A Complete Schedule of Services.
A detailed schedule of the care provided in our homes: personal care and activities of daily living, instrumental activities of daily living, medication administration and documentation, nutrition and dysphagia management, memory and behavioural support, individual service planning, and the clinical records maintained for each resident.
Range of Need We Accommodate
A single home accommodates residents at materially different acuity levels. It is the individual service plan that changes, not the placement, so a resident whose condition progresses is not required to relocate or transfer to unfamiliar caregivers.
Supervision and Standby Assistance
Indicated for residents requiring supervision, medication administration, meal provision and standby or intermittent assistance, but not continuous hands-on support. The resident retains independent performance of most activities of daily living with cueing and oversight.
Full Personal Care Assistance
Indicated for residents requiring hands-on assistance across multiple activities of daily living, including bathing, dressing, toileting, transfers and oral intake. Full assistance is available for every ADL, with two-person assist and mechanical transfer assessed individually.
Memory and Behavioural Support
Indicated for residents with Alzheimer's disease or other dementias, including those presenting exit-seeking behaviour, nocturnal agitation or significant disorientation. Delivered by a small, consistent caregiving team in a low-stimulation home with structured routine and close supervision.
Respite and Short-Term Placement
Short-duration placement during family caregiver hospitalisation, surgery, travel or planned respite, and for individuals requiring a supervised interim setting between hospital discharge and return home. Subject to availability; the same assessment and service planning process applies.
Activities of Daily Living (ADLs)
Full assistance is available for each ADL below. The level provided is determined by assessment and recorded in the individual service plan as independent, supervision or cueing, limited assistance, extensive assistance, or total dependence, and is charted each shift. Assistance is deliberately calibrated to retained ability: residents perform the components of a task they remain capable of performing, since support exceeding assessed need accelerates functional decline.
Bathing and Personal Hygiene
Showering or bathing at the frequency and time of day specified in the service plan, with assistance ranging from standby supervision to total care. Includes hair washing, shaving, oral and denture care, nail care, perineal care and application of prescribed topical preparations.
- Skin integrity assessed at every bath, with pressure areas, skin tears, bruising, rashes and oedema documented and reported
- Shower chairs, transfer benches, grab bars and handheld fixtures used as required
- Bed baths provided where a resident cannot safely be transferred
- Refusal of care documented, with re-approach at a later interval rather than escalation
Dressing and Grooming
Assistance selecting season-appropriate clothing and physical assistance with dressing and undressing, including adaptive clothing, compression stockings, orthotics, splints and prosthetics applied per order. Residents select their own clothing.
Toileting and Continence Management
Scheduled and as-needed toileting, transfers on and off the toilet, and full continence care including incontinence briefs, perineal hygiene and barrier cream application. Toileting and elimination patterns are documented.
- Scheduled toileting programmes implemented where indicated
- Bowel and bladder patterns charted; constipation and retention escalated to the prescriber
- Catheter and ostomy care provided within scope, coordinated with home health where a nursing order applies
- Change in continence status treated as a potential indicator of urinary tract infection or delirium and reported
Eating and Oral Intake
Assistance graded from meal set-up and verbal cueing through partial feeding assistance to total feeding assistance, provided at the resident's pace and in accordance with any dysphagia precautions. Residents are positioned upright for intake and for the interval afterwards specified in their plan.
- Percentage of meal consumed and fluid intake documented at each meal where ordered
- Aspiration precautions observed, including upright positioning, small bolus size and verbal pacing
- Adaptive utensils, plate guards, nosey cups and weighted cutlery supplied as required
- Sustained reduction in intake reported to the family and the prescriber
Mobility, Transfers and Positioning
Ambulation assistance, transfers between bed, chair, wheelchair and toilet, and repositioning for residents unable to shift independently. Transfer status independent, one-person assist, two-person assist, or mechanical lift is assessed prior to admission and reassessed on any change in condition.
