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Charleston Residential Limited

Current Status: 30 October 2013

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified.

General overview

Puriri Court provides residential care for up to 72 residents at rest home and hospital level care. Occupancy on the day of the audit was 60 residents (21 at rest home level care and 38 at hospital level care). The manager has many years management experience in aged care and moved from the assistant manager role to the manager role in February 2013. She is supported by a clinical manager who has been in the role since April 2013. There have been significant improvements in practice around falls management, pressure area risk management, nutrition management, continence management, restraint minimisation and safe practice, organisational management and quality and risk management and staffing. The GP, chaplain, families, residents and staff interviewed all spoke of improvements and an improved organisational culture in the service since the management changes.

This audit has identified no areas requiring improvement.

Audit Summary as at 30 October 2013

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

All standards applicable to this service fully attained with some standards exceeded

No short falls Standards applicable to this service fully attained

Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity

Some standards applicable to this service partially attained and of low risk

A number of shortfalls that require specific action to address

Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk

Indicator Description Definition

Major shortfalls, significant action is needed to achieve the required levels of performance

Some standards applicable to this service unattained and of moderate or high risk

Consumer Rights as at 30 October 2013

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs.

Standards applicable to this service fully attained.

Organisational Management as at 30 October 2013

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner.


Continuum of Service Delivery as at 30 October 2013

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.


Safe and Appropriate Environment as at 30 October 2013

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.


Restraint Minimisation and Safe Practice as at 30 October 2013

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation.


Infection Prevention and Control as at 30 October 2013

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme.


Audit Results as at 30 October 2013

Consumer Rights

Puriri Court strives to ensure that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. Individual preferences including cultural and spiritual needs are catered for. Residents and relatives spoke very positively about care provided by the service and report excellent communication with staff and management. Complaints processes are implemented and complaints and concerns are actively managed and well documented. There has been a reduction in the number of complaints since previous audit.

Organisational Management

Puriri Court has an established quality and risk management system that supports the provision of clinical care and support. Policies and procedures are reviewed regularly and are updated to reflect best practice, legislation and standards. Key components of the quality management system link to the facility's monthly continuous quality improvement and staff meetings. An annual resident and relative satisfaction survey is completed and there are regular resident meetings.

Quality and risk performance is reported across the facility meetings and also to the organisation's management team. Corrective action plans are utilised at Puriri Court to document actions to improve or enhance a current process or system or actions to improve outcomes or efficiencies in the facility. A corrective action plan is developed for every incident and every complaint. There is an active health and safety committee.

The service has in place a comprehensive orientation/induction programme that provides new staff with relevant information for safe work practice. There is a comprehensive in-service training programme covering relevant aspects of care and support that meets requirements.

There is a policy for determining staffing and skill mix for safe service delivery. Staff identified that staffing levels are good, staff turnover is now low and interviews with residents and relatives demonstrated that they have adequate access to staff.

Continuum of Service Delivery

Resident’s needs are assessed prior to entry and following entry the service conducts a thorough assessment process. There is an information pack available for residents/families/whānau at entry. Assessments, care plans and evaluations are completed by registered nurses. Residents and their relatives are involved in planning and evaluating care. Risk assessment tools and monitoring forms are available and implemented and are used to assess the level of risk and support required for residents. Service delivery plans demonstrate service integration and are individualised. Short term care plans are in use for changes in health status. Care plans are evaluated six monthly or more frequently when clinically indicated. The service facilitates access to other medical and non-medical services. Referral documentation is maintained on resident files. The majority of residents receive care from one general practitioner who visits the facility regularly and is in frequent contact with the registered nursing staff.

The two activities coordinators provide both individual and group activities. The programme is very popular with residents and the facility owns a bus and van so that residents can have frequent bus trips per week into the community.

The medicines management system follows recognised standards and guidelines for safe medicines management practice. Controlled drug balances are checked weekly by two registered nurses. Expired medicines are returned to pharmacy and the GP signs and dates discontinued medicines on the residents' medication charts.

All meals are prepared on site. The main meal is served at lunch time. Residents can access additional food overnight. The chefs cater for individual food preferences. Food and refrigeration temperatures are monitored and recorded. Individual and special dietary needs are catered for. Residents and relatives interviewed spoke favourably about the food service.

Safe and Appropriate Environment

The building has a current warrant of fitness. The physical environment is designed to be a homely environment and to minimise the risk of harm. A maintenance manager is on site five days a week and is continually monitoring and servicing the building. The hospital and rest home wings have space to ensure the needs of residents are met. Electrical and medical equipment is checked annually. Residents are able to bring their own possessions and are able to adorn their room as desired. There are documented cleaning and laundry services policies and procedures and all laundry is done on site. There is a plentiful supply of protective equipment, gloves, and aprons for staff. Appropriate training, information, and equipment for responding to emergencies are provided. There is an approved evacuation plan and fire drills are completed six monthly. The facility has civil defence kits and emergency management plans in place.

Restraint Minimisation and Safe Practice

There is a restraint minimisation manual that is applicable to the type and size of the service. The service has significantly reduced restarint use in the past year. There are 16 residents using restraint and six enablers in use. The service has reviewed all restraint documentation and all residents using restraint or enablers have a comprehenisve assessment and ongoing review. Training has been provided to staff around restraint and managing challenging behaviours.

Infection Prevention and Control

The infection control team at Puriri Court is integrated as part of the monthly continuous quality improvement meeting. There are also monthly meetings between the infection control coordinator and the facility manager. The infection control nurse implements the surveillance, organises training and implements and reviews internal audits. There is an infection control register in which all infections are documented monthly. A monthly infection control report is completed. An annual comparative summary and review of the programme is completed.

HealthCERT Aged Residential Care Audit Report (version 3.9)

Introduction

This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.

Audit Report

Legal entity name: Charleston Residential LimitedCertificate name: Puriri Court Rest Home & Hospital

Designated Auditing Agency: Health and Disability Audit New Zealand

Types of audit: Certification

Premises audited: Puriri Court Rest Home & Hospital

Services audited: Rest Home, Hospital

Dates of audit: Start date: 30 October 2013 End date: 31 October 2013

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: 60

Audit Team

Lead Auditor XXXXXX Hours on site

15 Hours off site

7

Other Auditors XXXXXX Total hours on site

15 Total hours off site

7

Technical Experts Total hours on site

Total hours off site

Consumer Auditors Total hours on site

Total hours off site

Peer Reviewer XXXXXX Hours 2

Sample Totals

Total audit hours on site 30 Total audit hours off site 16 Total audit hours 46

Number of residents interviewed 18 Number of staff interviewed 17 Number of managers interviewed 2

Number of residents’ records reviewed

9 Number of staff records reviewed 9 Total number of managers (headcount)

1

Number of medication records reviewed

16 Total number of staff (headcount) 72 Number of relatives interviewed 6

Number of residents’ records reviewed using tracer methodology

2 Number of GPs interviewed 1

Declaration

I, XXXXX, Director of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of the Designated Auditing Agency named on page one of this report (the DAA), an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of the DAA Yes

b) the DAA has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes

c) the DAA has developed the audit summary in this audit report in consultation with the provider Yes

d) this audit report has been approved by the lead auditor named above Yes

e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes

f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Yes

g) the DAA has provided all the information that is relevant to the audit Yes

h) the DAA Auditing Agency has finished editing the document. Yes

Dated Monday, 25 November 2013

Executive Summary of Audit

General OverviewPuriri Court provides residential care for up to 72 residents at rest home and hospital level care. Occupancy on the day of the audit was 60 residents (21 at rest home level care and 38 at hospital level care) . The manager has many years management experience in aged care and moved from the assistant manager role to the manager role in February 2013. She is supported by a clinical manager who has been in the role since April 2013. There have been significant improvements in practice around falls management, pressure area risk management, nutrition management, continence management, restraint minimisation and safe practice, organisational management and quality and risk management and staffing. The GP, chaplian, families, residents and staff interviewed all spoke of improvements and an improved organisational culture in the service since the management changes.This audit has identifed no areas requiring improvement.

Outcome 1.1: Consumer RightsPuriri Court strives to ensure that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. Individual preferences including cultural and spiritual needs are catered for. Residents and relatives spoke very positively about care provided by the service and report excellent communication with staff and management. Complaints processes are implemented and complaints and concerns are actively managed and well documented. There has been a reduction in the number of complaints since previous audit.

Outcome 1.2: Organisational ManagementPuriri Court has an established quality and risk management system that supports the provision of clinical care and support. Policies and procedures are reviewed regularly and are updated to reflect best practice, legislation and standards. Key components of the quality management system link to the facility's monthly continuous quality improvement and staff meetings. An annual resident and relative satisfaction survey is completed and there are regular resident meetings. Quality and risk performance is reported across the facility meetings and also to the organisation's management team. Corrective action plans are utilised at Puriri Court to document actions to improve or enhance a current process or system or actions to improve outcomes or efficiencies in the facility. A corrective action plan is developed for every incident and every complaint. There is an active health and safety committee.The service has in place a comprehensive orientation/induction programme that provides new staff with relevant information for safe work practice. There is a comprehensive in-service training programme covering relevant aspects of care and support that meets requirements. There is a policy for determining staffing and skill mix for safe service delivery. Staff identified that staffing levels are good, staff turnover is now low and interviews with residents and relatives demonstrated that they have adequate access to staff.

