SummitCare Canley Vales Approach to Unannounced Assessment Contact/Accreditation Visits

The leadership team at SummitCare Canley Vales philosophy in being prepared for Unannounced Assessment contact/Accreditation visits is to expect to receive one every single day. This can be challenging when unexpected things occur on a day to day basis, and these can range from unanticipated changes in the care needs of our residents to staffing issues. 


Looking after our Residents is our top priority, followed by supporting their families and their loved ones. This means we have to make sure all our systems and processes are current, up to date and followed by all staff and are firmly embedded into the way things are done at SummitCare Canley Vale.


The Manager of Care and Services elaborates below on her experiences in; the SummitCare feedback management systems, including complaints management, personal developments and staff training, nutrition and menus and of course their recent unannounced agency visit and their QPS telephone survey results. 

 Edition 68 SC 1 WarmthWorthWellbeingRound

One of the stand-out differences noticed by the Assessors who have visited SummitCare Canley Vale recently was the warmth and welcoming attitude of staff. Assessors from various visits have unanimously fed back to us that staff members have been visible and readily available to answer questions and have not shied away from showing them around and seeking answers for them as required. This is an important impression and starts with the person who opens the front door at the commencement of their visit and carries through to the team, demonstrating a culture of openness and support.


There is also a high focus on the resident’s perception of how their care needs and expectations are met. It is important to ensure that we have the correct systems and processes in place and that these are being followed. Our core purpose is to ensure the holistic approach to the wellness of our residents.



The residents are the foundation of everything we do at SummitCare Canley Vale.


Our recent Consumer Experience Survey highlighted to Assessors how well we capture information from our residents and translate it into making a positive impact on their daily lives.


Canley Vale has a highly effective complaints management system that particularly focuses on the cultural diversity at Canley Vale. Generally, in the Asian culture, raising concerns or complaints is stigmatised and therefore uncommon so when they do raise issues of any kind, we must act promptly and acknowledge their complaint. Not all can be resolved as quickly but keeping communication transparent and constant enables us to promote an open and communication style and partnership approach.


SummitCare has a very robust Feedback Management System. Feedback Management training is mandated for all staff at Canley Vale and across all SummitCare homes. This has been instrumental in changing the perception of Resident and their families feedback among staff. The team at Canley see the value of feedback, encourage it, embrace it, and realise it as an opportunity for continued improvement.


It is important that all staff across all disciplines are aware of the processes relating to the handling of feedback, even if they are not involved in the entire process, as this provides clarity in their role and responsibility for managing feedback at the most critical moment - the receipt of the comment. No concern is too big or too small and as we constantly endeavour to provide the best possible experience for our residents and their families, all feedback is valued equally.


During the unannounced visits from the Aged Care Quality Agency, the Assessors showed interest in the menus, food preparation and the meals themselves.  The Assessors engaged with residents and relatives asking questions like; what they thought of the food “food is fresh and smells nice”- very positive feedback from residents and relatives. It should be noted that SummitCare Canley Vale has a strong Asian culture but the menu is varied as we need to cater to all other cultures within our home. The outcome of having choices and a varied menu is excellent with our residents of Asian backgrounds liking Western food and all residents also enjoying the Asian menu.


Given the complexity of such a versatile demographic of residents at SummitCare Canley Vale, it is imperative that their individual choices are captured and respected. The team members responsible for the menus are invited and encouraged to be innovative in their work and do an incredible job of managing the challenges of catering to a variety of personal and cultural preferences whilst also ensuring the nutritional needs of Residents are met.


It is also important to consider the value of meal time. The delivery of meals is just as personal as the meal itself. One Assessor provided feedback that “it was great to see that not all residents were wearing clothing protectors, only those who needed or requested one” and commented on the positive interaction between staff and residents for the duration of the meal.


Clinical Results

SummitCare Canley Vales most recent contacts with the Quality Agency in both Announced and Unannounced visits have resulted in all 44 outcomes being met and exceeded - a testament to the leadership team. The visits had a strong focus on nutrition and hydration, skin care, behaviour management, and specialised nursing care. The need for good quality assessments, care plans, and contemporaneous documentation cannot be underestimated here, however the most telling evidence of the centres ability to meet these needs is of course the residents themselves. 


Utilising the QPS Benchmarking monthly and quarterly clinical indicator and audit results in addition to SummitCare’s own regular Care Management and Quality Systems provide a great way of identifying which clinical areas need particular attention and for which residents. In order to achieve excellence in Clinical Governance it is important to have a robust system for collecting and analysing data, and for developing and evaluating consequent action plans.


As a Care Manager or an RN supervising care it has proven extremely helpful having good oversight of all Residents and their care requirements. This is an area which has strengthened over time at SummitCare Canley Vale and continues to do so by building and nurturing a culture of trust, support and respect among staff, so that staff can be confident that their questions, suggestions and shared knowledge is welcomed and appreciated. Taking ownership of how your team perform and committing to their professional development not only empowers staff, but ultimately benefits residents through improved practices.


Survey Results - Residents and Relatives 

Edition 68 SC 2 Canley Vale

Canley Vale achieved an Employee Survey response rate of 93.55% and a 95.08% Relative Survey response rate demonstrating strong relationships.

As previously mentioned SummitCare Canley Vale values all feedback and is committed to seizing any, and all opportunities for improvement. We encourage this through a number of channels including;

 QPS Benchmarking Resident and Relative Experience Surveys, monthly induction meeting for new families and much more.  Although surveys are not mandatory for residents or their relatives to participate, we strongly encourage participation for this reason. We dedicate additional resources to achieving this by having our multilingual members of staff available to assist residents and relatives with understanding the survey questions and its purpose. The team at QPS have also been very versatile and sensitive to the needs of our cohort, working with our home, residents and their relatives so that CALD individuals can also be included. Over the last couple of years, we have been able to successfully improve the inclusion of our Asian residents giving a greater voice to those who historically have been culturally disinclined to offer feedback.


Employee Survey Results

Participation in the employee satisfaction survey has been increasing, this can be attributed to the growing culture of empowerment and supportiveness for staff. As a management team we recognise the immense value that all of our staff have to offer and understand how important it is that every member of the team feels heard and supported. Our doors are always open and as we do with residents and relatives, we always encourage staff to give feedback. With time and persistence, we have seen a shift in the culture of our staff, as they are more and more forthcoming and engaged, and they more readily contribute to feedback mechanisms such as the employee satisfaction survey.


We maintain that we are not perfect by any means and therefore cannot afford to be precious. Constructive criticism is embraced and equal respect is offered to everyone.


Take Home Message

Following contact with the Aged Care Quality Agency, one thing has been clear: we are on the same team and share a common objective - the BEST outcomes for our residents and families.  Each visit has provided an exciting opportunity to share the innovative ways we strive to achieve this. We are so strongly motivated by the best interests of our residents that a solid understanding and adherence to the systems and processes in place for ensuring optimal care is non-negotiable. Although this can be challenged by the unpredictable nature of aged care it is important to know your strengths and areas for potential improvement and be proactive in addressing the latter.


Being surrounded by a team of like-minded people also makes the world of difference. We are all 100% committed to achieving excellence, being creative and forward-thinking, and unafraid of failure. Because in the end, this will improve the lives of our residents and their families - they are the reasons for everything that we do.


Minh Nguyen, General Manager and Courtney Forrest Care & Services Manager, SummitCare Canley Vale