- Gait belts, walkers, canes, wheelchairs and mechanical lift equipment used per assessed transfer status
- Repositioning at prescribed intervals for residents at risk of pressure injury
- Fall risk assessed on admission and after any fall, with environmental modification implemented
- All falls documented as incidents, with post-fall assessment, family notification and prescriber report
- Homes are wheelchair accessible throughout
Overnight Care and Sleep Monitoring
Staff remain on site overnight. Residents requiring repositioning, toileting assistance, reassurance on waking disoriented, or documented sleep monitoring are checked at the intervals specified in their service plan, and those checks are recorded so that any change in sleep pattern is identifiable rather than anecdotal.
Instrumental Activities of Daily Living (IADLs)
IADLs are the higher-order tasks required to sustain an independent household. Loss of IADL function typically precedes ADL decline and is frequently what renders remaining at home unsafe. Each is assumed by the home on admission, with residents retaining participation wherever they are able and wish to.
Medication Management
Complete assumption of ordering, storage, administration and documentation, set out in full in the following section.
Meal Planning and Preparation
Menu planning, grocery procurement, and preparation of all meals and snacks in the home to each resident's prescribed diet and texture specification.
Housekeeping and Laundry
Routine cleaning of resident rooms and shared areas, bed linen changes, and personal laundry washed, dried and returned to the resident's room. Infection control practice is observed in the handling of soiled linen.
Transportation and Appointment Coordination
Scheduling of medical appointments, transport to and from them, and accompaniment where a resident is unable to report their own history or retain clinical instruction. Instructions received are transcribed into the record and implemented on return.
Personal Funds and Purchasing
Where a resident or guardian requests it, personal spending money is held and disbursed against an itemised ledger with retained receipts, reconciled and available to the resident, family or guardian on request. Residents retain control of their own funds wherever capacity permits.
Communication and Correspondence
Assistance with phone and video contact with family, management of incoming mail where requested, and support to residents with hearing, vision or expressive language impairment in making themselves understood.
Shopping and Personal Supplies
Procurement of personal care items, incontinence supplies, clothing and requested personal purchases, coordinated with the family or guardian.
Health System Navigation
Coordination across primary care, specialists, therapy providers, home health, hospice, pharmacy, durable medical equipment suppliers, insurers and case management, so that responsibility for follow-through does not fall to the family.
Medication Management and the eMAR
Medication administration is documented on an electronic medication administration record at the point of administration, not reconstructed at end of shift. Each entry records the medication, dose, route, time, administering staff member and outcome: administered, refused, held or unavailable with a reason recorded for anything other than administration.
Administration
- Scheduled and as-needed (PRN) medications administered per prescriber order, with indication and post-administration effect documented for every PRN dose
- Oral, topical, ophthalmic, otic, inhaled, transdermal, rectal and injectable routes administered within scope of practice and applicable delegation
- Insulin administration and blood glucose monitoring per order, with results recorded and out-of-range values escalated
- Time-critical regimens Parkinson's medications, anticoagulants, insulin administered within the prescribed window
- Crushing, splitting or administration with food undertaken only where permitted for that formulation
Documentation, Reconciliation and Controls
- Medication reconciliation performed on admission, on return from any hospitalisation or emergency department visit, and on every prescriber change
- Prescriber orders transcribed to the record and verified before first administration
- Controlled substances stored under separate lock with count records maintained
- Medication errors, omissions and near-misses documented as incidents, reported to the prescriber and to the family or guardian, and reviewed
- Discontinued medications removed from the active record and destroyed or returned per policy
- Refusals documented with re-approach, and persistent refusal reported to the prescriber rather than absorbed
Pharmacy and Supply
Refills are tracked in advance of exhaustion rather than at the point of running out. We coordinate directly with the resident's pharmacy on dispensing, blister or multi-dose packaging, delivery, prior authorisation and formulary substitution, and advise the prescriber where a substitution carries clinical implications.
Adverse Effects and Monitoring
Staff observe for and report the adverse effects associated with each resident's regimen, including sedation, orthostatic hypotension, confusion, gastrointestinal upset, bleeding, rash and extrapyramidal symptoms. New-onset confusion, falls, lethargy or appetite loss following a medication change is treated as potentially medication-related and reported to the prescriber.
