CLINICAL AGENCY STAFF

ORIENTATION
RESIDENTIAL SERVICES
AGENCY ORIENTATION & INFORMATION
We have provided you with this information so that
you can be informed of the policies and procedures
that are to be followed while you are on duty. We
hope that you will enjoy working here and would be
happy to receive any feedback/suggestions on the
content of this orientation.
SCC is a health promoting organisation
Southern Cross Care supports the World Health
Organisation’s framework for healthy ageing and
embraces opportunities for health and wellness across
the lives of customers and staff. This approach includes
building staff knowledge to support person centered,
healthy ageing of our customers and ensuring a
supportive environment through policies, equipment
and buildings to achieve these goals.
SCC Values
We choose to care, it’s in our nature
Each of us embrace the responsibility of care. In this
way we help create a life-affirming environment where
older people are engaged, vibrant and better for life
Aged Care Quality Standards
Southern Cross Care is required to comply with the Aged Care
Quality Standards. The Quality Standards provide a framework of
core requirements for resident and client quality and safety while
in residential or community care. The Quality Standards have a
strong focus on resident and client outcomes, experiences, choice
and dignity. Southern Cross Care strives to exceed resident and
client expectations by placing them at the centre of everything we
do and by continuing to improve.
Compliance with the Quality Standards is mandatory and all
Southern Cross Care services are required to demonstrate
performance on an ongoing basis to meet Australian Government
requirements. Southern Cross Care’s aim goes beyond the core
requirements to provide optimum outcomes and quality care and
services.
Aged Care Quality Standards
The Aged Care Quality Standards is a
set of eight individual standards and
requirements that focus on outcomes
for residents and clients, evaluation
and continuous improvement.
The Quality Standards are:
1. Consumer dignity and choice
2. Ongoing assessment and planning
with consumers
3. Personal care and clinical care
4. Services and supports for daily
living
5. Organisation’s service environment
6. Feedback and complaints
7. Human resources
8. Organisational governance
Aged Care Quality Standards
Each of the Quality Standards is expressed in three ways:
• a statement of outcome for the consumer
• a statement of expectation for the organisation
• Organisational requirements to demonstrate that the standard
has been met.
Southern Cross Care is expected to demonstrate that we:
• understand the requirement
• apply the requirement, and this is clear in the way we provide
care and services
• monitor how we are applying the requirement and the
outcomes achieved
• review outcomes and adjust practices based on the reviews to
keep improving.
Registered Nurse in Charge (After Hours) In the Absence of the RSM/CM

Registered Nurses In Charge are responsible for the whole site. This
includes staff supervision; ensuring customer wellbeing and health
outcomes are optimised at all times and medical issues are responded
to and treated appropriately.

The Registered Nurse must carry a portable phone and answer all
external calls for the site after hours. Any staff replacements are the
responsibility of the Registered Nurse in charge.

The main door also is connected to a phone. When the door bell is
pressed after hours it will ring on the phone. This is to notify the RN of
individuals wishing to enter the building.

There is a “Nurse In Charge Folder” containing relevant information

regarding residents and contact numbers.
 Agency Registered Nurse Orientation Process
It is the responsibility of the RN going off duty to conduct the orientation for
the oncoming agency RN:
Orientation Process:
Introduction to Key Personnel.
Explanation of the handover sheets (7 day handover sheet and iCare
handover functions).
• Explain the Resident preferred worker Procedure and letter of
agreement. For confidentiality any staff restrictions will be made
available via the RNIC folder.
Tour of the site including:
• Treatment room, location of drug charts, trolley, stock medications,
pharmacy re-ordering procedure, cytotoxic medication
equipment / bins, hypo kit, oxygen cylinders, suction equipment,
dressing folder and dressings.
• Fire Panel, Fire extinguishers and alarms.
• Electrical switchboards & procedure if power failure.
• Call system, operation and responsibilities.
Agency Registered Nurse Orientation (continued)
• Introduce to staff (especially those the agency will be working
with)
• Introduce to residents (where necessary) discreetly provide
resident information as appropriate
• Explanation of keys.
• Combination entry/exit system including codes.
• Offices in each area, location of files and relevant phone
numbers.
• Staff toilet and refreshment facilities.
• Site security procedure.
• Non Smoking information.
• Location of Policies and Procedures / Work tools / Manual and
any other relevant information.
Hazard Identification and Reporting

Hazards exist in every workplace and it is the

identification, reporting and control that helps prevent
incidents.
It is your responsibility to report all identified hazards in
the workplace. This is done via a Hazard/Near Miss
Report Form, which takes only a very short time to
complete. Completed forms should be handed to SCC
Staff so they can be followed up and logged on our
system.
 Injury Reporting
• All injuries are to be reported to the Registered Nurse. The Registered Nurse is expected
to provide any first-aid or other appropriate treatment to the accident victim as
required and ensure that appropriate subsequent care is provided.