Outcome 1.3: Continuum of Service DeliveryResident’s needs are assessed prior to entry and following entry the service conducts a thorough assessment process. There is an information pack available for residents/families/whānau at entry. Assessments, care plans and evaluations are completed by registered nurses. Residents and their relatives are involved in planning and evaluating care. Risk assessment tools and monitoring forms are available and implemented and are used to assess the level of risk and support required for residents. Service delivery plans demonstrate service integration and are individualised. Short term care plans are in use for

changes in health status. Care plans are evaluated six monthly or more frequently when clinically indicated. The service facilitates access to other medical and non-medical services. Referral documentation is maintained on resident files. The majority of residents receive care from one general practitioner who visits the facility regularly and is in frequent contact with the registered nursing staff. The two activities coordinators provide both individual and group activities. The programme is very popular with residents and the facility owns a bus and van so that residents can have frequent bus trips per week into the community. The medicines management system follows recognised standards and guidelines for safe medicines management practice. Controlled drug balances are checked weekly by two registered nurses. Expired medicines are returned to pharmacy and the GP signs and dates discontinued medicines on the residents' medication charts. All meals are prepared on site. The main meal is served at lunch time. Residents can access additional food overnight. The chefs cater for individual food preferences. Food and refrigeration temperatures are monitored and recorded. Individual and special dietary needs are catered for. Residents and relatives interviewed spoke favourably about the food service.

Outcome 1.4: Safe and Appropriate EnvironmentThe building has a current warrant of fitness. The physical environment is designed to be a homely environment and to minimise the risk of harm. A maintenance manager is on site five days a week and is continually monitoring and servicing the building. The hospital and rest home wings have space to ensure the needs of residents are met. Electrical and medical equipment is checked annually. Residents are able to bring their own possessions and are able to adorn their room as desired. There are documented cleaning and laundry services policies and procedures and all laundry is done on site. There is a plentiful supply of protective equipment, gloves, and aprons for staff. Appropriate training, information, and equipment for responding to emergencies are provided. There is an approved evacuation plan and fire drills are completed six monthly. The facility has civil defence kits and emergency management plans in place.

Outcome 2: Restraint Minimisation and Safe PracticeThere is a restraint minimisation manual that is applicable to the type and size of the service. The service has significantly reduced restarint use in the past year. There are 16 residents using restraint and six enablers in use. The servcie has reviewed all restraint documentation and all residents using restraint or enablers have a comprehenisve assessment and ongoing review. Training has been provided to staff around restraint and managing challenging behaviours.

Outcome 3: Infection Prevention and ControlThe infection control team at Puriri Court is integrated as part of the monthly continuous quality improvement meeting. There are also monthly meetings between the infection control coordinator and the facility manager. The infection control nurse implements the surveillance, organises training and implements and reviews internal audits. There is an infection control register in which all infections are documented monthly. A monthly infection control report is completed. An annual comparative summary and review of the programme is completed.

Summary of Attainment

CI FA PA Negligible PA Low PA Moderate PA High PA Critical

Standards 0 50 0 0 0 0 0

Criteria 0 101 0 0 0 0 0

UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited

Standards 0 0 0 0 0 0 0 0

Criteria 0 0 0 0 0 0 0 0

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

Continuous Improvement (CI) Report

Code Name Description Attainment Finding

NZS 8134.1:2008: Health and Disability Services (Core) Standards

Outcome 1.1: Consumer Rights

Consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs.

Standard 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1)Consumers receive services in accordance with consumer rights legislation.

ARC D1.1c; D3.1a ARHSS D1.1c; D3.1a

Attainment and Risk: FA

Evidence:

The code of health and disability rights is incorporated into care. Discussions with five caregivers (three from the hospital and two from the rest home and three registered nurses (one of who is the quality officer) identified their familiarity with the code of rights. A review of care plans and monthly staff meetings confirms that the service functions in a way that complies with the code of rights. Training around the code of rights and complaints was last provided in April 2013 with 18 staff attending. The auditors noted respectful attitudes towards residents on the day of the audit.

Criterion 1.1.1.1 (HDS(C)S.2008:1.1.1.1)Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.


Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2)Consumers are informed of their rights.

ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii


Evidence:

D6, 2 and D16.1b.iii The information pack provided to residents on entry includes how to make a complaint, code of rights pamphlet and advocacy information. Code of rights leaflets are available at the front entrance of the service. Code of rights posters are on the walls in the service. Client right to access advocacy services is identified for residents and families. If necessary, staff will read and explain information to residents as stated by five caregivers (three from the hospital and two from the rest home) and three registered nurses (one from the hospital and one from the rest home and the quality officer) interviewed. Information is also given to next of kin or enduring power of attorney (EPOA) to read to and discuss with the resident in private. Eighteen residents (five from the hospital and 13 from the rest home) and six family members (five from the hospital and one from the rest home) interviewed were able to describe their rights and advocacy services particularly in relation to the complaints process. Discussions with five caregivers and three registered nurses (one of who is the quality officer) identified they are aware of the right for advocacy and how to access and provide advocacy information to residents if needed.

Criterion 1.1.2.3 (HDS(C)S.2008:1.1.2.3)Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.2.4 (HDS(C)S.2008:1.1.2.4)Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3)Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4


Evidence:

D3.1b, d, f, i The service has a philosophy that promotes dignity and respect, quality of life, involving residents in decisions about their care, consultation, encouraging wellness and facilitating mixing with others. The home's mission focuses on providing the highest possible standard of care with respect and dignity. The five caregivers and three registered nurses talk about care being provided with dignity and respect.D14.4 There are clear instructions provided to residents on entry regarding responsibilities of personal belongings in their admission agreement. Personal belongings are expected to be documented and included in resident files and lists were sighted in eight of eight resident files sampled.D4.1a Resident files reviewed (nine of nine) identified that cultural and /or spiritual values, individual preferences are identified and these are discussed at the monthly staff meetings as issues are identified as described by the manager.The service has policies and procedures that are aligned with the requirements of the Privacy Act and Health Information Privacy Code. Residents' support needs are assessed using a holistic approach. The initial and on-going assessment includes gaining details of people’s beliefs and values with the two registered nurses interviewed stating that the care plans are completed with the resident. Interventions to support these are identified and evaluated. Residents are addressed by their preferred name and this is documented in nine of nine files reviewed. A policy is available for the staff to assist them in managing resident practices and/or expressions of intimacy and sexuality (sexuality and intimacy) in an appropriate and discreet manner with strategies documented to manage any inappropriate behaviour. There is one married couple at Puriri Court. They now choose not to share a room but when interviewed report they are always afforded privacy when together. There is a policy that covers abuse and neglect (resident's safety, neglect and abuse prevention and security) and staff have completed training last in June 2013 (19 staff attended). D5.4q There is a spiritual and counselling policy that includes availability of chaplaincy. There is a chaplain who visits the service weekly and when interviewed she reports that suggections she makes are implimented. Discussions with five caregivers and two registered nurses confirm that residents are able to access spiritual support of their preference. During the resident admission, spirituality and religion are discussed and documented. There are visits

by church groups regularly. Eighteen of 18 residents and six of six family members interviewed were able to confirm that their privacy and dignity was respected and staff were observed to be respectful on the day of the audit.

Criterion 1.1.3.1 (HDS(C)S.2008:1.1.3.1)The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.2 (HDS(C)S.2008:1.1.3.2)Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.6 (HDS(C)S.2008:1.1.3.6)Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.7 (HDS(C)S.2008:1.1.3.7)Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.


Evidence:

Finding:

Corrective Action:


Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4)Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i


Evidence:

A3.2 There is a cultural safety policy and a Maori Health Plan including guidelines for the provision of culturally safe services for Maori residents. This includes a description of how they will achieve the requirements set out in A3.1 (a) to (e) with objectives identified. The services' policies and procedures

states that the service will access appropriate Maori cultural advice to support the delivery of care to Maori residents and the manager states that this is through the services Kaumatua. D20.1i The service has developed a link the local iwi through the kaumatua who visits regularly and is available through this service if required. There are currently no residents who identify as Maori. The kaumatua identifes as of Nga Pui descent. Eighteen of 18 residents interviewed do not report any cultural needs but stated they are certain that any cultural needs they may have would be addressed. Family/whanau involvement is encouraged as confirmed by six of six family members interviewed and by the five caregivers and three registered nurses interviewed. Links are established with disability and other community representative groups as directed/requested by the resident/family/whanau as sighted in nine of nine files reviewed. Six of six family members spoke to confirm that their cultural needs are met.

Criterion 1.1.4.2 (HDS(C)S.2008:1.1.4.2)Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.3 (HDS(C)S.2008:1.1.4.3)The organisation plans to ensure Māori receive services commensurate with their needs.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.5 (HDS(C)S.2008:1.1.4.5)The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6)Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d


Evidence:

D3.1g The service provides a culturally appropriate service by asking residents and family members what their cultural needs are at each assessment, plan and review and through links with the community.D4.1c Nine of nine files reviewed included the residents social, spiritual and cultural needs. During the admission process the registered nurse/manager along with the resident complete the documentation as confirmed in interviews with the registered nurse/manager. Six of six family members interviewed felt that they were involved in decision making around the care of the resident.There are no residents who identify as requiring an interpreter. The service philosophy focuses on providing holistic care which is reflected in the individual resident care plan and this could be described by five caregivers and three registered nurses.

Criterion 1.1.6.2 (HDS(C)S.2008:1.1.6.2)The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs.


Evidence:

Finding:

Corrective Action:


Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7)Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e


Evidence:

Discrimination, harassment, professional boundaries and expectations are included in the employment agreement that all staff are required to read and sign before commencing employment. Staff can describe how professional boundaries are maintained. Discussion with the operations manager and a review of the complaints register identify that there have been no complaints regarding alleged harassment. There is a residents safety abuse and neglect prevention policy. Staff are able to describe the process for managing any allegations of abuse or neglect. Education regarding the code of rights and abuse and neglect is provided during the orientation of new staff and is expected to be completed annually as part of the in-service training programme. The registered nurse/manager is required to abide by a professional code of ethics. Discussions with five caregivers and three registered nurses indicate that they are aware of professional boundaries including taking of gifts etc.

Criterion 1.1.7.3 (HDS(C)S.2008:1.1.7.3)Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8)Consumers receive services of an appropriate standard.

ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c


Evidence:

A2.2 Services are provided at Puriri Court that adhere to the health and disability services standards. The service has policies and procedures and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards including those standards relating to the Health and Disability Services (Safety) Act 2001. The service has purchased policies from an independent contractor and these have been reviewed and amended in 2012 and 2013. There is an implemented quality improvement programme with an audit schedule implemented, review of complaints, management of incidents and accidents, documentation of any restraint or enabler use and documentation of infections with infection control surveillance completed.D1.3 All approved service standards are adhered to.D17.7c There are implemented medication competencies for all registered nurses and a training programme implemented. There are clear ethical and professional standards and boundaries within job descriptions.Eighteen of 18 residents and six of six family members interviewed spoke very positively about the care provided.The manager has attended a one day training for managers in 2013. She is able to describe how she is implementing best practice into the service. Initiatives introduced include (but are not limited to): Quality ImprovementThe introduction of a continuous quality improvement team and meeting where quality data, trends, improvements and initiatives are discussed. Meetings are held monthly.

Reduction in accidents/incidents/infections/restraintsFalls have reduced significantly in the last nine months. The service attributes this to increased staff education and awareness and proactive management of residents at risk.

Assessment and Care Planning.Puriri Court have introduced new models of assessment and planning which have reduced all clinical quality indicators at Puriri Court.

RosterFixed rosters have been introduced which has resulted in continuity of care for the residents and enables staff more certainty regarding work/life balance.

Staff interviewed report this as a positive initiative.Where the service identifies and increase in falls etc., they review the roster to identify if staffing needs require adjusting.

Palliative CareA purpose built room has been established to accommodate those who are approaching end of life. This room is large, providing comfort if family wish to stay with their loved one. It is private with a small deck attached. A monitor is positioned over bed to enable skyping to loved ones who cannot be with the resident. Staff who have expressed a desire to work in the area of palliative care are attending hospice training.

ComplaintsThere has been a significant reduction in the number of complaints. The number of compliments has increased.

In addition to the above Puriri Court continue to refurbish the facility.

Criterion 1.1.8.1 (HDS(C)S.2008:1.1.8.1)The service provides an environment that encourages good practice, which should include evidence-based practice.


Evidence:

Finding:

Corrective Action:


Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9)Service providers communicate effectively with consumers and provide an environment conducive to effective communication.

ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 ARHSS A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3


Evidence:

D12.1 Non-Subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so. The

Ministry of Health “Long-term Residential Care in a Rest Home or Hospital – what you need to know” is provided to residents on entry.D16.1b.ii The residents and family are informed prior to entry of the scope of services and any items they have to pay that is not covered by the agreement.D16.4b Six of six family members (five from the hospital and one from the rest home) stated that they are always informed when their family members health status changes and the 18 of 19 incident forms reviewed in September 2013 indicate that family are always informed where this is possible and appropriate. D11.3 The information pack is available in large print and advised that this can be read to residents. The service has policies and procedures available for access to interpreter services.There is an open disclosure policy, a complaints policy and an incident and accident policy and staff have had training around the code of rights including advocacy and open disclosure in April 2013 with 18 staff attending. The five caregivers and three registered nurses described the value of the training and how they apply this to the service. Eighteen residents (five from the hospital and 13 from the rest home and six of six family members interviewed state they were welcomed on entry and were given time and explanation about services and procedures. Resident meetings occur three monthly and family are invited to this and the operations manager and clinical nurse manager have an open-door policy that they is able to describe.Residents and family interviewed report that communication has improved significantly under the new management team.

Criterion 1.1.9.1 (HDS(C)S.2008:1.1.9.1)Consumers have a right to full and frank information and open disclosure from service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.9.4 (HDS(C)S.2008:1.1.9.4)Wherever necessary and reasonably practicable, interpreter services are provided.


Evidence:

Finding:

Corrective Action:


Standard 1.1.10: Informed Consent (HDS(C)S.2008:1.1.10)Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

ARC D3.1d; D11.3; D12.2; D13.1 ARHSS D3.1d; D11.3; D12.2; D13.1


Evidence:

Written informed consent is gained for do not resuscitate or resuscitation orders appropriately for nine of nine files sampled. Nine files were reviewed and found to have valid consents. It was stated by the clinical manager (a registered nurse) that family involvement occurs with the consent of the resident. Other forms of written consent included consent to share information and consent for transportation. A review of nine files found all consents were present and signed by the resident or their EPOA. EPOA documents are kept on the resident's file. Eighteen residents (five from the hospital and 13 from the rest home and six of six family interviewed confirm that they are given good information to be able to make informed choices. Two caregivers interviewed conform information was provided to residents prior to consents being sought and they were able to decline or withdraw their consent. Staff received training around obtaining informed consent in 2013. D13.1 There were nine of nine admission agreements sighted.D3.1.d Discussion with six family identified that the service actively involves them in decisions that affect their relative’s lives.

Criterion 1.1.10.2 (HDS(C)S.2008:1.1.10.2)Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.4 (HDS(C)S.2008:1.1.10.4)The service is able to demonstrate that written consent is obtained where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.7 (HDS(C)S.2008:1.1.10.7)Advance directives that are made available to service providers are acted on where valid.


Evidence:

Finding:

Corrective Action:


Standard 1.1.11: Advocacy And Support (HDS(C)S.2008:1.1.11)Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f


Evidence:

D4.1d; Discussion with six family members (five from the hospital and one from the rest home) family and 18 of 18 residents identified that the service provides opportunities for the family/EPOA to be involved in decisions and they state that they have been informed about advocacy services.ARC D4.1e, The resident file includes information on residents family/whanau and chosen social networks. Client right to access advocacy services is identified for residents and is available at the entrance to the service. The information identifies who the resident can contact to access advocacy services. Information provided to residents prior to entry to the service provides them and family with advocacy information. Staff are aware of the right for advocacy and how to access and provide advocacy information to residents if needed and training has been provided.The chaplian interviewed reports that she often acts as a resident advocate and any suggestions she makes are well received.The five caregivers and three registered nurses described informing residents of advocacy services.

Criterion 1.1.11.1 (HDS(C)S.2008:1.1.11.1)Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.


Evidence:

Finding:

Corrective Action:


Standard 1.1.12: Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12)Consumers are able to maintain links with their family/whānau and their community.

ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f


Evidence:

D3.1h Discussion with six of six family indicates that they are encouraged to be involved with the service and care.D3.1.e Discussion with five caregivers and three registered nurses as well as the six relatives that they are supported and encouraged to remain involved in the community and external groups such as attendance at church, bowls etc.The service has open visiting and relatives were sighted coming and going on the day of the audit. All relatives interviewed report they are welcome to visit at any time.

Criterion 1.1.12.1 (HDS(C)S.2008:1.1.12.1)Consumers have access to visitors of their choice.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.12.2 (HDS(C)S.2008:1.1.12.2)Consumers are supported to access services within the community when appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.1.13: Complaints Management (HDS(C)S.2008:1.1.13)The right of the consumer to make a complaint is understood, respected, and upheld.

ARC D6.2; D13.3h; E4.1biii.3 ARHSS D6.2; D13.3g


Evidence:

The service has complaints management policies and procedures in place.D13.3h. A complaints procedure is provided to residents and their family within the information pack at entry.Complaint forms are available at the entrance to the building. Staff are aware of the complaints process and to whom they should direct complaints. The complaint process is in a format that is readily understood and accessible to residents/family/whanau. Eighteen residents (five from the hospital and 13 from the rest home and six family members (five from the hospital and one from the rest home) interviewed confirm they are aware of the complaints process and they would make a complaint to the manager if necessary. One relative who has made two complaints in 2013 stated these were thoroughly investigated, he was kept well informed and the complaints were quickly resolved to his satisfaction and there has been no recurrence of the issues raised. There is a complaints register in place. A complaints folder is maintained with the documentation related to each complaint including sign off of the complaint. Documentation for each complaint is summarised on the standard form and contains details of the actions taken to address the issues. All complaints are forwarded by the manager to the DHB as part of the monitoring process following the last certification audit. There were two complaints in January 2013, two complaints in February 2013, four complaints in March 2013, three complaints in April 2013, one complaint each in May and June 2013 and no complaints since this time. There has been one complaint through the DHB since the previous audit which was partially substantiated. There is evidence of an

investigation and corrective action implemented as a result of this complaint. The corrective action includes engaging a local dietitian who is easy to access at short notice.

Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1)The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3)An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.


Evidence:

Finding:

Corrective Action:


Outcome 1.2: Organisational Management

Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.

Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1)The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5


Evidence:

Puriri Court provides residential care for up to 72 residents at rest home and hospital level care. Occupancy on the day of the audit was 60 residents (21 at rest home level care and 39 at hospital level care). One short term hospital level resident is under the medical aspect of the contract. There is a business and strategic plan which document the organisations mission and goals. The stated mission is ‘we are a customer focused organization, promoting excellence in aged care to maintain our reputation as one of the “best”.Since the previous certification audit the service has undergone a restructure of management positions and a change in management personnel. There is now an operations manager who has 30 years of aged care experience and was previously in the role of assistant manager at the facility for four years. She has also previously managed an aged care facility. The operations manager has been in the position for since February 2013. The operations manager is supported by a new clinical nurse manager who has three years’ experience in aged care. She has been in the role since April 2013. There is a physiotherapist who is contracted to the service and provides assessments and interventions on an as required basis.ARC, D17.3di (rest home), D17.4b (hospital): The operations manager has maintained professional development activities related to managing a rest home and hospital with attendance at monthly NZACA meetings and a one day NZACA managers training day.

Criterion 1.2.1.1 (HDS(C)S.2008:1.2.1.1)The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3)The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.


Evidence:

Finding:

Corrective Action:


Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2)The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers.