Dementia Care and Behaviour Support
Memory care delivered at a four-resident ratio differs materially from memory care in a large unit: controlled ambient stimulation, a consistent caregiving team, and staff proximity sufficient to permit redirection before agitation escalates. Non-pharmacological intervention is the first-line approach.
Environmental and Routine Intervention
Consistent caregivers, an invariant daily sequence, meals at fixed times, familiar personal objects in the room, controlled noise and lighting, and orientation cues. Predictability is more effective in reducing anxiety and resistance than intervention after the fact.
Behaviour Support Plans
Where a resident has a written behaviour support plan, it is implemented consistently across every caregiver and every shift. Antecedents, behaviours and consequences are charted against the plan so that triggers can be identified, interventions evaluated for efficacy, and the plan revised on evidence rather than impression. Charting is available to the prescriber, the case manager and the family.
Presentations Managed
- Agitation, restlessness and sundowning
- Exit-seeking and wandering, managed through close staff proximity and environmental design
- Resistance to personal care and medication
- Repetitive vocalisation and questioning
- Disorientation, hallucination and delusional belief
- Sleep-wake cycle disturbance
Redirection, reassurance and modification of the environment precede any pharmacological response. Acute change in behaviour is investigated for a medical cause , infection, pain, constipation, dehydration or medication effect before being attributed to dementia progression.
Dignity in Delivery
Personal care is provided privately and without haste. Residents are not corrected in the presence of others, and staff do not contest a resident's stated belief where doing so would cause distress. Physical and chemical restraint are not used as a substitute for supervision.
Assessment, Service Planning and Clinical Documentation
Care is not delivered from memory. Every resident is admitted under a written individual service plan and supported by a maintained clinical record. The documents below are prepared and held by the home for each resident.
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Pre-admission Assessment
Review of diagnoses, medication regimen, ADL and IADL status, transfer and fall risk, cognition, behaviour, dietary and swallowing requirements, continence, sensory impairment, communication needs, advance directives and funding. Drawn from referral documentation, family-reported history and direct assessment of the individual. Placements the home cannot safely support are declined at this stage.
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Individual Service Plan
Completed prior to admission. Specifies the assistance required for each ADL and IADL, the medication regimen, diet and texture orders, transfer status and equipment, monitoring parameters, behavioural approaches, emergency contacts, advance directive status, and the personal preferences that support successful adjustment.
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Admission and Service Agreement
A written agreement setting out the services provided, the fee and what it includes, house expectations, resident rights, the grievance procedure, and the circumstances under which a placement may end.
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Ongoing Documentation
Daily ADL charting, medication administration entries, intake and output where ordered, sleep and behaviour logs, progress notes, incident reports, weight and vital sign records, and a communication log recording contact with families, prescribers and case managers.
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Scheduled and Triggered Review
Service plans are reviewed on a scheduled basis and immediately following any hospitalisation, fall, significant weight change, medication change, new diagnosis or observed decline. Families, guardians and case managers participate in review.
Records Maintained for Each Resident
- Individual service plan and assessment history
- Electronic medication administration record (eMAR)
- Daily ADL and personal care documentation
- Behaviour and sleep tracking, where indicated
- Progress notes and change-in-condition records
- Incident and accident reports
- Physician orders and appointment outcomes
- Advance directives, DNR and POLST documentation
- Personal funds ledger, where the home holds funds
- Family and case manager communication log
Documentation Requested at Referral
Supplied by the referring organisation or family where available. A missing document does not preclude a referral.
- Health insurance and Medicare or Medicaid identification
- Individual service plan (ISP) from the current provider
- Behaviour support plan (BSP), where one exists
- Recent hospital or facility discharge summary
- Current medication list and physician orders
- Functional assessment and diagnoses
- Guardianship or power of attorney documentation
- Advance directives, DNR or POLST
- Tuberculosis screening results
The Home and Daily Life
Accommodation
- Private furnished bedroom
- Residents may paint and decorate
- Personal furniture and belongings admitted
- Cable television and internet access
- Maximum of four residents per home
Household Services
- Housekeeping and room cleaning
- Personal laundry and linen service
- All meals, snacks and beverages
- Shared living and dining areas
- 24-hour on-site staffing
Access and Safety
- Wheelchair accessible throughout
- Adapted bathing and toileting facilities
- Resident and visitor parking
- Fire safety and evacuation procedures
- Staff on site around the clock for continuous supervision
Engagement and Activity
Activity reflects ordinary domestic life rather than a fixed programme: participation in household tasks where a resident wishes it, music, television and radio, games and puzzles, time outdoors in suitable weather, and conversation at mealtimes. Engagement is documented where it forms part of a behavioural or cognitive care approach. Residents who prefer solitude are not required to join group activity.
Visiting and Community Contact
Visiting is not restricted to fixed hours. Families are welcome to visit, share a meal or take a resident out. Clergy, hospice teams, therapists, case managers, friends and volunteers are received in the home. Continued contact with the wider community is a component of care rather than an interruption to it.
Provided Within the Placement
- Private furnished accommodation
- All meals, snacks and therapeutic or texture-modified diets
- Assistance with all activities of daily living
- Instrumental activities of daily living, as set out above
- Medication administration, documentation and pharmacy coordination
- Housekeeping, laundry and linen service
- 24-hour supervision including overnight staffing
- Transportation to medical appointments
- Assessment, service planning and clinical documentation
- Care coordination with providers, case managers and family
Billed or Provided Externally
- Physician, specialist, dental, vision and podiatry services
- Prescription costs, medical supplies and durable medical equipment
- Physical, occupational and speech therapy
- Home health nursing beyond the hours a licensed adult family home may provide
- Hospice and palliative services
- Personal spending money and personal purchases
Each of these is coordinated by the home, and providers may attend residents on site. Cost and coverage depend on the individual's insurance and funding arrangements, which are reviewed with the family or case manager directly.
Questions from Case Managers and Families
What acuity level can you accept?
Full assistance with every activity of daily living, medication administration including injectables and blood glucose monitoring, texture-modified diets and dysphagia precautions, full continence care, mechanical transfer subject to assessment, memory and behavioural support, and behaviour support plan implementation. Beyond room and board, a licensed adult family home may provide up to seven hours of nursing care per resident per week. Acuity beyond that threshold requires skilled nursing placement, and we identify it at assessment.
How is medication administration documented?
On an electronic medication administration record completed at the point of administration, capturing medication, dose, route, time, administering staff member and outcome. PRN administration additionally records indication and effect. Reconciliation is performed on admission, after any hospitalisation, and on every prescriber change. Errors and omissions are documented as incidents and reported to the prescriber and the family or guardian.
Is the home staffed overnight?
Yes. Staff remain on site overnight, and residents requiring repositioning, toileting assistance or sleep monitoring are checked at the intervals specified in their service plan, with those checks documented. Specific arrangements vary by home and by the acuity of the residents in residence; please enquire regarding the home under consideration.
Will you accept a resident who wanders or exit-seeks?
In many cases, this is the indication for our memory and behavioural support approach. Suitability is determined individually. Exit-seeking, nocturnal agitation, physical aggression toward others and elopement history are each assessed prior to placement to establish that the home is safe for the individual and for the other residents.
Can a resident remain in the home on hospice?
Yes. Residents may remain in place while receiving hospice services, with the home working alongside the hospice team and following the hospice plan of care. Continuity of environment and caregiver at end of life is of considerable clinical and personal benefit, and avoiding an unnecessary transfer is generally in the resident's interest.
What happens when a resident's needs increase?
The service plan is reassessed and revised, and the level of assistance provided increases accordingly substantially, in most cases, without any change of placement. Where a resident comes to require care beyond the scope of a licensed adult family home, we advise the family and case manager early and assist in planning an orderly transition rather than deferring to a crisis.
How are families and case managers kept informed?
Updates are provided at an agreed frequency by phone or email, with immediate notification of any significant change in condition, a fall, an acute illness, a hospitalisation, a medication change, or a sustained change in intake, mood or function. Contact is recorded in the resident's communication log.
Discuss a Placement
We will advise whether an individual's needs can be met in our homes, and set out what that placement would involve.