• Following the provision of any treatment that may be required, it is the responsibility of
the senior duty person to investigate the circumstances of the injury to determine if any
action is to be taken to correct any hazard/situation so as to prevent a recurrence.

• If any action is taken to eliminate a hazard or potentially unsafe/harmful situation this

must be clearly documented on the injury/illness report form (residents – located on
iCare & staff/visitors available via intranet.)

• Accidents/Incidents are to be reported and documented before the completion of the

duty on which they were sustained.

• Completed Injury/Illness reports are to be completed and handed to SCC staff so they
can be followed up and logged on our system.
Elder Abuse (Reportable Assault)
*Report any allegation / incident of reportable assault to the Site Manager at the
earliest possible convenience to seek advice on what steps to take.

What is a reportable assault?

A reportable assault as defined in the Act (section 63-1AA) means:
unlawful sexual contact with a resident of an aged care home, or
unreasonable use of force on a resident of an aged care home.

Unlawful sexual contact

Unlawful sexual contact refers to non-consensual sexual contact involving residents in
aged care facilities. Reporting requirements under the law are designed to protect
vulnerable residents, not to restrict their sexual freedom. Where the contact involves
residents with an assessed cognitive or mental impairment (refer to below definition),
the resident may not have the ability to provide informed consent, therefore this
should be reported.
Elder Abuse (Reportable Assault)
Unreasonable use of force
Unreasonable use of force as defined in the Act is intended to capture assaults
ranging from deliberate and violent physical attacks on residents to the use of
unwarranted physical force on a resident. This may include hitting, punching or
kicking a resident regardless of whether this causes visible harm, such as bruising.
It is recognised that in the aged care environment, there may be circumstances where
a staff member could be genuinely trying to assist a resident, and despite their best
intentions the resident is injured because the person bruises easily or has fragile skin.
Injury alone therefore may not provide evidence of either the use of unreasonable
force or the seriousness of an assault. However in these circumstances if an allegation
is made a reportable assault form should be lodged within the required timeframe.

The Guide for aged care staff provides more information on how to assess whether
an incident is reportable.

*Refer to the Reportable Assault Procedure on the Intranet.

Missing Residents
Report any active or resolved missing resident incident to the Site Manager at the
earliest possible convenience.
Compulsory reporting of unexplained absences or missing residents is the
responsibility of an approved provider under the Aged Care Act 1997 (the Act).

A resident is considered missing when they are absent and the service is unaware of
any reasons for the absence.
Approved providers should report the missing resident to the police within a
reasonable timeframe so an appropriate response and action can be taken to locate
the resident.

If a resident is absent from the service, the absence is unexplained and the absence
has been reported to the police, approved providers are required to tell the
department about the missing resident within 24 hours of reporting the absence to
the police.

If an approved provider fails to meet compulsory reporting requirements the

department may take compliance action.

*Refer to the Missing Resident Procedure on the Intranet.

Agency Staff Time Slips
An agency staff member is not permitted to sign the time slip
of another agency staff member unless only agency RN is only
available as senior staff member. No shift is to exceed 7.6
hours unless authorised by the Site Manager.

Combination Codes for Secure Areas

Entry and Exit from some areas will require a swipe card / fob.
The code for entry to the secure area Nurse Station will be in
your Site Agency Staff Orientation & Information Booklet.
Entry Code to front door will be in your Site Agency Staff
Orientation & Information Booklet, (changed every 3 mths).
 Medication Management
Medication Charts & Administration
This applies to all nursing and care staff and external health practitioners
(e.g. general practitioners and pharmacists) working within SCC
residential and community setting. The policy expresses the
organisation’s interpretation of applicable legislation and professional
guidelines which promote safe, quality use of medicines and medication
management.
Southern Cross Care (SA&NT) Inc. is committed to engaging all
stakeholders according to their roles and responsibilities in best practice
medication management. The results and outcomes for safe, quality use
of medicines and medication management can be measured via:
• Medication Incident Reports,
• Critical Incidents Reports,
• Medication Audits,
• Medication Competencies.
 Medication Management
MediMap