ARC D3.1; D19.1a; E3.3a ARHSS D3.1; D4.1a; D19.1a


Evidence:

When the manager is absent the clinical nurse manager with three years’ experience at the service undertakes the manager’s duties as confirmed during interview with the manager and the clinical nurse manager. For any extended period of leave the manager would be temporarily replaced by a relieving manager associated with the service that has experience managing rest homes and is well known to the organisation.

Criterion 1.2.2.1 (HDS(C)S.2008:1.2.2.1)During a temporary absence a suitably qualified and/or experienced person performs the manager's role.


Evidence:

Finding:

Corrective Action:


Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3)The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

ARC A4.1; D1.1; D1.2; D5.4; D10.1; D17.7a; D17.7b; D17.7e; D19.1b; D19.2; D19.3a.i-v; D19.4; D19.5 ARHSS A4.1; D1.1; D1.2; D5.4; D10.1; D16.6; D17.10a; D17.10b; D17.10e; D19.1b; D19.2; D19.3a-iv; D19.4; D19.5


Evidence:

The service has a business risk assessment and management plan and this includes a quality plan. The service has in place a range of policies and procedures to support service delivery that are reviewed regularly. A number of policies have been updated since the previous audit to better reflect practice and this includes falls management. Quality data is collected and evaluated and used for quality improvement. Incidents, infections and complaints are actively analysed for trends and any trends and improvements required are reported through the CQI meeting (minutes sighted for January, to October 2013) and the monthly staff meetings (minutes sighted for January to October 2013). There are also monthly health and safety, three monthly restraint and monthly infection control meetings (minutes sighted). Key components of the quality system link to service delivery. Corrective actions are documented against all identified issues with RN, CQI and staff meeting minutes evidencing that issues are addressed in these forums. There is a document control system. All policies include the date the policy was last reviewed and a review date. Documents no longer relevant to the service are removed and archived. Discussion with five caregivers, three registered nurses and the clinical nurse manager identified that staff are familiar with the policies and procedures. There are implemented health and safety policies that include hazard identification with a health and safety officer appointed. She is able to describe her role in monitoring health and safety with oversight of the maintenance issues and hazard register. A review of the documentation indicates that maintenance issues and hazards are resolved promptly. The service has policies, procedures, processes and systems that support the provision of clinical care and support including care planning.D5.4 Puriri Court has the following policies/ procedures to support service delivery; 1) Continence Policy (updated since the previous audit). Continence assessments were evident in six of six resident files.2) Challenging behaviour policy. A challenging behaviour assessment and management plan is used in both of the two resident files reviewed.3) Pain management policy and procedure. There is an assessment tool able to be utilised for a resident with pain/on controlled drugs and one of two identified with ongoing pain have pain assessments completed regularly e.g. daily/every two days.4) Personal grooming and hygiene policy5) Pressure are risk management policy.6) Wound care policy and procedures with all wounds identified as having a wound assessment and plan. 7) Transportation of subsidised residents policy and procedure includes costs, resident, and staff safety.8) D10.1 A policy around death and dying. The policy outlines immediate action to be taken upon a resident's death and that all necessary certifications and documentation is completed in a timely manner.9) Vehicle/transportation policy. 10) The service has a health and safety management system and this includes the identification of a health and safety officer. Security and safety policies and procedures are in place to ensure a safe environment is provided. Emergency plans ensure appropriate response in an emergency.There are infection control policies and procedure and a restraint policy and health and safety policies and procedures.

D19.2g: Falls prevention strategies are in place that include the analysis of falls incidents, post falls review of falls assessment risk, the identification of interventions on a case by case basis to minimise future falls and a new process where during the day there is always a caregiver from each area stationed in the linge to reduce falls.

Criterion 1.2.3.1 (HDS(C)S.2008:1.2.3.1)The organisation has a quality and risk management system which is understood and implemented by service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.3 (HDS(C)S.2008:1.2.3.3)The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.4 (HDS(C)S.2008:1.2.3.4)There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5)Key components of service delivery shall be explicitly linked to the quality management system.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.6 (HDS(C)S.2008:1.2.3.6)Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7)A process to measure achievement against the quality and risk management plan is implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.8 (HDS(C)S.2008:1.2.3.8)A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.9 (HDS(C)S.2008:1.2.3.9)Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include:(a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk;(b) A process that addresses/treats the risks associated with service provision is developed and implemented.


Evidence:

Finding:

Corrective Action:


Standard 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4)All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner.

ARC D19.3a.vi.; D19.3b; D19.3c ARHSS D19.3a.vi.; D19.3b; D19.3c


Evidence:

D19.3b; There is an incident and accident policy that includes definitions, and outlines responsibilities including immediate action, reporting, monitoring and corrective action to minimise and debriefing. In the past year the service has reviewed and redeveloped the incident management procedure. Following an incident the first staff member on the scene completes an incident form. This is them passed to the registered nurse on duty who ensures that progress notes have been completed and completed the RN assessment and a corrective action plan for every incident. This is then placed under the operations managers door and all incidents from the previous day (or weekend) are reviewed and discussed each morning by the operations manager and the clinical nurse manager. Any additional actions required are then implemented. Nine of nine files sampled (three from the rest home and six from the hospital) indicate that all incidents noted in the progress notes for September 2013 have a corresponding incident form. A full corrective action plan is develped by the registered nurse for every incident.Incidents/accidents and near misses are investigated and a log of incidents occurs monthly. There is a discussion of incidents/accidents in monthly CQI and staff meetings.D19.3c Discussions with the clinical nurse manager and operations manager confirms that there is an awareness of the requirement to notify relevant authorities in relation to essential notifications. The service currently has a scabies outbreak with five residents identified as having scabies. The DHB infection control specialist and Public Health have been informed.

The five caregivers, three registered nurses, the clinical nurse manager and the operations manager interviewed are all familiar with the incident/accident reporting process and describe discussion of these at the staff meeting.

Criterion 1.2.4.2 (HDS(C)S.2008:1.2.4.2)The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.4.3 (HDS(C)S.2008:1.2.4.3)The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.


Evidence:

Finding:

Corrective Action:


Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7)Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

ARC D17.6; D17.7; D17.8; E4.5d; E4.5e; E4.5f; E4.5g; E4.5h ARHSS D17.7, D17.9, D17.10, D17.11


Evidence:

There are a total of 72 staff with job descriptions in place for all positions. Human resources policies are implemented. An orientation programme is in place that includes the assessment of initial medication competencies if relevant for the staff member and sign off included in nine of nine files reviewed (the clinical nurse manager, one cook, one activities coordinator, two registered nurses and four caregivers). The five caregivers, three registered nurses, the clinical nurse manager could describe the orientation training with the most recent staff member describing an improved orientation programme. An annual in-service education programme is in place. The annual training plan covers a range of subjects and attendance at these is recorded on staff records. Discussions with five caregivers, three registered nurses, the clinical nurse manager and the operations manager and a review of documentation demonstrates a commitment to the education of staff that is implemented into practice. Reference checks were present in all the staff files for staff employed since the mew manager commenced. D17.7d: There are implemented competencies for staff related to medication with all relevant registered nurses and the clinical nurse manager completing annually. All health professionals have a current practicing certificate. Nine of nine staff have police checks completed.

Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2)Professional qualifications are validated, including evidence of registration and scope of practice for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3)The appointment of appropriate service providers to safely meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4)New service providers receive an orientation/induction programme that covers the essential components of the service provided.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.5 (HDS(C)S.2008:1.2.7.5)A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8)Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

ARC D17.1; D17.3a; D17.3 b; D17.3c; D17.3e; D17.3f; D17.3g; D17.4a; D17.4c; D17.4d; E4.5 a; E4.5 b; E4.5c ARHSS D17.1; D17.3; D17.4; D17.6; D17.8


Evidence:

The service has a documented rationale for determining staffing levels and skill mixes for safe service delivery. There is a roster that provides sufficient and appropriate coverage for the effective delivery of care and support.The operations manager and clinical nurse manager work 40 hours per week and are supported by the quality officer who is a registered nurse. The clinical manager and a senior registered nurse share on call duties around clinical matters.Laundry is done by staff specific to these duties.Staff turnover has been low recently. There was a moderate turnover following the restructure of staff rosters but this has now reduced. The service does use agency staff and agency staff are orientated before commencement of duties. The use of agency staff has reduced significantly in the past year.The GP interviewed confirmed that staffing is appropriate to meet the needs of residents.Eighteen residents (five from the hospital and 13 from the rest home and six family members (five from the hospital and one from the rest home) state that there are sufficient staff on duty at all times.

Criterion 1.2.8.1 (HDS(C)S.2008:1.2.8.1)There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.


Evidence:

Finding:

Corrective Action:


Standard 1.2.9: Consumer Information Management Systems (HDS(C)S.2008:1.2.9)Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

ARC A15.1; D7.1; D8.1; D22; E5.1 ARHSS A15.1; D7.1; D8.1; D22


Evidence:

The service retains relevant and appropriate information to identify residents and track records. This includes comprehensive information gathered, at admission, with the involvement of the family. There is sufficient detail in resident files to identify residents' on-going care history and activities. Resident files are in use are appropriate to the service. There are policies and procedures in place for privacy and confidentiality. Staff can describe the procedures for maintaining confidentiality of resident records. Files and relevant resident care and support information can be accessed in a timely manner.D7.1 Entries are legible, dates and signed by the relevant caregiver, registered nurse, clinical nurse manager or other staff member including designation. Resident’s files are protected from unauthorised access by being locked away in an office or cupboard. Informed consent is obtained from residents/family/whanau on admission to display photographs. Information containing sensitive resident information is not displayed in a way that can be viewed by other residents or members of the public.Individual resident files demonstrate service integration. This includes medical care interventions. Medication charts are in a separate folder with medication and this is appropriate to the service.

