resident said that the quality of food goes up and down, the food is often cold and that her soup on the day was cold. The resident said, ‘You have to eat it because there is nothing else until dinner’. - - - - - Another resident said that her brussels sprouts were cold. A relative said that they would like more assistance for residents at meal times.

The menu is on display in the dining areas and this shows that there is a choice of two meals at lunchtime. Management said that staff know what residents liked and disliked so gave them appropriate meals or asked on the day. None of the residents interviewed were aware of the choice of meals, only two were aware of alternatives and minutes of meetings and an improvement log confirmed that choices of meals ‘run out’ or are not available on the day. Observation at the time of the review audit indicated that some staff are not aware of residents’ likes, dislikes, preferences or special diets and this was confirmed by comments in surveys and minutes of meetings and interviews. For example a resident who is Jewish and does not eat pork was given pork sandwiches. Another resident was given egg sandwiches despite them saying that they did not like or eat egg. The majority of residents and representatives interviewed said that the food was ‘not good’, ‘never like your own’, ‘had gone off and was not as good as before’, ‘nothing flash’, ‘not much choice’ and one commented that the food was ‘good’ and another ‘all right’. The surveys and minutes of meetings confirm that there have been on-going negative comments relating to the food, but that some residents are satisfied with the food.

Skin care Non Comp Comp

Pressure sores should rarely occur with good nursing but are only too common. Poor nutrition, dehydration, immobility, a failure of nurses to move residents regularly and a failure to inspect and provide skin care all contribute. It is a cause of unnecessary suffering and death.

Residents’ skin integrity needs are not consistently identified and met. Residents’ pressure area care needs are not consistently provided for with appropriate pressure relieving devices. The service has failed to provide specified care and services such as air mattresses to those residents who have an identified need. Relatives have been asked to hire or buy pressure relieving devices such as air mattresses and air cushions. Residents’ pedicure needs have not been consistently met.
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A resident was found by their relative to have their toenails growing across their feet, digging in and causing pain and difficulty walking. This was documented on an improvement log in August 2004. Other residents and relatives commented that the podiatrist rarely visits and only attends a few residents.

Behavioural management Non Comp Comp

Residents’ individual behavioural management needs are not consistently assessed, documented and reviewed.
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There is no provision for detailing triggers for behaviours so that behaviours may be prevented or minimised. The progress notes are not used to describe what happened and there were no detailed behavioural assessments in the files that described actual behaviours to aid correct identification of challenging behaviours. Residents have been identified as having challenging behaviours when their general condition may have caused them to behave in certain ways. For example, residents with painful conditions have been identified as ‘verbally disruptive’ and ‘attention seeking and demanding’. A resident who is vocal regarding their rights and the rights of others is identified as ‘attempting to control and dominate staff/other residents or family and friends’.

Sleep Non Comp Comp

Residents’ sleep care needs are not consistently assessed, documented and reviewed. Residents’ assessments document sleeping patterns following admission but do not consistently document individual sleep preparation routines, daytime naps and individual preferences for settling.
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Residents’ preferences for settling such as night time drinks and snacks are not consistently documented on the assessments and where they are, they are not consistently transferred to the care plans (sleep management plan).
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Five of the residents’ assessed needs/preferences for settling and sleeping were not transferred from the assessments to the care plans.

Standard 3: Resident Lifestyle

The nursing home is the residents home, the only one they have. Not only are they entitled to individualised care but this is the context in which they will live out their social selves and give meaning to their lives. The environment should facilitate this with friendly interaction and social activities.

Continuous improvement Non Comp Non-Comp

Amity at Caulfield does not have a framework that assists it to actively pursue continuous improvement. While audits are conducted for expected outcomes across all of the Accreditation Standards, actions taken to address identified issues are not always effective in correcting areas of non-compliance. Suggestions and complaints have not been actioned or responded to. Results of continuous improvement activities do not show improvements for residents and other stakeholders.