MediMap is an electronic medication management system. It is used

by:
• The doctor to order, review and change medications
• The Pharmacy to supply medications
• Nursing staff to administer and re-order medications and to
record INR results, blood glucose levels, blood pressure and
sighting transdermal patches

Resources available on Merlin (

https://merlin.southernxc.com.au/systems/medimap-system-hub/)
include MediMap Quick Reference Guide, Frequently Asked
Questions, and MediMap System Hub.
Physical and chemical Restraint (antipsychotics use).
SCC adopts a restraint free approach to limit any use of physical or chemical
restraint.
Most of our homes have limited bed rails and beds are positioned
appropriate to a residents need. e.g. if a resident is walking, the bed would
be tagged and measured to the individuals height and left in this position
(to enable the resident to sit to stand safely).

Although antipsychotic medicines may be appropriate for adults with severe

mental health issues or long term mental illness (e.g. to reduce or eliminate
the distressing symptoms of psychosis, paranoia confused thinking
delusions and hallucinations), there is concern that these medicines are
being prescribed and used in appropriately in people aged 65 years and
over for their sedative effects. This is a form of chemical restraint for people
with psychological and behavioural symptoms of dementia or delirium.
Physical and chemical Restraint (continued).
Behavioural symptoms of dementia must be investigated along with person-
centred and non-pharmacological strategies before psychotropic medication
use, where possible. If any’ prn’ antipsychotic medications are used (this must
be, last resort), this must be the lowest dose and monitored for effectiveness/
adversity and use must be in consulted with the RN on duty.
The RN/EN/PCW’s can support positive behaviour by:
• Establishing a trusting respectful relationship with residents and their
loved ones
• Stopping what you know may trigger or influence changes in any
person’s behaviour
• Anticipating changes that may create concern for a resident – these
changes, and what actions to take, should be clearly identified in the residents
care plan
Antimicrobial Stewardship
Antimicrobial stewardship (AMS) is a range of activities to ensure
antibiotics are used safely and effectively. Antimicrobials include
antibiotics to treat bacterial infections, antivirals to treat viral infections
and antifungals treating fungal infections. The World Health Organisation
refers to antibiotic resistance as one of the greatest threats to human
health.

Health Care Workers have a vital role in preserving the power of

antibiotics. Everyone can be a "steward" to preserve antibiotics by
practicing infection control and undertaking measures to prevent
infections, such as using standard precautions and effective hand
washing, and preventing the need for antibiotics.
Medication Management
Responsibilities:
Registered Nurse– is responsible for:
• Management and administration of all Scheduled, Prescribed
and PRN medication,
• Management of Secure Drug keys,
• Documentation for receipt/disposition of Scheduled Drugs,
• Documentation, monitoring and evaluation processes in relation
to administration.

Enrolled Nurse / Credentialed Staff Member:

• As above under the direction (direct or indirect) of an RN and
subject to the correct labelling and packaging from a qualified
pharmacist.
Medication Management
General principles:
The charts are kept in the Treatment Room of each unit and contain a photograph of each
resident.
Charts are to be signed immediately following your witnessing of the resident taking the
medication.
It is not acceptable to give all medications and then sign for these in all charts at the same time.
It is not acceptable to dispense all medications into pots in the treatment room at once and then
take them out to the residents.
Either the trolley is to be used and taken to each resident or medications given and signed for one
at a time or medications are to be dispensed into pots and then administered to the resident and
signed for before getting the next residents medication ready.
• For detailed information please refer to the following:
• Medication Administration and Management
• Medication PRN administration
• Nurse Initiated Medication Authority
• S8 Medications Administration and Management
• Application and Disposal of S8 Transdermal Patches
• Drug Fridge Monitoring Work Instruction
• Drug Fridge Temperature Chart
• Cytotoxic Management Guidelines / procedure
Imprest Medication
Imprest stock is located in insert dept/site for after hours access. All telephone
orders need to be confirmed with 2nd signatory.
PRN Medication
All PRN medications must be approved by RN before administration by an EN.
All PRN medication must be documented in progress notes regarding the
effect.
PRN analgesia requires a pain evaluation chart to be completed in iCare.
Medication Error Reporting
All appropriate action within professional limitations is to be taken to ensure
the wellbeing of the resident.
The resident’s GP is to be notified of the medication error and observations
commenced if necessary.
A Medication Incident form is to be completed and placed in insert location
out tray.
All medication errors need to be reported in iCare.