Criterion 1.2.9.1 (HDS(C)S.2008:1.2.9.1)Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.7 (HDS(C)S.2008:1.2.9.7)Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.9 (HDS(C)S.2008:1.2.9.9)All records are legible and the name and designation of the service provider is identifiable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.10 (HDS(C)S.2008:1.2.9.10)All records pertaining to individual consumer service delivery are integrated.


Evidence:

Finding:

Corrective Action:


Outcome 1.3: Continuum of Service Delivery

Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.

Standard 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1)Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.

ARC A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2; E3.1; E4.1b ARHSS A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2


Evidence:

The service has policy documents to guide staff when admitting residents to the facility. A range of information is provided to prospective residents and their families on or prior to entry. n information The 18 residents interviewed (13 from the rest home and five from the hospital) and six family members (five hospital and one from the rest home) confirm they had been provided with information about entry processes at the point of their first enquiry to the service. The local NASC are familiar with entry criteria and processes. D13.3 The admission agreement reviewed aligns with a) -k) of the ARC contract.D14.1 Exclusions from the service are included in the admission agreement.D14.2 The information provided at entry includes examples of how services can be accessed that are not included in the agreement.

Criterion 1.3.1.4 (HDS(C)S.2008:1.3.1.4)Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.


Evidence:

Finding:

Corrective Action:


Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2)Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate.

ARHSS D4.2


Evidence:

No residents referred for admission since the previous audit have been declined (confirmed in discussions with the clinical nurse manager). The clinical nurse manager and the facility manager would discuss with the prospective resident and their family and the NASC if they believed that a prospective admission was not appropriate to ensure that the person’s needs were met. If the situation arose, the person and their family would be informed of the reasons for the decline.

Criterion 1.3.2.2 (HDS(C)S.2008:1.3.2.2)When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services.


Evidence:

Finding:

Corrective Action:


Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3)Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

ARC D3.1c; D9.1; D9.2; D16.3a; D16.3e; D16.3l; D16.5b; D16.5ci; D16.5c.ii; D16.5e ARHSS D3.1c; D9.1; D9.2; D16.3a; D16.3d; D16.5b; D16.5d; D16.5e; D16.5i


Evidence:

Each resident is assessed on entry to the service and an initial assessment and plan of care is completed within 24 hours of admission (confirmed in review of nine of nine clinical records (six hospital including one medical and three rest home). Following their initial assessment a broader range of assessments are conducted over the next three weeks. A summary of these assessments and information gathered is collated by the resident’s key RN and a long term plan of care is developed. Residents are seen by their general practitioner within 48 hours of admission, medicines are charted and an assessment of the residents medical needs and or stability is conducted and documented. D16.2, 3, 4: Nine of nine clinical records (six hospital including one medical admitted for short term care pre and post medical investigations at the DHB and three rest home) identified that in all nine files an assessment was completed within 24 hours and all nine files identify that the long term care plan was completed within three weeks. There is documented evidence that the care plan was reviewed by a RN and amended when the resident’s current health changed. All nine of nine care plans evidenced ongoing evaluation.D16.5e: Nine of nine resident files reviewed identified that the GP had seen the resident within two working days. It was noted in resident files reviewed that the GP has assessed the resident as stable and is to be seen three monthly. In the majority of situations the GP reviewed the resident more frequently in the months following admission to confirm stability. One GP provides care for 56 of the 60 residents. The GP was interviewed and was very satisfied with the decisionmaking of staff and their response to her instructions.

A range of assessment tools where completed in resident files on admission and completed at least six monthly or earlier including (but not limited to);skin integrity, potential for pressure areas, potential for falls, continence, a mini nutritional assessment, the presence of pain.

Tracer Methodology: Hospital level residentXXXXXX This information has been deleted as it is specific to the health care of a resident.

Tracer methodology: Rest home residentXXXXXX This information has been deleted as it is specific to the health care of a resident.

Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1)Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.3 (HDS(C)S.2008:1.3.3.3)Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.4 (HDS(C)S.2008:1.3.3.4)The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4)Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

ARC D16.2; E4.2 ARHSS D16.2; D16.3d; D16.5g.ii


Evidence:

Residents needs, their support requirements and any preferences are recorded on admission by a registered nurse (confirmed in discussions with 18 of 18 residents (five hospital and 13 rest home) and six of six relatives (five hospital and one rest home). An initial plan is developed based on information gathered from the needs assessment process, interviewing of the resident and their family, the findings from the range of assessment tools used on admission (eg,nutritional needs, mobilty, level of pain, falls risk, risk of pressure areas, and continence management); information gathered by staff who have been providing care, and information from the resident’s GP. Needs are summarised after two to three weeks by a registered nurse prior to the development of the resident’s long-term care plan (confirmed in review of five of five long term hospital residents records). The sixth resident was a three day short term medical admission.

The short term medical admission was admitted from her home. She was admitted under a residential and community services for primary options agreement which the facility holds with Manaia PHO.

Residents receive ongoing assessment throughout their care (eg, falls risk is reviewed if a resident falls, and pain levels are reassessed each time a resident requires pain relief). Each resident has an allocated registered nurse who is responsible for guiding the resident’s care under the direction of the clinical nurse manager.

Criterion 1.3.4.2 (HDS(C)S.2008:1.3.4.2)The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.


Evidence:

Finding:

Corrective Action:


Standard 1.3.5: Planning (HDS(C)S.2008:1.3.5)Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

ARC D16.3b; D16.3f; D16.3g; D16.3h; D16.3i; D16.3j; D16.3k; E4.3 ARHSS D16.3b; D16.3d; D16.3e; D16.3f; D16.3g


Evidence:

The long term plan of care for each resident is developed by a registered nurse in consultation with the resident their family and other staff. The registered nurse types the plan out so that it is easy to read and the plan is then signed by the resident/ and or their family and the registered nurse (confirmed in discussions with 18 of 18 residents (five hospital and 13 rest home) and six of six relatives (five hospital and one rest home). The plan includes an integrated range of care domains, which include but are not limited to: personal hygiene needs, dietary preferences, mobility, skin integrity, continence, sexuality, spiritual and cultural preferences.

D16.3k, Short term care plans are in use for changes in health status.Short term care plans are used for a range of situations including but not limited to wounds, infections, and falls.D16.3f; Nine of nine resident files reviewed identified that family were involved in the planning of care.

Criterion 1.3.5.2 (HDS(C)S.2008:1.3.5.2)Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.5.3 (HDS(C)S.2008:1.3.5.3)Service delivery plans demonstrate service integration.


Evidence:

Finding:

Corrective Action:


Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6)Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

ARC D16.1a; D16.1b.i; D16.5a; D18.3; D18.4; E4.4 ARHSS D16.1a; D16.1b.i; D16.5a; D16.5c; D16.5f; D16.5g.i; D16.6; D18.3; D18.4


Evidence:

Services are provided according to the long term plan. Caregivers sign off a check list of cares each shift to record what cares were provided on which day. The registered nurses record cares provided on progress notes. There is an entry in the progress notes for each shift. A verbal handover, white boards and a diary are used to communicate special needs of residents to each incoming shift of care staff. Each resident with a wound has a wound management plan in place to ensure all residents who require active wound management receive appropriate care. Lists are kept to prompt registered nurses as to who needs medical review. A handover occurs between incoming and outgoing shifts. The morning handover occurs at 7 am. The registered nurses on the morning shift brief the clinical nurse manager at 9 am each morning during the week. She then briefs the facility manager as to which residents have significant needs to ensure everyone is informed appropriately. Staff have developed effective communication systems to ensure effective service delivery. The GP visits frequently during the week and is available on the telephone if staff need to talk to her. D18.3 and 4 Dressing supplies are available.Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified for day use, night use, and other management.Specialist continence advice is available as needed and this could be described by the clinical nurse manager, the senior registered nurse, a registered nurse and the quality officer who is an RN who oversees clinical quality..Staff have access to ongoing inservice (eg, continence management in-service was held August 2013; wound management in-service was held October 2013; Skin integrity was held Oct 2013, the ageing process was held Oct 2013 and pain management in October 2013). Wound assessment and wound management plans are in place for eleven residents (which consists of two patients with pressure areas (one grade, one grade, one grade four), eight skin tears and one chronic leg ulcer. The resident with wounds are having input from the district wound nurse specialist and the GP. The other pressure area and three other skin tears are having more intensive GP monitoring

The registered nurses interviewed are aware of how to access from a wound specialist or continence nurse.Residents and relatives interviewed are satisfied with the standard of care provided (confirmed in discussions with 18 of 18 residents ( five hospital and 13 rest home) and six of six relatives (five hospital and one rest home).

Criterion 1.3.6.1 (HDS(C)S.2008:1.3.6.1)The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.


Evidence:

Finding:

Corrective Action:


Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7)Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service.

ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h


Evidence:

The service is provided by two activities coordinators who are both training to complete diversional therapy qualifications (both coordinators interviewed). One coordinator works 36 hours a week (Monday to Friday) and the other works 24 hours a week (Mondays,Wednesdays, Thursdays and Fridays). Most residents will the attend the group programme in the lounge. On occasions and depending on the programme, the other activities coordinator may run a separate programme in another lounge or they may take residents on a bus trip. Each resident has a documented social history on admission and a record is made of their preferred activities. An individual activities programme is developed for each resident to meet their preferences. A group programme is developed to meet the needs of both the hospital level residents and the rest home level residents. The group programme includes (but is not limited to) activities to promote physical health (eg excerises, Tai Chi three times a week, indoor golf, indoor bowls, volley ball, gardening, walks); activities to promote cognitive wellbeing (eg, news and views(reading newspaper and discussing issues of whats going on in commuty and the rest of the world,crosswords, quizzes, buzz groups ideas, bingo, memory games; activities to promote social interaction and communication (eg, music, DVDs, visiting entertainers eg, kapa haka, blind dogs, trumpet player harmonica player, piano players, dancers) and external visits to the community. The facility owns its own bus and bus trips happen three times a week. Bus trips are used to take residents shopping, on picnics, to eat fish and chips, to visit the museum, ten pin bowling, school productions, garden centres, garden viewing trips to determine the best garden in the street, to the beach, and other

destinations. The bus is driven by one activities cordinator or the bus driver. Both drivers have a current first aid certificate and a current P endorsement and Class 2 license to drive the bus. The bus seats 19 resident and is hoist capable to take wheelchairs. In addition to the bus there is a van which is used to take a smaller number of residents to events (eg, a weekly RSA visit). Spiritual needs are met. Once a month there is a multi-demonimational service offered on site. The residents choose to have this service monthly as previously it was held fortnightly. There is a catholic chaplian who visits on request and an Anglican minister. One resident goes on his scooter to church every week and others are driven by family. A resident was recently admitted from another aged care facility in the area expressely because she liked the group and individual activities programme on offer for the hospital residents. She appreciated that the bus was hoist capable as she is wheelchair dependent. She appreciated that there were bus trips at least three times a week and there were lots of outling to choose from. She is able to paint and can enjoy her longstich. She and her family spent some time working with the staff to discuss the programme before she was admitted. The group programme is developed a month in advance and can change on the day depending on group preferences and the weather. A record is kept of actual events. Both actitivities coordinators have contact with their peers and diversional therapists working in the area. One attends a bi monthly diversional therapy meeting and the other attends the Forget Me Not adult day care center to meet with their diversional therapist once a month The residents very much enjoy the range of activities on offer and their interactions with the activities coordinators (confirmed in discussions with 18 of 18 residents (five hospital and 13 rest home) and six of six relatives (five hospital and one rest home). D16.5d Resident files reviewed identified that the individual activity plan is reviewed when their plans of care are reviewed or earlier if the resident wishes to change their individual programme.

Criterion 1.3.7.1 (HDS(C)S.2008:1.3.7.1)Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8)Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

ARC D16.3c; D16.3d; D16.4a ARHSS D16.3c; D16.4a


Evidence:

Plans of care are reviewed continually by registered nurses. All residents have a three monthly review with the GP. Their plan of care is evaluated by the resident, their family, the GP and registered nursing staff at any stage on request or if their needs change (confirmed in discussions with 18 of 18 residents (five hospital and 13 rest home) and six of six relatives (five hospital and one rest home). If a resident is stable then their care is reviewed at least every six months. Evaluations may require a complete revision of the plan of care or an amendment. Progress towards meeting goals or support needs are considered (evidenced in review of nine of nine clinical records).D16.4a Care plans are evaluated six monthly more frequently when clinically indicatedARC: D16.3c: All initial care plans were evaluated by the RN within three weeks of admission.

Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2)Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3)Where progress is different from expected, the service responds by initiating changes to the service delivery plan.


Evidence:

Finding:

Corrective Action:


Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9)Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4


Evidence:

Referral to other health and disability service providers occurs (eg two residents with complex wounds are being seen by the community wound nurse).Other residents are referred to specialist medical services as needed. Referral documentation is maintained on resident files. All referrals are co-ordinated by the registered nurses unless the referral is to a medical specialist in which case a letter from the GP is then required.

D16.4c;The clinical nurse manager provided an example where a resident who needed urgent reassessment to facilitate her admission to a psychogeriatric unit within 12 hours or her admission. The nurses can refer to a dietitian for advice. Residents and families are involved in decisionmaking related to referrals. D 20.1 Discussions with registered nurses identified that the service has access to specialist nurses employed by Whangarei Base Hospital.

Criterion 1.3.9.1 (HDS(C)S.2008:1.3.9.1)Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.


Evidence:

Finding:

Corrective Action:


Standard 1.3.10: Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10)Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


Evidence:

Registered nurses are guided by policy for transferring or discharging residents. The policy includes guidelines for discharge and for transfer. All relevant information is documented and communicated to the receiving health provider or service. A transfer form accompanies residents to receiving facilities with a transfer letter, with accompanying photocopied relevant documentation including medication charts. The registered nurses are available for any follow up or queries.

Criterion 1.3.10.2 (HDS(C)S.2008:1.3.10.2)Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives.


Evidence:

Finding:

Corrective Action:


Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12)Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d


Evidence:

Staff are guided by a comprehensive medicines management policy. The facility is using the robotics system to package tablet medicines. Other medicines

are packaged by the pharmacist in pharmacy labelled containers. Medicines are managed by registered or the enrolled nurse. All staff administering medicines have been asssessed as competent. Medicines are reconcilled and checked on entry to the facility by registered nurses on duty on the day of delivery. Expiry dates of medicines are written on the container when appropriate (eg, eye drops). Medicine requiring refrigeration are stored appropriately in dedicated refridgerators and the temperatures of these refridgerators are checked. Staff use three medicine trollies to distribute medicines (one trolley for the hospital wing, one for B wing and a trolley for C wing).Medicines are administered according to medicine charts documented by medical staff. The administration charts record allegy status and the signatures of the staff administering the medicines. There are charts for PRN medicines and medicines that are not packaged robotically. Standing orders are not used. All residents have PRN charted and there is policy to cover a telephone order in an unusual event. The hospital residents have access to a small imprest stock which includes an imprest stock of controlled drugs. Controlled drugs are stored in locked cupboards in locked medicine rooms. Controlled drugs are signed for correctly. Controlled drugs are checked weekly and there is a six monthly stocktake by the contracted pharmacist who last checked the stock on 19 Oct 2013. Medicine errors are reported through the incident/accident system and monitored by the quality officer (RN) and the clinical nurse manager. Medicines are reviewed three monthly to ensure continuation of supply. The GP signs the resident’s chart when the reviews occur. Three residents are self-administering medicines. They have been assessed by a registered nurse using the self-assessment tool included in the Medicine Care Guide for residential aged care published by the Ministry of Health. The competency framework in use was developed using the Medicine Care Guide. Residents who self-administer medicines are monitored and lock their medicines away in their rooms when not in use. There is a system of internal audit in place (the last internal audit was conducted in March 2013 and the corrective actions identified have been addressed and corrected). The distribution of medicines at lunch time was observed on the day of audit and was appropriate.D16.5.e.i.2; Sixteen of sixteen medication charts reviewed identified that the GP had seen the resident within the last three months or had reviewed the resident 3 monthly and the medication chart was signed.

Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1)A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3)Service providers responsible for medicine management are competent to perform the function for each stage they manage.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5)The facilitation of safe self-administration of medicines by consumers where appropriate.


Evidence:Three in rest home

Finding:

Corrective Action:


Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6)Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.


Evidence:

Finding:

Corrective Action:


Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13)A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c


Evidence:

Food services policies and procedures are in use and appropriate to the service setting. Residents are able to use two dining rooms (one in the hospital area and another in the rest home). They also have the option of eating in their bedrooms. The kitchen is staffed by two chefs (one chef works Tues to Friday 7 am to 5pm and another who works Saturdays, Sundays and Mondays. The chefs cook all meals They are assisted by two part-time kitchen hands that assist the chefs with food preparation and kitchen tasks. The menu is a six week rotating summer/winter menu which has been approved by a dietitian (on 20 July 2012). If changes are required to the menu then these changes are approved in discussion with the facility manager and dietitian. There are documented protocols for the management of residents with unexplained weight loss or gain, including referral to a dietitian and speech language therapist as required. Resident's individual dietary needs are identified, documented and reviewed on a regular basis. Copies of dietary profiles are held in the kitchen and in resident files. Resident likes and dislikes are known and catered for and written up on whiteboard so that staff can read them easily when serving. Special eating and drinking utensils and equipment is available Additional snacks are available for residents when the kitchen is closed e.g. fruit, sandwiches, and yoghurts. Ensure is made up by registered nurses. Residents are offered fluids throughout the day.Residents' files sampled demonstrate regular monthly monitoring of individual consumer’s weight and nutritional needs. Nutritional needs and interventions are identified and documented. Residents and family members are very complimentary of the food service provided. They report that their individual preferences are well catered. Visual inspection of the kitchen provides evidence of compliance with current legislation and guidelines. Food is delivered by commercial operators. Food is stored in dedicated refrigerators, freezers or cool store. There is a system of food rotation in place. There is a contracted provider for kitchen waste disposal.The two chefs have completed food safety education (evidence sighted). Monitoring records available include food temperatures, and fridge / freezer temperature recordings for the kitchen. Food is transported to the rest home servery in a bain marie. Special events are catered for (eg, birthdays) The kitchen is included in the internal audit programme. It was last audited in May 2013 and no corrective actions were identified.D19.2 Staff have been trained in safe food handling.Residents and relatives are satisfied with the food service (confirmed in discussions with 18 of 18 residents (five hospital and 13 rest home) and six of six relatives (five hospital and one rest home) and the food on the day of audit that was observed met expectations and was observed to be hot and well presented.

Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1)Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2)Consumers who have additional or modified nutritional requirements or special diets have these needs met.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5)All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.


Evidence:

Finding:

Corrective Action:


Outcome 1.4: Safe and Appropriate Environment

Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.

Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1)Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

ARC D19.3c.v; ARHSS D19.3c.v


Evidence:

Staff are guided by a policy on the management of waste and hazardous substances. There is policy on the use of chemicals to ensure effective management of potentially hazardous substances (eg, for spill management and blood and body fluids). There is a process for disposing of infectious and hazardous waste (eg, sharps).Staff have access to personal protective equipment (eg gloves and aprons) (observed).

Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1)Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.1.6 (HDS(C)S.2008:1.4.1.6)Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2)Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a; D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4


Evidence:

The facility has a current building warrant of fitness which expires 1 December 2013. A maintenance manager is employed full time (interviewed).The physical environment is appropriate to the needs of the residents. Planned and reactive maintenance systems are in place and were reviewed. (records sighted). Medical equipment is calibrated and tested (last tested and serviced on 1 May 2013). Medical equipment serviced included blood pressure equipment, nebulisers, electric beds, mattress pumps, oxygen concentrator, suction units and a foot spa. Hoists were also serviced (and are next due for servicing on 2 October 2014). Hot water temperatures are checked monthly by the maintanance manager. Records show that temperatures at the tap are maintained in a safe range of between 40-45 degrees Celcius. The maintenance manager had the hot water system externally tested on 30 September 2013 to check the main tank temperature which is heating to 60 degrees Celcius. Electrical tagging is done annually onsite by mainteance manager, who is qualified to use the testing tool. Electrical tagging was last tested 2 October 2013 and is an ongoing process. Medical and other equipment is safely stored. Corridors are wide enough to allow residents to pass each other safely. Safety rails are secure and appropriately located. There are minimal changes in floor surfaces. Equipment does not clutter passageways. The external areas are safely maintained and are appropriate to the resident group. They include seating and shade.There are two internal courtyards. Registered nurses and caregivers confirm that they have access to appropriate equipment. Residents and staff interviewed confirm they know the processes they should follow if any repairs/maintenance are required and that requests are appropriately actioned. Residents interviewed confirm they are able to move freely around the facility and that the accommodation meets their needs.ARC D15.3: The following equipment is available: shower chairs, hoists, pressure relieving mattresses, a shower bed and lifting aids.

Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1)All buildings, plant, and equipment comply with legislation.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.4 (HDS(C)S.2008:1.4.2.4)The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.6 (HDS(C)S.2008:1.4.2.6)Consumers are provided with safe and accessible external areas that meet their needs.


Evidence:

Finding:

Corrective Action:


Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3)Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

ARC E3.3d ARHSS D15.3c


Evidence:

Residents have access to an adequate number of toilets and showers (confirmed in discussions with 18 of 18 residents and five of five caregivers). The hospital wing contains some rooms with ensuites. There are communal toilets and showers throughout the premises. Residents in B wing all use communal showers and toilets. 'C' wing rooms all have an ensuite toilet and two communal showers. There are adequate communal toilets that are easily accessible and signed. There are separate toilets for visitors and for staff.

Hot water is monitored on an on-going basis by care and support staff. It is formally tested by the maintenance manager every two to three months throughout all areas of the facility. Resident areas are tested and maintained at less than 45 degrees Celsius.

Hand washing and drying facilities are available in each en-suite and communal toilet. There is evidence of alcohol hand gel stations situated conveniently throughout the facility. There are adequate visitor’s toilets with hand basins with paper towels ensuring infection prevention and control. Staff and residents have access to adequate hand washing facilities throughout the facility (confirmed in discussions with five of five caregivers and 18 of 18 residents). Fixtures and fittings in toilets, and showers are able to be cleaned easily and comply with infection control guidelines.

Criterion 1.4.3.1 (HDS(C)S.2008:1.4.3.1)There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.


Evidence:

Finding:

Corrective Action:


Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4)Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii


Evidence:

There is adequate room in each resident’s bedrooms for personal belongings and there is sufficient room for both staff and residents to move around easily (confirmed in discussions with 18 of 18 residents, five of five caregivers and observed on the tour of the premises). Residents' rooms all have single doors in two wings and double doors in the other wings. The only time residents are required to be transferred from their bedrooms is in an emergency situation and the registered nurses confirm that ambulance gurneys have no problem with access.

Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1)Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.


Evidence:

Finding:

Corrective Action:


Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5)Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

ARC E3.4b ARHSS D15.3d


Evidence:

There are three lounge areas (one in each wing) to allow for activities, resident relaxation and privacy when having visitors. Communal areas are bright and airy and allow freedom of movement for all residents including those with mobility aids. There are three dining areas (one dining area in each wing).There is room for outdoor relaxation and there are two internal courtyards.

Criterion 1.4.5.1 (HDS(C)S.2008:1.4.5.1)Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6)Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e


Evidence:

The service has in place policies and procedures for effective management of cleaning and laundry practices. Chemicals are supplied by Ecolab and installed on the wall in Ecolab dispensers in the cleaning cupboards which are able to be locked when not in use. Cleaning is performed by two cleaners each day Monday to Friday and this reduces to one cleaner each day on the weekends. Cleaners are employed seven hours a day from Monday to Friday and five hours a day on the weekends. Staff are trained in the use of chemicals by Ecolab staff (confirmed in interview with two of two cleaners and two of two laundry staff). All laundry is done in house. There are two laundries on site and two staff typically to do

the laundry. Both staff work 7 am to 1pm each day and there is a roster to cover all seven days of the week for both laundries. Chemicals are stored in fixed containers in the laundry. Each laundry has two commercial washers and driers and the ability to soak and sluice. There is a laundry manual available that includes the use of personal protective equipment, handling of linen, waste disposal and with hazard controls. Laundry and cleaning processes are monitored for effectiveness by internal audits which were last conducted in June 2013.

Criterion 1.4.6.2 (HDS(C)S.2008:1.4.6.2)The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.6.3 (HDS(C)S.2008:1.4.6.3)Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.


Evidence:

Finding:

Corrective Action:


Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7)Consumers receive an appropriate and timely response during emergency and security situations.

ARC D15.3e; D19.6 ARHSS D15.3i; D19.6


Evidence:

Documented systems are in place for essential, emergency and security services. Policy and procedures documenting service provider/contractor identification requirements appropriate to the resident group and setting along with policy/procedures for visitor identification. There are also policy/procedures for the safe and appropriate management of unwanted and/or restricted visitors.

Letters from New Zealand Fire Service reviewed dated October 2001 advising approval of fire evacuation schemes. The last trial evacuation was held in July 2013.

Staff interviews and review of files provides evidence of current training in relevant areas. All registered nurses and most caregivers have current first aid certificates as confirmed in staff interviews and in staff files sampled. Emergency and security situation education is provided to service providers during their orientation phase and at appropriate intervals. This includes fire safety training and emergency security situations. Staff records sampled evidences current training regarding fire, emergency and security education. Processes are in place to meet the requirements for the 'Major Incident and Health Emergency Plan' in the Service Agreement.

A visual inspection of the facility evidences: information in relation to emergency and security situations is readily available/displayed for service providers and residents; emergency equipment is accessible, stored correctly, not expired, and stocked to a level appropriate to the service setting; A visual inspection of the facility evidences: emergency lighting, torches, extra food supplies, blankets, and cell phones. There is a portable gas cooker should the mains gas supply fail. There is sufficient stored water for three litres per person per day for three day.An appropriate call bell system that is easily used by the resident or staff to summon assistance if required. Call bells are accessible / within easy reach, and are available in resident areas, e.g. bedrooms, ablution areas, ensuite toilet/showers, the lounge and dining room. D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included.

Criterion 1.4.7.1 (HDS(C)S.2008:1.4.7.1)Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.3 (HDS(C)S.2008:1.4.7.3)Where required by legislation there is an approved evacuation plan.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.4 (HDS(C)S.2008:1.4.7.4)Alternative energy and utility sources are available in the event of the main supplies failing.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.5 (HDS(C)S.2008:1.4.7.5)An appropriate 'call system' is available to summon assistance when required.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.6 (HDS(C)S.2008:1.4.7.6)The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.


Evidence:

Finding:

Corrective Action:


Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8)Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

ARC D15.2f ARHSS D15.2g


Evidence:

Each common area and bedroom has access to an external window and are well lit with natural light. The building is ventilated by opening doors and windows. Heating is by central heating. The maintenance manager monitors temperatures using wall barometers. Residents are not exposed to

secondary smoke. Smoking is only permitted in the one designated area and there are plans to go smoke free on the site when the last resident stops smoking.

Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1)Areas used by consumers and service providers are ventilated and heated appropriately.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2)All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.


Evidence:

Finding:

Corrective Action:


NZS 8134.2:2008: Health and Disability Services (Restraint Minimisation and Safe Practice) Standards

Outcome 2.1: Restraint Minimisation

Services demonstrate that the use of restraint is actively minimised.

Standard 2.1.1: Restraint minimisation (HDS(RMSP)S.2008:2.1.1)Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


Evidence:

The restraint minimisation procedure has a philosophy is to promote quality of life by ensuring that the use of restraint is kept to a minimum, and only used to ensure the safety of the consumer, staff and other residents or visitors to the facility and to ensure that restraint is applied, only after alternatives have been tried and the benefits and risks of restraint have been considered. The service has reduced restraint use from 37 resdients in July 2012 to 16 currently.The restraint minimisation procedure includes that an enabler limits the freedom of movement of the resident e.g. a bed rail put in place at the consumer’s request for safety. The intention of the enabler determines whether or not a piece of equipment, device or furniture is an enabler. Where the intention is to promote independence, comfort and safety and the intervention is voluntary, this constitutes an enabler. The use of an enabler must be the least restrictive option to safely meet the needs of the consumer. The two files sampled of residents who use an enabler showed a signed consent form and the care plan clearly document that the enabler is voluntary. The restraint co-ordinator has a documented role description.There are currently 16 residents using restraint and six residents using enablers at the facility.

Criterion 2.1.1.4 (HDS(RMSP)S.2008:2.1.1.4)The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.


Evidence:

Finding:

Corrective Action:


Outcome 2.2: Safe Restraint Practice

Consumers receive services in a safe manner.

Standard 2.2.1: Restraint approval and processes (HDS(RMSP)S.2008:2.2.1)Services maintain a process for determining approval of all types of restraint used, restraint processes (including policy and procedure), duration of restraint, and ongoing education on restraint use and this process is made known to service providers and others.

ARC D5.4n ARHSS D5.4n, D16.6


Evidence:

Only staff who have completed training are permitted to apply restraints. There are responsibilities and accountabilities determined in the restraint policy that includes responsibilities for key staff. Interviews with the restraint coordinator and review of her signed job descriptions identified understanding of the role.