Unresolved improvement logs are located at reception and are freely available to the public. Examples of these include:

• 20 August 2004: A relative wrote that their loved one:
  • Cannot reach the call bell.
  • Needs a new television remote control and this has been requested ‘at least 3 times’.
  • Drinks black tea but has been given white tea ‘of late’.
  • ‘Please ensure that her reading glasses are cleaned daily’.
• 29 August 2004: A relative expressed concerns about a pressure sore on their mother’s bottom and asked whether their mother was being turned often enough at night. The relative wrote that they were concerned because a pressure sore on their mother’s heel had taken six months to heal.

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A resident and representative satisfaction survey was conducted in June 2004. Respondents identified the following issues:

• ‘Residents’ idiosyncrasies need to be recorded in resident folders so staff know how to deal with issues’.
• Insufficient activities are provided.
• ‘[Resident] has presented with various cuts and abrasions and I have not been told, nor have I been able to find out how they occurred’.
• ‘When there have been care or health issues we have pointed out, we have never had a follow up phone call and find it difficult to find out what, if any, action was taken’.

The team was unable to determine whether any action had been taken to address any of the issues.

Privacy and dignity Non-Compliant Non-Compliant

When residents are ware-housed they are stripped of privacy and dignity as they are processed by overworked staff.

Residents’ privacy, dignity and confidentiality is not recognised or respected and residents’ dignity is compromised by staff practices. Residents and relatives advised that they are not treated in ways that accord with their individual needs and preferences.
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A relative said that their mother’s dignity is not recognised or respected and that there are often food spills on their mother’s clothing, which are not cleaned off. The relative showed the team two articles of clothing with stains and said that this occurred on a daily basis. The relative said that one day when they visited, their mother’s hair was done in a style that the resident never wears, with no dentures in and the bathroom ‘stunk’.

A relative reported that staff often refer to their mother as ‘she’. While the team were talking with the relative, a staff member approached and asked the relative, ‘Where is she?’ The relative asked, ‘Who is she? Do you mean my mother?’
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The team observed a resident in the dining room on the second day of the review audit. The resident had food dribbling from their mouth, the team did not sight any intervention.

The resident agreement states that a spa bath is available to residents and a resident reported that the spa is highlighted on the tour given to prospective residents. The spa is located in the middle of Acacia (the dementia-specific unit). Resident access is limited to Acacia, as a code must be entered on a keypad. Increased traffic into the unit unsettles the residents. The spa bath room is used as a store room for equipment, such as overbed tables, linen skips and lifting machines. A resident said that the spa is of poor design, with one jet at the feet only. The resident said that they had been left alone to use the spa and that the call bell was unable to be reached from the spa bath. The resident reported the issue to manager and was told that residents are not to be left unsupervised while in the spa. The resident said that staff do not have the time to stay with them and it is ‘not really relaxing to have someone standing over you’. The resident said that on the two occasions they had attempted to have a spa:

• The first carer did not know how to use the electronic settings so the resident did not get to have a spa.
• The second carer was able to use the electronic settings but they did not have the time to stay with the resident and he was left alone in the spa.

The resident said that the whole experience was not very therapeutic and ‘definitely not relaxing’.
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There were a number of handwritten notes on the main doors to the residents’ rooms, and inside the residents’ rooms about care requirements. The acting director of nursing stated that the families had put them there. One note was a prompt for staff to give the resident their medication and at what times the medication was to be given. A note on another resident’s bathroom door stated that after showering the resident, the resident needed to be seated into a chair and the call bell was to be placed within the resident’s reach. One resident’s representative stated they put notes up on the door so that staff would know what to do. These notes identified individuals by name and detailed personal care requirements and could be read from areas accessible by the public.

Standard 4: Physical Environment and Safe Systems

Continuous improvement Non Comp Non-Comp

Suggestions and complaints have not been actioned or responded to. Results of continuous improvement activities do not show improvements for residents and other stakeholders.

Unresolved improvement logs are stored in a folder in a reception and are available to the public. Unresolved complaints and requests included:

28 July 2004: Complaints about cleaning standards, namely: overbed tables, fridges in residents’ rooms, rooms, bathrooms, bedrooms, wardrobes and shower chair wheels.

31 July 2004: The kitchen was left in a mess and afternoon tea was not provided to residents as a result.

5 August 2004: A confidential log stating that the plates and food were cold.

12 August 2004: A request for more kylies, as ‘quite a few’ do not have material attached to them to tuck into the beds. ‘Residents are sliding on their kylies whilst they are in bed’.

14 August 2004: A residents’ room was not cleaned, despite the fact that the cleaning stand had been set up outside the door. A recorded action indicated that the room was due to be cleaned on 16 August 2004.

15 August 2004: Afternoon tea was served at 4:45pm. The evening meal is served at 5pm.

28 August 2004: A request for glass or perspex in the door to Acacia (the dementia-specific unit), following a resident being ‘knocked over’ as a carer entered the unit, as the peephole is ‘not satisfactory’.

31 August 2004: A comment by a staff member regarding black bags ‘full of dirty pads’ two days running next to the lounge and pan rooms in Acacia. The staff member stated that they had reported this to the registered nurse on duty on 30 August 2004.

4 September 2004: Concerns regarding furniture being ‘covered in dust’ in Acacia and accumulations of dust under beds, on skirting boards and on the bed head.

7 September 2004: ‘A couple of residents on vitamised diets have commented that they seem to receive the same or similar meals for lunch & dinner.’ The meal offered to residents on vitamised diets is not the same as that offered to those on regular meals. ‘It would also be good if we could tell the residents what their vitamised meal is. ie. Beef, lamb, what the vegies are etc’.

Living environment Non Comp Comp

Management has not ensured that residents’ safety and comfort is consistently delivered in accordance with their assessed needs. Alternatives to restraint are not trialled or documented and management was not aware of the number of residents who have chemical restraint.

The service has a policy of minimal restraint and has policies and procedures in place that are not being implemented.
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The residents’ files do not have the reason for restraint consistently documented on the care plans or in the progress notes and there is no ongoing review and evaluation of the effectiveness of the management plan or use of restraint. There is no documentation to suggest that the residents are monitored for ‘adverse effect of medication or tolerance’.

Residents who are having chemical restraint did not have trials of alternatives documented and there was no restraint authorisation documented as required by the service’s policy and procedure. Risk assessments had been documented, however, these do not document trialling of alternatives and there is no documentation regarding consultation about the use of chemical restraint.

Catering, cleaning and laundry services Non Comp Non-Comp

The assessors were particularly critical of food handling practices which they described at length. It is too long and complex to reproduce here.

Residents’ quality of life is not enhanced by current catering cleaning and laundry practices due to lack of resources, staff supervision and training.
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On 1 September 2004 and during the review audit the team observed that linen to make a resident’s bed was stored at the bottom of their wardrobe. A relative stated that the carers always put the linen there, and they have to give it to the laundry staff to rewash. The relative stated there are not enough towels for the residents and they have to take towels home to wash them for the resident’s use the next day. Laundry staff stated that they do rewash a lot of linen that has been stored incorrectly, and often have to do an extra towel cycle in the afternoons to make sure there are enough towels for the next day. Management supplied additional towels and face washers on the first day of the review audit. These were washed and put into circulation during the review audit. The team observed staff taking linen around to residents’ rooms in the afternoons.

Assessment team’s recommendation regarding accreditation

The assessment team recommends that the Aged Care Standards and Accreditation Agency Ltd not revoke the accreditation of Amity at Caulfield.

The assessment team recommends that the period of accreditation be varied.

For Updates:- A good way to check for recent developments in aged care is to go to the aged care crisis group's search page and enter the name of the company, nursing home or key words relating to any other matter in the search box. Most significant press reports are flagged there. The aged care crisis web site has recently been restructured and some of the older links used from this site may not work.

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Web Page History This page created Sept 2006 by Michael Wynne