*Report any Schedule 8 medication incidents to Site Manager at the earliest

possible convenience.
Pharmacy Re-ordering

Non packed medications can be ordered in each unit using Webster forms.
Please see pharmacy procedure manual for more details regarding
medication requirements.

Night Time Lock-Up / Security Procedure

All external doors will be checked to ensure they are secure at 5pm.
External doors are to be checked by the night Registered Nurse at the
commencement of his/her duty once afternoon staff have vacated the
premises.
All doors to be checked are highlighted on the site plan.
Fire Plan Information
The fire board is located in the reception area and contains site maps
and relevant information including evacuation /assembly points and
identification of emergency coordinator / wardens etc.

This is where the Fire Service will respond if the fire alarm is activated.

**Note: All electronically locked/secured doors will automatically

unlock when the fire alarm is activated – including the front door and
memory support unit.
Phone Numbers
A comprehensive phone list is on the desk in each area.

Internal Phone Numbers

Outside Line dial 0 then the number

To transfer a call from the portable phone, press R then the number required,
then hang up.

External Phone Numbers

Doctors
Each resident’s doctor’s number is located on the front sheet of their file or on
their medication chart. Information is also available under resident details in
iCare
Power Switchboard Procedure
If power is lost, the emergency lighting will automatically switch on.
Bedroom power is automatically lost and hallways are activated. If
the site has a backup generator, this will automatically start and
provide some circuits with emergency power.

There are emergency boxes containing extension leads, phones,

and torches, (see site agency booklet for location).

Oxygen concentrators and air mattresses need to be plugged into

hall ways.

Senior on call must be notified so the maintenance department can

check the fault.
Person Centred Software

Person Centred Software (PCS) is a mobile solution for evidencing direct care
interactions, electronic care planning and reporting. PCS provides a mobile
interactive solution for care planning and monitoring by using a hand held
device to schedule and record care planning and delivery. Care staff record the
care provided and all care interactions through a mobile device, which is
monitored by nursing staff. The system is easy to use and icon driven with
limited need for typing.

All care and service requirements are ‘tasked’ and viewed on the hand held
device and delivered within specific time frames. Resident outcomes and
interactions are documented through ‘real time’ recording on the device,
ensuring information is always current.
Progress Reports
Progress notes are to be written for all residents where there has been an event
or issue that is significant or the interests of the residents or facility will be best
upheld if the matter is documented for future reference. As an indicator, if it is
worth noting on the handover sheets then it is worth noting in the progress
notes. All progress notes are in iCare.

Language will be kept to professional and objective statements with enough

information to allow the reader to fully understand the situation/issue being
described.

All progress notes are to be written in the below format:

Issue
Action
Outcome
Document * (asterix) if ongoing concern or active issue and/or R if
resolved
Progress Reports
For example:
Handover Sheets
iCare Handover
Handover sheets are available through iCare. These
provide a summary of information entered in iCare over
a certain period of time. Details of how to access iCare
handover sheets can be found in the site orientation
booklet.
7 Day handover sheet
Each unit/nurses station has a 7 day handover folder. The 7 day
handover sheet is an A3 document that captures ‘exceptional’
clinical information for each resident over a 7 day view.
The 7 day handover sheet needs to updated at the completion of
each shift.
Alert Form
The Alert form is a paper based tool that complements the 7
day handover sheet located in each nurses station. The alert
form is a tool used for all important changes that need to be
handed over from shift to shift:
e.g. – dietary change, commencement of safety checking,
change in mobility status etc.
Resident Care Plans

Assessment Documentation
All assessment tools are located in iCare.

Wound Management
Treatment records are to be completed following each treatment
provided; treatment records are located in iCare.
In the event that a wound is sustained, a Wound Assessment form
must be generated for the resident; the wound assessment records is
located in iCare.
Wound assessments are to be completed by RN’s only.
Complex wounds require weekly RN review
Safety Checklist
All staff are responsible for adhering to the standards, legislative requirements and
the guidelines documented in Southern Cross Care (SA & NT) Inc. policies and
procedures.
All staff will ensure that care and services are delivered according to the orders as
detailed in the resident’s care plan.
Pagers or call system will not be turned off at any time.
Needles and syringes will be disposed of in the Sharps Container in each Treatment
Room.
Gloves are to be worn when handling blood and body fluids.
Southern Cross Care (SA & NT) Inc. has a centralised manual handling program.
Which clearly defines correct lifting techniques for specific tasks associated with
care.
All slide sheets and mechanical lifters are to be used with 2 staff present at all times.
Any faulty equipment or potential hazards must be reported in maintenance books
located in each area and where possible eliminated.
Place a lock out tag on faulty equipment & remove from service until repaired.
Call Bell Management
Every Personal Care Worker, Enrolled Nurse and Registered Nurse has a Dect. Phone or pager
at all times. Call bell escalations are the responsibility of all staff members.
*If acting as the Registered Nurse in charge, you will need to urgently investigate call bells that are
escalated to your dect.phone (attend the resident in person).
If you are attending to a resident when another resident calls, explain that you are busy with
another resident and give them an indication of how long you will be before attending to their
needs. It is important to respond to the calling resident as soon as possible to ensure their
needs are met.

Call bell escalations are as follows:

PCW – initial call;
PCW – second call (2 mins);
EN (4 mins); and
RN (8 mins).

Please ensure all bells are cancelled on responding, as bell will not register again until
cancelled.

Faults in the Call Bell System/Units

**Any faults in the system should be reported to the Site Manager
immediately
Comments and Complaints
(proactively managing and capturing feedback)

If you receive a comment or complaint, please

complete the verbal feedback log located in each
area.
Site Staff Responsibilities.
The on call RN is to be notified of the following:
• Any security issues – After hours staff are to wear duress alarm at all times. If there
are concerns regarding security or intrusions, press duress alarm immediately, and
the police will attend.
• Any incident involving Elder Abuse
• Any resident who has been found to, or have been reported to wander away from
the facility or to have absconded.
• Any equipment fault (electronic or mechanical) where resident/staff safety is placed
at risk; a hazard/near miss form is to be completed
• Any resident who falls and it results in a head injury, broken or suspected broken
limb, large skin tear, unconscious episode, vomiting or any other injury.
• Any Medication incidents
• Any resident requiring emergency treatment or hospitalisation.
• Any unexpected death of a resident.
• Any serious complaint by a resident, representative or staff member.
• Any request for additional staff, hours, resources or overtime.
• Inability to adequately staff the site
• Staff Misconduct.
 Management of a Resident Death
*Report any planned and /or unexpected death to the Site Manager immediately
to seek advice.

*Refer to the following procedures on the intranet:

Reportable death to the Coroner (if applicable);
Last Offices
Privacy & Confidentiality – our expectations
• Southern Cross Care must comply with the Privacy Act 1988 (Cth)
the Australian Privacy Principles and its professional obligations.
• Our Privacy Policy explains this in detail, and tells you when
resident and customer information can be accessed by, or disclosed
to, others.
• Our Privacy Policy is on the home page of our website at
https://southerncrosscare.com.au/media/W1siZiIsIjIwMTgvMTAvMj
IvNHZqMW1kZjNwYl9Qcml2YWN5X1BvbGljeV9QdWJsaWNfLnBkZiJ
dXQ/Privacy%20Policy%20%28Public%29.pdf
• Southern Cross Care must keep all personal information about
residents, customers and employees strictly confidential.
• As you are a contractor to Southern Cross Care, you are also
required to comply with these privacy obligations.
 Privacy & Confidentiality – our expectations
• It is imperative that you, your staff and any sub-contractors, keep private and
confidential the business of Southern Cross Care, including information regarding
its residents, customers and employees .

• The requirement for maintaining privacy and confidentiality extends beyond the
boundaries of Southern Cross Care, work hours, and your particular engagement.

• As a general rule, you should assume that all information gained during the course
of your work is private and should be treated confidentially.

• If someone requests personal or confidential information from you, ensure you

refer the request to your SCC contact. If in doubt, contact the Residential Services
Manager at the work site.
Consequences of a breach of privacy or confidentiality

• If you release resident, customer or employee information

without authorisation, our organisation might:
 need to report it to the Commonwealth Privacy Commissioner
 need to inform all customers who are impacted
 face a penalty of up to $1.8m if it is a serious data breach
 terminate your engagement
• We are committed to protecting privacy and confidentiality,
which are essential to our Values. It is a strict requirement that
all contractors, their staff and any sub-contractors support this
commitment.