Strathearn Village's due diligence to address several quality of care issues has paid off over the past few months.
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The Village's High Care Facility recently received full accreditation after meeting all 44 expected standard outcomes.
This showed drastic improvement since an audit in July.
When the Australian Aged Care Quality Agency conducted the earlier inspection, it reported that the facility had not met 12 of the necessary requirements.
Strathearn was notified that a failure to meet one or more expected outcomes in the accreditation standards had placed, or may place, the safety, health or well being of a care recipient at serious risk.
According to the audit, some of the standards not met included continuous improvement, clinical care, pain management, palliative care, nutrition and hydration, skin care, behavioural management, and mobility, dexterity and rehabilitation.
CEO Matt Downie said all prior areas of concern had now been rectified.
"They [Australian Aged Care Quality Agency] found a number of issues around care documentation that we should be improving upon," he said.
"We worked through those in conjunction with the Quality Agency over three months and also engaged external consultants to work through the process.
"That essentially concluded in early October; all of the areas identified were resolved.
"Basically, the High Care Facility issues came down to documentation gaps.
"Staff were taking steps to address something but, because it sometimes wasn't documented, the reviewer didn't know.
"It does put more of an onus on staff to document what is done, and we've made changes to improve our response to that."
Mr Downie added the Quality Agency had also been to inspect the Strathearn House facility this week.
He was confident of receiving a positive report.
"They were here on Tuesday and, although we haven't got the report yet, we've received verbal confirmation that all areas were met," he said.
"We were given plenty of praise, particularly in relation to our food and dining area."