Criterion 2.2.1.1 (HDS(RMSP)S.2008:2.2.1.1)The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.2: Assessment (HDS(RMSP)S.2008:2.2.2)Services shall ensure rigorous assessment of consumers is undertaken, where indicated, in relation to use of restraint.



Evidence:

A restraint assessment that includes strategies tried, risks, cultural needs and any issues is completed as part of the consent and assessment form in use. This assessment is present in three of three resident files for residents using restraint. Interventions and risks identified through the assessment process are transferred into care plans. Restraint documentation identifies the involvement of family. Assessments are undertaken by the clinical nurse manager or another registered nurse and the GP with input from the family.

Criterion 2.2.2.1 (HDS(RMSP)S.2008:2.2.2.1)In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to:(a) Any risks related to the use of restraint;(b) Any underlying causes for the relevant behaviour or condition if known;(c) Existing advance directives the consumer may have made;(d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes;(e) Any history of trauma or abuse, which may have involved the consumer being held against their will;(f) Maintaining culturally safe practice;(g) Desired outcome and criteria for ending restraint (which should be made explicit and, as much as practicable, made clear to the consumer);(h) Possible alternative intervention/strategies.


Evidence:

Finding:

Corrective Action:


Standard 2.2.3: Safe Restraint Use (HDS(RMSP)S.2008:2.2.3)Services use restraint safely



Evidence:

The restraint team includes the restraint co-ordinator, the GP, a registered nurses and a caregiver.The service has an approval process (as part of the restraint minimisation and safe practice policy) that is applicable to the service.There are approved restraints documented in the policy. The restraint co-ordinator is responsible for completing the documentation with input from registered nurses.The approval process includes ensuring the environment is appropriate and safe, that alternatives have been considered and attempted and restraint is used as a last resort.The service has an up to date restraint/enabler register. Restraint monitoring forms include type of restraint used times restraint on/off, visual checks time, care given and comments/effectiveness of restraint. Six of six restraint monitoring forms sighted show that restraint is always monitored within stated timeframes.

Criterion 2.2.3.2 (HDS(RMSP)S.2008:2.2.3.2)Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made:(a) Only as a last resort to maintain the safety of consumers, service providers or others;(b) Following appropriate planning and preparation;(c) By the most appropriate health professional;(d) When the environment is appropriate and safe for successful initiation;(e) When adequate resources are assembled to ensure safe initiation.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.4 (HDS(RMSP)S.2008:2.2.3.4)Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to:(a) Details of the reasons for initiating the restraint, including the desired outcome;(b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint;(c) Details of any advocacy/support offered, provided or facilitated;(d) The outcome of the restraint;(e) Any injury to any person as a result of the use of restraint;(f) Observations and monitoring of the consumer during the restraint;(g) Comments resulting from the evaluation of the restraint.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.5 (HDS(RMSP)S.2008:2.2.3.5)A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.4: Evaluation (HDS(RMSP)S.2008:2.2.4)Services evaluate all episodes of restraint.



Evidence:

The restraint evaluation includes the areas identified around future options to avoid the use of restraint, review of frequency of use and effectiveness as part of the care plan and restraint review and the impact the restraint has had on the resident. Family have participated in the evaluation for the use of restraint where evaluation has occurred. Three of three files sampled for residents using restraint have a documented evaluation.

Criterion 2.2.4.1 (HDS(RMSP)S.2008:2.2.4.1)Each episode of restraint is evaluated in collaboration with the consumer and shall consider:(a) Future options to avoid the use of restraint;(b) Whether the consumer's service delivery plan (or crisis plan) was followed;(c) Any review or modification required to the consumer's service delivery plan (or crisis plan);(d) Whether the desired outcome was achieved;(e) Whether the restraint was the least restrictive option to achieve the desired outcome;(f) The duration of the restraint episode and whether this was for the least amount of time required;(g) The impact the restraint had on the consumer;(h) Whether appropriate advocacy/support was provided or facilitated;(i) Whether the observations and monitoring were adequate and maintained the safety of the consumer;(j) Whether the service's policies and procedures were followed;(k) Any suggested changes or additions required to the restraint education for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.4.2 (HDS(RMSP)S.2008:2.2.4.2)Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.


Evidence:

Finding:

Corrective Action:


Standard 2.2.5: Restraint Monitoring and Quality Review (HDS(RMSP)S.2008:2.2.5)Services demonstrate the monitoring and quality review of their use of restraint.

ARC 5,4n ARHSS D5.4n, D16.6


Evidence:

Individuals approved restraint is reviewed at least three monthly through the restraint meeting and as part of the facility approval team review with family involvement. Restraint usage throughout the facility is analysed and information fed back to staff via all facility meetings.

Criterion 2.2.5.1 (HDS(RMSP)S.2008:2.2.5.1)Services conduct comprehensive reviews regularly, of all restraint practice in order to determine:(a) The extent of restraint use and any trends;(b) The organisation's progress in reducing restraint;(c) Adverse outcomes;(d) Service provider compliance with policies and procedures;(e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice;(f) If individual plans of care/support identified alternative techniques to restraint and demonstrate restraint evaluation;(g) Whether changes to policy, procedures, or guidelines are required; and(h) Whether there are additional education or training needs or changes required to existing education.


Evidence:

Finding:

Corrective Action:


NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards

Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1)There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service.

ARC D5.4e ARHSS D5.4e


Evidence:

The service and the environment minimise the risk of infection to residents, staff and visitors. The infection prevention and control programme is well known by staff as described by five caregivers and three registered nurses. There are documented processes implemented. There has been a comprehensive annual review of the infection control programme last in July 2013.

There are infection control policies that meet the Infection Control Standard SNZ HB 8134.3.1.2008 with policies reviewed in 2013.The infection control programme includes clear lines of accountability and is appropriate for the size, complexity, and degree of risk associated with the service.The infection control coordinator (a registered nurse) could describe how the service would manage an outbreak. Staff and visitors suffering from infectious diseases are advised not come to the facility. Residents suffering from infections will be isolated. An outbreak management policy is documented.Staff are aware not come to work when suffering from infections (confirmed at interviews with five caregivers and the three registered nurses interviewed). There is a staff policy around what should happen if staff are sick.The service currently has a scabies outbreak with five residents identified as having scabies. A full skin check has been completed and documented for all residents and staff. The DHB infection control specialist and Public Health have been informed and the service is actively working with the GP to treat the affected residents.

Criterion 3.1.1 (HDS(IPC)S.2008:3.1.1)The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.3 (HDS(IPC)S.2008:3.1.3)The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.9 (HDS(IPC)S.2008:3.1.9)Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.


Evidence:

Finding:

Corrective Action:


Standard 3.2: Implementing the infection control programme (HDS(IPC)S.2008:3.2)There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



Evidence:

The facility has adequate human, physical and information resources to implement the infection prevention and control programme. Administrative resources are available. The registered nurse who is the infection control coordinator is able to describe access to the DHB and the GP if advice and support is needed. The infection control coordinator would predominantly work with the DHB infection control specialist if any issues were identified. Infection prevention and control policies and procedures guide the infection control personnel in implementing the infection prevention and control programme.

Criterion 3.2.1 (HDS(IPC)S.2008:3.2.1)The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.


Evidence:

Finding:

Corrective Action:


Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3)Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a


Evidence:

Infection control and prevention policies and procedures are documented and implemented. The infection prevention and control policies and procedures contained in the infection prevention and control manual are directly linked to the overarching infection prevention and control programme and the quality and risk management programme through monthly CQI and staff meetings.D 19.2a: Infection control policies include hand washing policy and technique, standard precautions policy, isolation, disinfection, outbreak procedure, cleaning, disinfection and sterilisation guidelines, single use equipment, and policy and guidelines for antimicrobial usage and renovation and construction etc. Infection prevention and control policies and procedures are documented in a user friendly format and accessible to all staff. Policies and procedures relate to health and disability sector infection control standards and relevant reference material.

Criterion 3.3.1 (HDS(IPC)S.2008:3.3.1)There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.


Evidence:

Finding:

Corrective Action:


Standard 3.4: Education (HDS(IPC)S.2008:3.4)The organisation provides relevant education on infection control to all service providers, support staff, and consumers.



Evidence:

All staff receive infection prevention and control education at orientation and as part of the on-going education programme. All infection control education sessions are documented with PowerPoint presentations sighted. Resident education is expected to occur as part of providing daily cares. Support plans can include ways to assist staff in ensuring this occurs. Visitors are advised of any outbreaks of infection and are advised not to attend until the outbreak has been resolved. A sign is pre template to be displayed if there is a need to alert visitors. The infection control coordinator i.e. registered nurse/manager is responsible for coordinating education and training to staff. The five caregivers and three registered nurses interviewed said that education was included in training throughout the year. Infection control education was last delivered by the DHB infection control resource person in August 2013 and included hand hygiene and standard precautions. Twenty seven staff attended.

Criterion 3.4.1 (HDS(IPC)S.2008:3.4.1)Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.


Evidence:

Finding:

Corrective Action:


Criterion 3.4.5 (HDS(IPC)S.2008:3.4.5)Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept.


Evidence:

Finding:

Corrective Action:


Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5)Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.


Evidence:

Policies and procedures document infection prevention and control surveillance methods. The surveillance data is collected, collated and analysed to identify areas for improvement or corrective action requirements. Trends are analysed and discussed at monthly CQI and staff meetings and three monthly infection control meetings.Detailed information on the type of infections, treatment, duration of treatment and its effectiveness are recorded. Resident's infection trends/patterns are identified and recorded. Any corrective actions are acted upon as sighted in the meeting minutes.

Criterion 3.5.1 (HDS(IPC)S.2008:3.5.1)The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.


Evidence:

Finding:

Corrective Action:


Criterion 3.5.7 (HDS(IPC)S.2008:3.5.7)Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.


Evidence:

Finding:

Corrective Action:
