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Beta Pacifica Corporation Limited - Roseneath Lifecare

Current Status: 8 April 2014

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Provisional 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

Roseneath Care Services provides residential care for up to 46 residents and occupancy on the first day of the audit is 42. The service provider is certified to provide geriatric hospital level care, rest home level care and dementia level care. The facility is currently operated by Roseneath Care Services Limited. This provisional audit is undertaken to establish the extent to which the existing provider conforms to the requirements of the Health and Disability Services Standards and the district health board (DHB) funding contract prior to a change in ownership. This audit also establishes how well prepared the prospective provider is to provide a health and disability service. The Compliance and Policy Manager for the prospective provider, Beta Pacifica Corporation Limited, is interviewed during this audit. Residents and family members interviewed provide positive feedback on the care provided.

There are 23 areas identified during this audit that require improvement. The required improvements relate to: management of consent processes; maintenance of a complaints register; the currency of the strategic plan for the existing provider; maintenance of the quality and risk management programme including a risk register; analysis of quality improvement data; development of corrective action plans to address shortfalls in service; human resources management including criminal vetting, reference checking and review of staff performance; completion of orientation by new staff; the provision and management of in-service education and competency assessments for staff; management of resident documentation including resident progress notes and care plans; management of medication documents and processes; monitoring of residents’ weights; management of food service documentation including review of the menu and signing off of kitchen cleaning schedules; monitoring of restraint use for each resident; quality review of restraint used within the facility; the ongoing education of the infection control co-ordinator; and analysis of infection surveillance data.

HealthCERT Aged Residential Care Audit Report (version 4.0)

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: Beta Pacifica Corporation Limited

Certificate name: Beta Pacifica Corporation Limited - Roseneath Lifecare

Designated Auditing Agency: The DAA Group Limited

Types of audit: Provisional Audit

Premises audited: Roseneath Lifecare

Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit: Start date: 8 April 2014 End date: 9 April 2014

Proposed changes to current services (if any):Please note that dementia services are provided at Roseneath Lifecare

Total beds occupied across all premises included in the audit on the first day of the audit: 42

Audit Team

Lead Auditor XXXX Hours on site

16 Hours off site

16

Other Auditors XXXXX Total hours on site

16 Total hours off site

12

Technical Experts Total hours on site

Total hours off site

Consumer Auditors Total hours on site

Total hours off site

Peer Reviewer XXXXX Hours 4

Sample Totals

Total audit hours on site 32 Total audit hours off site 32 Total audit hours 64

Number of residents interviewed 5 Number of staff interviewed 17 Number of managers interviewed 2

Number of residents’ records reviewed

8 Number of staff records reviewed 8 Total number of managers (headcount)

2

Number of medication records reviewed

16 Total number of staff (headcount) 60 Number of relatives interviewed 4

Number of residents’ records reviewed using tracer methodology

3 Number of GPs interviewed 1

Declaration

I, XXXXX, Director of Wellington hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of The DAA Group Limited, an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of The DAA Group Limited Yes

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

c) The DAA Group Limited 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 Not Applicable

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

h) The DAA Group Limited has finished editing the document. Yes

Dated Monday, 28 April 2014

Executive Summary of Audit

General OverviewRoseneath Care Services provides residential care for up to 46 residents and occupancy on the first day of the audit is 42. The service provider is certified to provide geriatric hospital level care, rest home level care and dementia level care. The facility is currently operated by Roseneath Care Services Limited. This provisional audit is undertaken to establish the extent to which the existing provider conforms to the requirements of the Health and Disability Services Standards and the district health board (DHB) funding contract prior to a change in ownership. This audit also establishes how well prepared the prospective provider is to provide a health and disability service. The Compliance and Policy Manager for the prospective provider, Beta Pacifica Corporation Limited, is interviewed during this audit. Residents and family members interviewed provide positive feedback on the care provided.

There are 23 areas identified during this audit that require improvement. The required improvements relate to: management of consent processes; maintenance of a complaints register; the currency of the strategic plan for the existing provider; maintenance of the quality and risk management programme including a risk register; analysis of quality improvement data; development of corrective action plans to address shortfalls in service; human resources management including criminal vetting, reference checking and review of staff performance; completion of orientation by new staff; the provision and management of inservice education and competency assessments for staff; management of resident documentation including resident progress notes and care plans; management of medication documents and processes; monitoring of residents’ weights; management of food service documentation including review of the menu and signing off of kitchen cleaning schedules; monitoring of restraint use for each resident; quality review of restraint used within the facility; the ongoing education of the infection control co-ordinator; and analysis of infection surveillance data.

Outcome 1.1: Consumer RightsResidents and their families are provided with a range of information related to their rights at the time of admission and this is discussed with them on an on-going, as-required basis. Staff demonstrated a good understanding of residents’ rights and there is evidence of open communication between residents/families and staff. There are well developed policies to guide service provision that respects individual rights, cultural preferences and needs and this was confirmed in all interviews with residents and families.

The service has an open visiting policy and residents are encouraged to maintain their links with the community.

The mechanism for ensuring that residents consent to receiving aged residential care services is contained in the Resident Admission Agreement. Only two of the eight residents’ files reviewed contain a signed Admission Agreement and this is identified as an area requiring improvement. A second area identified as requiring improvement is that only residents complete an advance directive, rather than this being done on their behalf by their Enduring Power of Attorney.

Improvements are required with management of the complaints register as not all complaints and actions taken are entered in the register. The care manager is responsible for complaints. Staff, residents and family members interviewed report residents can use the complaints issues forms to raise any issues they have.

Outcome 1.2: Organisational ManagementRoseneath Care Services Limited is the current governing body and is responsible for the service provided at Roseneath Care Services. Planning documents reviewed include a mission statement, values, goals and objectives. The quality and risk management plan and the strategic plan are past their next review dates and improvements are required to this aspect of service delivery.

The facility is managed by the current owner who works full time on site. The facility manager is supported by a care manager who is a registered nurse and who was appointed to this position in January 2014. Improvements are required as the care manager does not have any previous management experience or training and has not completed an orientation to their role.

Beta Pacifica Corporation Limited is proposing to purchase the facility and assume responsibility for the provision of services from 30 May 2014. The compliance and policy manager for the prospective purchaser is interviewed and has been involved in the aged care sector for the last 10 years in various roles. The general manager for the prospective purchaser has extensive experience in owning and managing aged care facilities. A quality and risk management plan for the prospective purchaser is reviewed as is an organisational structure.

There is a documented internal audit programme available although improvements are required to several aspects of the management of the quality and risk management programme. These improvements include, but are not limited to, the currency of the quality and risk management plan, analysis of quality improvement data to identify trends and reporting of this data, maintenance of the internal audit programme including completion of resident/relative surveys, development of corrective action plans to address identified shortfalls, and maintenance of a risk register. Adverse events are documented on accident/incident forms and an electronic database.

There are policies and procedures on human resources management although improvements with human resource management are required. The improvements include: ensuring the validation of practising certificates for all service providers who require them to practice; completion of reference checking and criminal vetting for all new staff; ensuring all staff have current job descriptions and performance reviews; completion of orientation by all staff; the development and implementation of a documented inservice education programme; and ensuring that all staff who work in the dementia unit have completed the dementia specific unit standards.

There is a documented rationale for determining staffing levels and skill mix in order to provide safe service delivery. The minimum number of staff is provided during the night shift and consists of one registered nurse and two caregivers. The care manager is on call after hours. Care staff interviewed report there is adequate staff available and that they are able to get through their work.

Resident information is entered into a register in an accurate and timely manner. Residents' files are integrated; however improvements relating to the completeness of the entries in residents’ documentation are required.

Outcome 1.3: Continuum of Service DeliveryAll residents have an individualised plan for their service delivery, based on a range of clinical assessments. The General Practitioner visits the facility at least weekly and stated he is satisfied with the standard of services being provided. The service also has well-developed relationships with a range of specialist services at the Wairarapa District Health Board.

A minimum of one registered nurse is available to lead care delivery 24 hours a day and there are established processes in place to ensure continuity of care.

An experienced and qualified diversional therapist manages the varied and interesting activities programme, supported by a part-time recreational assistant. A dedicated mobility van is available to take residents on outings.

Service delivery plans do not include all the required support and interventions. There is no evidence that resident progress towards achieving goals is evaluated, or that service delivery plans are changed when progress is different from that expected. The care plan format for residents receiving Stage III dementia care does not contain all the requirements included in the age residential care contract. These are identified as areas for improvement.

Although there is a comprehensive medication policy in place there is no evidence that staff engaged in the administration of medications have had their medication administration competency assessed. Minor changes are needed to ensure that medication standing orders also include contra-indications for medication administration. There is no evidence that the temperature of the medication fridge is regularly monitored, and there are missing entries in the medication administration records. These are identified as areas for improvement.

There is no evidence that residents are being weighed on a regular basis, or that action is being taken if there are significant weight losses or weight gains. There is also no evidence that the menu has been reviewed by a registered dietician. While the kitchen was observed to be maintained in a hygienic manner, there were incomplete records related to implementation of the kitchen cleaning schedules. These are identified as areas for improvement.

Outcome 1.4: Safe and Appropriate EnvironmentBedrooms provide single accommodation and the majority have wash hand basins and toilets. There is an adequate number of toilet and shower facilities available throughout the facility. Residents' rooms are large enough to allow for the safe use of mobility aids, lifting aids, as well as a carer. There are separate lounges and dining areas available throughout the facility. An external area is available for sitting and shading is provided in external areas. An appropriate call bell system is available and security systems are in place.

Visual inspection provides evidence of sluice facilities, safe storage of chemicals and equipment, and that protective equipment and clothing is provided and is used by staff. Review of documentation provides evidence there are appropriate systems in place to ensure the residents’ physical environment is safe, and facilities are fit for their purpose.

There are policies and procedures for waste management, cleaning and laundry, and emergency management and these are known by staff. All laundry is washed on site and cleaning and laundry systems include appropriate monitoring systems in place to evaluate the effectiveness of these services. There are safe and hygienic storage areas for cleaning equipment, soiled linen and chemicals.

Outcome 2: Restraint Minimisation and Safe PracticeThere are currently seven residents using restraint and no residents using enablers. A restraint minimisation and safe practice policy is reviewed as is an up-to-date restraint register. Improvements are required with the management of documentation for residents who are using restraints. These include improvements to the monitoring forms and documenting in resident care plans the risks associated with the restraint used. Residents who are using restraint have their restraint usage reviewed two monthly, however, there is no facility wide quality review of restraint usage and improvements are required to address this.

Outcome 3: Infection Prevention and ControlA detailed and current plan is in place to guide infection prevention and control and minimise the risk of infection. The infection control coordinator is very new to the role and has not undertaken any training related to infection control management. This is identified as an area requiring improvement.

Limited infection surveillance data is available and this is not being analysed appropriately. This is also identified as an area requiring improvement.

Summary of Attainment

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

Standards 0 36 0 5 8 0 0

Criteria 0 78 0 8 14 0 0

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

Standards 0 0 1 0 0 0 0 0

Criteria 0 0 1 0 0 0 0 0

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

HDS(C)S.2008 Standard 1.1.10: Informed Consent

Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

PA Moderate

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

PA Moderate There is no evidence of consent to receiving residential aged care services in six of eight residents’ files reviewed.

There is evidence that all residents consent to receiving aged residential care services.

90

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

PA Low In one of three files of residents receiving Stage III dementia care, a

Only residents will make decisions related to their advance directive.

180


valid. family member with Enduring Power of Attorney has completed the advance directive on behalf of the resident.

HDS(C)S.2008 Standard 1.1.13: Complaints Management

The right of the consumer to make a complaint is understood, respected, and upheld.

PA Low

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

PA Low The complaints register: (i) does not include all of the complaints that have been received prior to 15 December 2013; and (ii) does not document the actions taken.

Provide documented evidence that the complaints register includes all complaints received and documents all actions taken.

90

HDS(C)S.2008 Standard 1.2.1: Governance

The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

PA Low

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

PA Low There is no documented evidence that the strategic plan for 2010 – 2012 has been reviewed and it is past the documented review date.

Provide documented evidence that the strategic plan has been reviewed.

90

HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems

The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

PA Moderate

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

PA Moderate Quality improvement data is not being comprehensively analysed and evaluated to identify trends. There is no documented

Provide documented evidence that quality improvement data is being comprehensively analysed to identify trends, and that quality improvement data is

90


evidence that quality improvement data is being reported to quality, clinical and/or staff meetings.

being reported to staff.

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

PA Low (i)There is no up-to-date quality and risk management plan available; (ii) There is minimal documented evidence available to indicate that the quality and risk management plan was maintained throughout 2013. (iii) There is no documented evidence available indicating that a resident satisfaction survey has been completed.

Provide documented evidence that (i) an up-to-date quality and risk management plan is available and is fully implemented; and (ii) a resident / family satisfaction survey is completed as part of the quality improvement programme.

180

HDS(C)S.2008 Criterion 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.

PA Moderate (i)Corrective action plans are not being developed, implemented and monitored to address areas identified as requiring improvement following internal audits and adverse events and in meeting minutes. (ii) Meeting minutes reviewed do not consistently provide evidence that responsibilities and timeframes for corrective actions are documented.

Provide documented evidence that: (i) corrective action plans addressing areas requiring improvement are being developed, monitored, evaluated and signed off as having been completed; and (ii) meeting minutes clearly document who is responsible for developing and implementing the corrective action/s and the timeframes for this.

90

HDS(C)S.2008 Criterion 1.2.3.9 Actual and potential risks are identified, documented and where appropriate communicated to consumers,

PA Moderate The ‘Health and Safety Register’ is not comprehensive and does not include all actual and

Provide documented evidence that actual and potential risks are identified, documented, monitored,

90


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.

potential risks associated with providing the service, for example human resources management, governance, business continuity risks are not identified and documented.

analysed, evaluated and reviewed on a regular basis.

HDS(C)S.2008 Standard 1.2.7: Human Resource Management

Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

PA Moderate

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

PA Low Eight staff files reviewed and there is no documented evidence of (i) criminal vetting having been completed on any of the eight staff files; (ii) reference checking has been completed on five of the staff files; (iii) job descriptions on six of the staff files; and (iv) the restraint co-ordinator and the infection control co-ordinator do not have job descriptions for these roles on their personal files.

Provide evidence that: (i) all new staff have criminal vetting and reference checking completed; (ii) all staff have job descriptions on their files; and (iii) the restraint co-ordinator and infection control co-ordinator have job descriptions for these roles.

180

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

PA Moderate (i)There is no documented evidence on seven of the eight staff

Provide evidence that: (i) all new staff receive an orientation to their role; and

90


essential components of the service provided.

files reviewed to indicate that an orientation has been completed. (ii) The care manager has not had any management training and has not completed an orientation to the role of care manager.

(ii) the clinical manager receives an orientation to the role of care manager.

HDS(C)S.2008 Criterion 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.

PA Moderate (i)There are no documented inservice education programmes available for 2013 and 2014.(ii) Core inservice education sessions have not been provided on a regular basis, for example, medication management, infection control, management of challenging behaviours, chemical safety, cultural awareness, the principles of informed consent, open disclosure, fire safety training, and emergency and security management education.(iii) Medication competencies are not current for all staff who are involved in medication management(iv) There is no documented evidence of current performance appraisals on eight of eight staff files reviewed(v) Ten of the 12 staff working in the dementia

Provide evidence that: (i) an inservice education programme covering all of the core education sessions is developed and implemented for 2014 and beyond; (ii) staff involved in medicine management complete medication competencies on at least an annual basis and that records of these are kept; (iii) all staff have current performance appraisals; (iv) that all staff working in the dementia unit commence and complete the dementia specific unit standards as identified in the district health board contract (E4.5); and (v) all registered nurses have current first aid certificates and that there is at least one staff member on each shift with a current first aid certificate.

90


unit have not commenced or completed the dementia specific unit standards.(vi) Five of the eight registered nurses do not have current first aid certificates and unable to determine there is a staff member on each shift with a current first aid certificate.

HDS(C)S.2008 Standard 1.2.9: Consumer Information Management Systems

Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

PA Low

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

PA Low Staff are not recording their full names when making entries in resident’s progress notes

Provide confirmation that staff are documenting their first and last names and their designation when making entries in records.

180

HDS(C)S.2008 Standard 1.3.5: Planning

Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

PA Moderate

HDS(C)S.2008 Criterion 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.

PA Moderate Service delivery plans do not describe the required support and interventions. Service delivery plans for residents receiving specialist dementia care do not include all of the information required under section E4.3 ii and iii (care planning) in the age related residential care services agreement.

(a)There is evidence that all care plans describe the required support and interventions necessary to achieve desired resident outcomes.(b) There is evidence that the care plans of all residents in the Stage III dementia unit comply with the requirements of the age related residential care services agreement.

90


HDS(C)S.2008 Standard 1.3.8: Evaluation

Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

UA Moderate

HDS(C)S.2008 Criterion 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.

UA Moderate There is no evidence that evaluations are being undertaken in a comprehensive and timely manner.

Provide evidence that service delivery plans are evaluated in a timely and comprehensive manner.

90

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

PA Moderate There is limited evidence that service delivery plans are changed when progress is different from expected.

Provide evidence that service delivery plans are updated when progress is different from expected.

90

HDS(C)S.2008 Standard 1.3.12: Medicine Management

Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

PA Moderate

HDS(C)S.2008 Criterion 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.

PA Moderate (i)Standing orders do not include contraindications for administration (ii) There is no evidence that the temperature of the medication fridge is being monitored (iii) There are missing entries in two of sixteen medication administration records (iv) There is no evidence that medications are checked on arrival from the pharmacy.

(i)Standing orders include contraindications for administration.(ii)Provide evidence that the temperature of the medication fridge is monitored daily.(iii)Provide evidence that medication administration records are complete.(iv)Provide evidence that medications are checked on arrival from the pharmacy.

60

HDS(C)S.2008 Criterion 1.3.12.3 Service providers responsible for medicine management are

PA Moderate There is no evidence that staff involved in the

Provide evidence that all staff involved in medication

90


competent to perform the function for each stage they manage.

administration of medicines have been assessed as competent to undertake this role.

management have been assessed as competent to undertake this role. .

HDS(C)S.2008 Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

PA Moderate

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

PA Moderate (i)There is no evidence that resident’s weight is monitored regularly. (ii) There is no evidence that a registered dietician has reviewed the menu.

(i)Provide evidence that residents are weighed on a regular basis. (ii) Provide evidence that the menu is reviewed by a registered dietician.

60

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

PA Low Although there is documented evidence of daily kitchen cleaning being completed as scheduled, the documentation related to weekly and monthly cleaning is more sporadic. There is also no evidence that the dishwasher machine is checked regularly.

Provide evidence that all cleaning is undertaken in accordance with the cleaning schedule.

90

HDS(RMSP)S.2008 Standard 2.2.3: Safe Restraint Use

Services use restraint safely PA Moderate

HDS(RMSP)S.2008 Criterion 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

PA Moderate (i) Monitoring Forms for one hospital resident is not comprehensive and does not include the time the restraint (lap belt) is applied and released. (ii) The care plan does not include the risks associated with the restraint used (lap belt) including the duration the

Provide evidence that (i) comprehensive monitoring of restraint use is occurring, including the actual time the restraint is applied and released and the duration of restraint use; and (ii) the care plans identify the risks associated with the restraint being used.

90


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.

restraint should be used for (Refer also criterion 1.3.3.3.)

HDS(RMSP)S.2008 Standard 2.2.5: Restraint Monitoring and Quality Review

Services demonstrate the monitoring and quality review of their use of restraint.

PA Low

HDS(RMSP)S.2008 Criterion 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

PA Low There is no restraint approval group that reviews the restraint practice for the facility to identify trends, the progress towards reducing restraint, compliance with policies and procedures, education and training needs and whether or not any changes are required to the policies and procedures.

Provide evidence that a restraint approval group is established that conducts comprehensive regular reviews of restraint practices for the facility including: the identification of trends, the progress towards reducing restraint usage, compliance with the organisation’s policies and procedures, identification of education and training needs for staff, and identifies whether or not any changes are required to the policies and procedures

180


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.

HDS(IPC)S.2008 Standard 3.4: Education

The organisation provides relevant education on infection control to all service providers, support staff, and consumers.

PA Moderate

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

PA Moderate The Infection Control Coordinator has not undertaken any training related to infection control management.

Provide evidence that the Infection Control Coordinator has completed appropriate education in infection control management.

90

HDS(IPC)S.2008 Standard 3.5: Surveillance

Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.

PA Low

HDS(IPC)S.2008 Criterion 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.

PA Moderate Infection surveillance is not being analysed in a comprehensive manner, and there is no evidence of actions arising from the data that is being collected.

Provide evidence that infection surveillance data is analysed and appropriate actions are taken as required.

90

Continuous Improvement (CI) ReportCode 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:On interview, ten of ten clinical staff (two team leaders, five caregivers and three registered nurses), two management staff (owner and Clinical Care Manager), and the diversional therapist all demonstrate a good understanding of residents’ rights, and are able to describe how they ensure those rights are maintained during service delivery. Throughout the audit visit staff were observed to be offering resident choices, treating them with respect and dignity, and knocking on their rooms prior to entering.

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:As part of the admission process, all prospective residents/families are given copies of the Code of Health and Disability Services Consumers’ Rights (the Code) and the Nationwide Health and Disability Advocacy Service, and additional copies of these brochures are prominently displayed in the reception area. This information is discussed with them at the time of admission by the Clinical Care Manager (CCM), or a Registered Nurse (RN). If further information is required, or residents’ needs change, the CCM and RNs are available for ongoing discussions with residents/families.

On interview, five of five residents (two hospital level care, three rest home care) and four family members (two with a family member in Stage III dementia care and two in rest home care) express their satisfaction with the information provided to them about rights, and that residents’ rights are being respected. On interview, the GP confirms that resident rights are respected and maintained and spoke highly of the care delivery staff.

The prospective purchaser has been involved in aged care ownership, governance and management for the last 15 years and has a thorough knowledge of the consumer rights it must adhere to.

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:A range of policies (including resident’s rights and responsibilities, abuse and neglect, and the provision of culturally and spiritually appropriate services) guide the provision of individualised resident service delivery.

Individualised care plans are developed for each resident, which include a strong focus on maintaining abilities and rehabilitation (eight of eight care plans are reviewed – three Stage III dementia, two rest home and three hospital). A personal communication profile form, completed at the time of admission, includes information on resident values and beliefs, family details, significant life events, personal and work history, and interests and hobbies.

All residents have a single room and are encouraged to personalise these with personal bric-a-brac and furniture. Staff were observed to knock prior to entering resident rooms and resident privacy was maintained during service delivery.

On interview, five of five residents confirm they are treated with respect and that their dignity and privacy are maintained. During the audit visit, residents in the Stage III dementia unit were noted to be treated in a calm and respectful manner, with every effort being made by staff to maintain an environment conducive to their wellbeing.

Policy, house rules and employment contracts outline expectations of staff related to abuse and neglect. On interview, the GP expressed no concerns with abuse or neglect, and his satisfaction with the services being provided. On interview, ten of ten clinical staff confirm their understanding of what constitutes abuse and neglect and the processes to be followed if this is suspected. (Refer to Criterion 1.2.7.5 re staff training). The hardcopies of resident information, such as resident files and medication charts, are stored in locked trolleys and during the audit visit these were consistently observed to be locked when unattended. All electronic records are on password-protected computers.

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:There are currently no residents who identify as Maori.

A policy on culturally and spiritually appropriate service delivery is available to guide the provision of culturally appropriate services for all residents, including Maori. The policy incorporates the philosophy of the Te Whare Tapa Wha model, and includes a Maori health plan, information on tikanga practices and other relevant information. A comprehensive list of the names and contact details for Maori cultural advisors and other sources of information is available. The service also maintains strong links with the Whaiora Health Service, based in Masterton.

Five clinical staff identify as Maori, including the CCM, who expresses her confidence in the ability of staff to meet the needs of Maori residents.

Following the death of a resident, their room is blessed by a local minister prior to a new resident being admitted.

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:A policy on culturally and spiritually appropriate service delivery guides the provision of culturally appropriate services for all residents.

On admission, all residents complete a personal communication profile (sighted in eight of eight residents’ records) which includes their values and beliefs, and personal preferences. On interview, five of five residents and four of four family members confirm culturally safe services are provided and their values and beliefs are respected.

Regular church services are held in the facility and residents also attend church services in the community.

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:On interview, ten of ten clinical staff confirm their understanding of what constitutes discrimination and the processes to be followed should this be suspected.Expectations of staff related to discrimination are contained in policies and house rules and the CCM reports this is included in staff orientation (refer to criterion 1.2.7.5).

On interview, five residents confirm they are not experiencing any discrimination and outline how they would raise their concerns should this arise. On interview, the GP confirms his satisfaction with service provision standards and his confidence that residents are not being discriminated against.

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:Clinical service delivery is guided by a range of policies and procedures (for example, wound management, continence management, pressure area risk management and pain management) that are comprehensive and reviewed on an annual basis (last reviewed in February 2014). It is noted however that some of the literature/resources referred to in these policies requires updating.

There are well-established professional networks which support an understanding of appropriate practice standards. Referrals are made to a variety of specialist staff from the Wairarapa District Health Board (sighted in two residents’ files), and there are close links with the Kahukura palliative care service in the Wairarapa.

A RN is on duty 24 hours per day and available to provide support and guidance to care delivery staff. The GP visits on a weekly basis, and as-required, and is also available after-hours. On interview, the GP confirms his satisfaction with the standard of care delivery, the appropriate and timely notification of any changes in resident needs, and that prescribed treatments are implemented.

The CCM and ten of ten clinical staff report they have access to regular and ongoing education relevant to service delivery (refer to criterion 1.2.7.5).

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:A policy on open disclosure helps guide staff and management communication – refer to criterion 1.2.4.

On interview, five of five residents state they feel comfortable with their communication with staff. Regular resident meetings (minutes sighted) are also held, where residents have the opportunity to raise any issues/suggestions they may have with management, and be kept informed with matters relating to the facility.

Four of four family members interviewed expressed their satisfaction with their communication with staff and advise they are promptly informed of any changes to their family member’s condition, and/or accidents and incidents. Eight of eight incident forms reviewed demonstrate that families are contacted following any incidents or

accidents. Family communication sheets, detailing contact from and with families, are in four of the eight residents’ files reviewed.

The CCM advises that if necessary interpreter services can be accessed through the Wairapapa District Health Board (WDHB), although no written information was sighted related to this.

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

Attainment and Risk: PA Moderate

Evidence:All prospective residents are provided with an admission pack, which contains a range of information, including the philosophy of the service, open disclosure, complaints and concerns, and the Code of Rights and responsibilities. Four of four family members, and two of two residents, confirm they have the information they need to allow them to be actively involved in their treatment and decision-making.

The service has a Resident Admission Agreement form, which includes all the requirements set out in Part D13 of the Age Related Residential Care Services Agreement. The mechanism for obtaining the consent of residents to the provision of aged resident care services is contained with the Resident Admission Agreement. Six of eight residents’ files reviewed do not contain a signed copy of the admission agreement and this is identified as an area for improvement. All eight files contain a number of separate consent forms related to various activities, such as having photographs taken, the release of health information, and consent to outings.

The policy on advance directives states that only a resident may make decisions related to their future health care treatment or procedures. In one of three care plans reviewed in the Stage III dementia unit, a family member who has Enduring Power of Attorney (copy sighted in resident file) has completed the advanced directive form, rather than the resident. This is identified as an area for improvement.

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:Written consent to receiving residential aged care is contained within the resident admission agreement. In six of the eight resident files reviewed there is no evidence of a completed resident admission agreement and management confirm these have not been completed. All eight resident files reviewed contain several written consent forms related to interventions, such as the release of health information, and the taking of photographs.

Finding:There is no evidence of consent to receiving residential aged care services in six of eight residents’ files reviewed.

Corrective Action:There is evidence that all residents consent to receiving aged residential care services.

Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

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.

Attainment and Risk: PA Low

Evidence:The policy on advance directives states that only a resident may make decisions related to their future health care treatment or procedures. In one of three care plans reviewed in the Stage III dementia unit, a family member who has Enduring Power of Attorney has completed the advanced directive form rather than the resident. All other advanced directives reviewed across the service were completed by the resident concerned.

Finding:In one of three files of residents receiving Stage III dementia care, a family member with Enduring Power of Attorney has completed the advance directive on behalf of the resident.

Corrective Action:Only residents will make decisions related to their advance directive.


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:At the time of admission residents are provided with a copy of the Nationwide Health and Disability Advocacy Service brochure, and further copies of this brochure are prominently displayed in the reception area. This is discussed with residents/families on admission by the CCM or an RN and further discussions are held if further information is required.

Five of five clinical staff confirm their understanding of the advocacy and support services and what steps should be taken to assist residents/families to access this if they so require. Four of four residents interviewed also confirm their understanding of how they would access advocacy or support and all expressed their comfort in approach the CCM or one of the RNs in the first instance if they had any concerns

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:Residents are actively encouraged to maintain community and family links. The service has an open visiting policy and four of four family members interviewed confirm

they always feel welcome when they visit. When residents are well enough, they are encouraged to maintain their community interests, and to visit family. One of the residents interviewed has a mobility scooter and is able to leave the facility as desired.

A dedicated mobility vehicle is available for regularly outings which enable residents to participate in a range of community events, drives and visits, such as the recent trip to the SPCA. Community groups and entertainers also visit the facility on a regular basis.

Residents are supported to access health care services outside of the facility, such as visits to the dentist, or the optician.

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:Improvements with the management of complaints are required as there is no historical complaints documentation available for review. A complaints register has been commenced by the recently appointed care manger but nothing is available prior to this (see criterion 1.1.13.3). The complaints register reviewed documents two complaints for 2014 and one for December 2013.

The care manager and owner/manager reports there have been no complaint investigations by the Health and Disability Commissioner, the Ministry of Health, Police, Accident Compensation Corporation (ACC) or Coroner since the previous audit at this facility.

Complaints policies and procedures are compliant with Right 10 of the Code. Systems are in place to ensure residents are advised on entry to the facility of the complaint processes and the Code. The admission information pack includes information on complaints and the Code and copies of these are given to all residents and their families as part of the admission process. Residents and family interviewed demonstrate an understanding and awareness of these processes and report they can raise any issues during their meetings.

A visual inspection of the facility evidences that the complaint process is readily accessible and/or displayed.

Not all district health board contractual funding requirements are met.

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:A ‘Complaints Register 2014’ is reviewed and documents two complaints for 2014 (11 March 2014 and 01 April 2014) and one for 15 December 2013. The care manager advises during interview that there was no complaints register kept for 2013 and that they started this register when they became care manager.

The policy is reviewed and provides the requirements/guidance around the complaints process. The care manager is now aware of responsibilities relating to complaints management.

The complaints folder includes documentation between the district health board (DHB) and the facility relating to three complaints received; one in March 2012, one in October 2013 and one in March 2014. Only the March 2014 complaint is recorded in the complaints register.

Finding:The complaints register: (i) does not include all of the complaints that have been received prior to 15 December 2013; and (ii) does not document the actions taken.

Corrective Action:Provide documented evidence that the complaints register includes all complaints received and documents all actions taken.


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:Beta Pacifica Corporation Limited is proposing to purchase this business and assume responsibility for the provision of services from 30 May 2014. The general manager for the prospective purchaser has been involved in aged care ownership, governance and management for the last 15 years. The existing provider and prospective provider advise they have had preliminary discussions with the district health board (DHB) portfolio manager concerning transfer of the aged related residential care (ARC) contract to the prospective purchaser.

A ‘Quality and Risk Management Plan 2012 - 2013’ (review due December 2013) is reviewed during this audit that includes goals and objectives. A ‘Roseneath Care Services Strategic Plan 2010 – 2012’ is reviewed with a review date November 2012. Improvements are required with the currency of both the strategic plan and quality and risk management plan. During interview the Compliance and Policy Manager for the prospective provider, Beta Pacifica, advises they are proposing to update the

quality and strategic plans for Roseneath Lifecare (see criterion 1.2.1.1 and link criterion 1.2.3.7). A transition plan/acquisition checklist is reviewed and identifies timeframes and responsibilities for the prospective purchaser.

Roseneath Care Services Limited is the current service provider and governing body. The owner is on site five days a week and in conjunction with the care manager is responsible for the day-to-day management of the facility. A new care manager was appointed in January 2014 and they are responsible for management of all aspects of clinical care. Prior to being appointed as the care manager this registered nurse was the clinical nurse and worked alongside the previous care manager who left in January 2014. The care manager’s personal file is reviewed and there is no documented evidence they have completed an orientation and received management training (see link to criterion 1.2.7.4). This finding is confirmed during interview of the care manager. The care manager has worked in the aged care sector since their graduation as a registered nurse in 2006.

Organisational structures for the current provider (Roseneath Care Services Limited) and the prospective provider (Beta Pacifica Corporation Limited) are reviewed. The prospective provider advises that with the exception of the responsibilities currently assumed by the existing owner/manager, they are not proposing to change any of the key personnel and staffing levels. The prospective purchaser advises during interview the care manager will be provided with supervision and support from an Operations Manager who is a registered nurse. The prospective purchaser advises the organisational structure will be reviewed over time and any necessary adjustments will be made as required.

Also reviewed are documented values, mission statement and philosophy. The service philosophy is in an understandable form and is available to residents and their family / representative or other services involved in referring residents to the service.

Roseneath Lifecare is certified to provide geriatric hospital level care, rest home level care and dementia services. There are 46 beds and 32 of these beds are able to be used by either rest home or hospital level care residents. There are 14 beds in the dementia unit. On the day of this audit there are 17 residents assessed as hospital, 12 assessed as rest home and 13 assessed as requiring dementia level care.

Roseneath Care Services Limited has contracts with the district health board (DHB) to provide aged related residential care (rest home, dementia and hospital services), day care, respite care, long term support for chronic health conditions and health recovery beds.

Not all district health board funding requirements are met.

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:‘Roseneath Care Services Strategic Plan 2010 – 2012’ is reviewed during this audit and has a review date of November 2012 documented. During interview the compliance and policy manager for the prospective provider, Beta Pacifica, advises they are proposing to review and update all documentation.

Finding:There is no documented evidence that the strategic plan for 2010 – 2012 has been reviewed and it is past the documented review date.

Corrective Action:Provide documented evidence that the strategic plan has been reviewed.


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:There are appropriate systems in place to ensure the day-to-day operations of the service continues should the owner/manager and/or the care manager (CM) be absent. The CM fills in for the owner/manager when they are absent and a senior registered nurse fills in for the CM if they are absent. Interview of the CM confirms their responsibility and authority for this role. The prospective provider advises they will review the organisational structure with regards to the responsibilities currently undertaken by the exisiting owner/manager. Twenty four hour registered nurse cover is provided and the prospective provider advises 24 hour cover will continue to be provided. They also advise they will provide clinical support for the CM via the Operations Manager.

Services provided meet the specific needs of the resident groups within the facility.

The district health board funding requirements are met.

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 prospective purchaser is interviewed and advises they are not proposing to change any of the policies and procedures following purchase. They advise they will be reviewing all documentation, including the quality and risk management plan and policies and procedures, within the first 12 months of ownership. Policies and procedures reviewed during this audit have been reviewed in February 2014 by the care manager.

Several areas requiring improvement have been identified during this audit relating to management and maintenance of the quality and risk management systems. That is, the quality and risk management plan has not been reviewed since December 2012); quality improvement and internal audit data is not available for 2013; quality improvement data is not being comprehensively analysed to identify trends and is not being reported to staff; a resident satisfaction survey has not been completed; corrective action plans are not developed to address shortfalls in service; and there is no risk register available that identifies all of the risks associated with providing services (see criteria 1.2.3.6, 1.2.3.7, 1.2.3.8 and 1.2.3.9.). The prospective purchaser advises they are proposing to strengthen the existing quality and risk management systems that are currently in place.

Quality improvement data is reported, collected and collated and is reviewed for 2014 only as there is no data for 2013 available for review during this audit. Staff advise during interview that quality information is reported to them via the staff meetings. Staff advise they are aware the quality improvement data is graphed but they do not always see copies of these graphs.


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:Quality improvement data for 2014 is reviewed during this data. There is no quality improvement data available for review for 2013 and the care manager advises this data was not collected. Bar graphs for the 2014 data are reviewed.

Monthly reports of numbers of falls, accidents and incidents, and infections for January to March 2014 inclusive are reviewed and provide evidence of collation of the clinical data that is collected.

Finding:Quality improvement data is not being comprehensively analysed and evaluated to identify trends. There is no documented evidence that quality improvement data is being reported to quality, clinical and/or staff meetings.

Corrective Action:Provide documented evidence that quality improvement data is being comprehensively analysed to identify trends, and that quality improvement data is being reported to

staff.


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:The current provider has a ‘Quality and Risk Management 2012 – 2013’ that was last reviewed on 12 December 2012 and the footer has the next review date as December 2013. A quality and risk management plan for 2011-2012 is also reviewed.

A ‘Roseneath Care Services Ltd Quality Monitoring Programme (sic) 2014’ is reviewed along with completed internal audits and quality improvement data for 2014. There are no internal audits available for review for 2013 and the care manager advises that apart from the kitchen and activities areas, there were no internal audits completed for 2013.

Quality, staff and clinical meeting minutes are reviewed during this audit and these are not being held on a regular basis.

Finding:(i)There is no up-to-date quality and risk management plan available; (ii) There is minimal documented evidence available to indicate that the quality and risk management plan was maintained throughout 2013. (iii) There is no documented evidence available indicating that a resident satisfaction survey has been completed.

Corrective Action:Provide documented evidence that (i) an up-to-date quality and risk management plan is available and is fully implemented; and (ii) a resident / family satisfaction survey is completed as part of the quality improvement programme.


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:Internal audit tools reviewed have a section headed ‘Recommendations’ at the end of it and are completed in a few of the internal audits that have been completed for 2014.

The ‘Accident/Incident Report’ has a ‘Follow Up Action’ section and a heading ‘C.A.R. (Corrective Action Report) Completed Yes / No ‘. Staff and clinical meeting minutes reviewed include a heading ‘Action’. Quality meeting minutes have headings for ‘Action Point’, ‘Responsibility’, and ‘Date Complete’. Under the date completed heading in quality minutes the word ‘ongoing’ is used frequently.

Finding:(i)Corrective action plans are not being developed, implemented and monitored to address areas identified as requiring improvement following internal audits and adverse events and in meeting minutes. (ii) Meeting minutes reviewed do not consistently provide evidence that responsibilities and timeframes for corrective actions are documented.

Corrective Action:Provide documented evidence that: (i) corrective action plans addressing areas requiring improvement are being developed, monitored, evaluated and signed off as having been completed; and (ii) meeting minutes clearly document who is responsible for developing and implementing the corrective action/s and the timeframes for this.


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:The care manager advises the organisation’s risk register is the ‘Health and Safety Register’ which is reviewed during this audit as well as an ‘Emergency Plan’. The ‘Health and Safety Register’ is not comprehensive and only has environmental hazards recorded. Completed ‘Hazard Identification Reporting Sheets’ are reviewed.

Finding:The ‘Health and Safety Register’ is not comprehensive and does not include all actual and potential risks associated with providing the service, for example human resources management, governance, business continuity risks are not identified and documented.

Corrective Action:Provide documented evidence that actual and potential risks are identified, documented, monitored, analysed, evaluated and reviewed on a regular basis.


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:The prospective purchaser, the existing owner/manager, and the care manager advise during interview that they are not aware of any legislative compliance issues that could affect the service.

Staff document adverse events on an ‘Accident / Incident Report Form’ and these are reviewed by the registered nurse before being given to the care manager for review and sign off. The care manager records these adverse events on an electronic spreadsheet and collates this data at the end of each month for graphing and reporting to the clinical meetings. The analysis of this data is rudimentary and improvements are required (see link criterion 1.2.3.6).

There is an open disclosure policy. Residents' documentation reviewed provides evidence of communication with families/next-of-kin/enduring power of attorney (EPOA) following adverse events involving the resident, or any change in the resident’s condition.

Staff confirm during interview that they are made aware of their notification responsibilities through job descriptions (see link criterion 1.2.7.3) and policies and procedures, which is confirmed via review of documentation. Policy and Procedures comply with essential notification reporting (e.g. health and safety, human resources, infection control). The owner/manager advises there have been no notifications of significant events made to the Ministry of Health.

The district health board funding requirements are met.

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:Improvements are required with human resource management as evidence of reference checking, criminal vetting, job descriptions, competency assessments, education records, current performance reviews and completed orientations are not available on all of the staff files reviewed (see criteria 1.2.7.3, 1.2.7.4 and 1.2.7.5).

Improvements are also required with the education programme as there is also no documented inservice education programme available for 2014 and not all staff working in the dementia unit have completed the dementia specific unit standards (see criterion 1.2.7.5).

Written policies and procedures in relation to human resources management are available and are reviewed during this audit. The skills and knowledge required for each position within the service is documented in job descriptions which outline accountability, responsibilities and authority, which were reviewed on two of the eight staff files reviewed along with employment agreements. The owner/manager advises that copies of these job descriptions are available for staff as required.

The care manager is responsible for management of the inservice education programme and advises they are currently developing an inservice education plan that will include all core education sessions. The care manager advises they are also proposing to develop a spreadsheet to record all staff education attended and competencies completed.

At the beginning of this audit copies of current practising certificates are not held for all staff that require them to practice. However, by the end of this audit copies of these have been obtained. It is recommended that improvements to the management of annual practising certificates be developed and implemented with a view to ensuring that copies of current annual practising certificates are held for all staff that require them to practice (criterion 1.2.7.2).

Care staff interviewed (five caregivers, two team leaders, three registered nurses) advise they have completed an orientation, including competency assessments (as

appropriate), however, there is minimal documented evidence on staff files to confirm this and improvements are required (see criterion 1.2.7.4 and 1.2.7.5). Care staff also confirm their attendance at on-going in-service education. Care staff report they do not have current performance appraisals.


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:Eight staff files are reviewed and all have individual employment agreements. Interview notes and evidence of reference checking is evident on some of the staff files. The care manager advises during interview that the employment agreement allows for criminal vetting but that this does not occur.

Finding:Eight staff files reviewed and there is no documented evidence of (i) criminal vetting having been completed on any of the eight staff files; (ii) reference checking has been completed on five of the staff files; (iii) job descriptions on six of the staff files; and (iv) the restraint co-ordinator and the infection control co-ordinator do not have job descriptions for these roles on their personal files.

Corrective Action:Provide evidence that: (i) all new staff have criminal vetting and reference checking completed; (ii) all staff have job descriptions on their files; and (iii) the restraint co-ordinator and infection control co-ordinator have job descriptions for these roles.


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:The care manager advises during interview that care staff receive an orientation that lasts three months at the end of which the staff member’s performance is assessed. An orientation booklet dated 2007 is reviewed during this audit. During interview care staff advises they have received an orientation.

The care manager’s personal file is reviewed and there is no evidence they have completed an orientation to the role of care manager. This finding is confirmed during interview of the care manager.

Finding:(i)There is no documented evidence on seven of the eight staff files reviewed to indicate that an orientation has been completed. (ii) The care manager has not had any management training and has not completed an orientation to the role of care manager.

Corrective Action:Provide evidence that: (i) all new staff receive an orientation to their role; and (ii) the clinical manager receives an orientation to the role of care manager.


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:The ‘Staff Inservice’ education folder is reviewed and includes inservice education programmes for 2010 to 2012 inclusive. The care manager advises during interview that the previous care manager had not developed an inservice programme for 2013.

The care manager is responsible for management of the inservice education programme and advises they are currently developing an inservice education plan that will include all core education sessions. The 2014 programme is not able to be located during this audit. The care manager advises they are also proposing to develop a spreadsheet to record all staff education attended and competencies completed.

The care manager advises during interview that electronic staff training records and records of competency assessments had been maintained by previous managers and that these are not able to be accessed as they are password protected and no-one knows the password.

The owner/manager and care manager advise the ACE education modules are available but they do not have an on-site ACE assessor who is approved to assess the ACE papers. The owner/manager contacted an ACE assessor during this audit who is visiting on Friday 11 April 2014 to enrol all care staff who are working in the dementia unit and who have not completed the dementia specific unit standards (ARC E4.5)

During interview care staff advise inservice education is provided but there is limited documentation available on staff files and in training records to confirm this has occurred in 2013.

An attendance record is reviewed for wound management training provided by a company representative who supplies wound care products on 21 March 2014 and was attended by eight staff.

Various attendance records are reviewed for 2012 including but not limited to: ‘Understanding Dementia’ education which was provided on 12 July 2012 and was attended by 15 staff; the Code which was provided on 15 and 20 March 2012 and 10 July 2012 and was attended by 36 staff; infection control education was provided on 23 May 2012 and was attended by 10 staff.

A blank template for inservice attendance is reviewed.

An appraisal schedule is in place however improvements are required as not all staff have current staff appraisals.

A medicine management audit completed on 12 February 2014 is reviewed and states “All staff currently going through med competency programme.” Staff files are reviewed and there is no documented evidence to support that staff are in the process of completing their medication competencies.

Staff training records indicate that not all registered nurses have current first aid certificates. One of the four caregivers who works the night shift has a current first aid certificate as do the two team leaders and three of the eight registered nurses.

Finding:(i)There are no documented inservice education programmes available for 2013 and 2014.(ii) Core inservice education sessions have not been provided on a regular basis, for example, medication management, infection control, management of challenging behaviours, chemical safety, cultural awareness, the principles of informed consent, open disclosure, fire safety training,and emergency and security management education.(iii) Medication competencies are not current for all staff who are involved in medication management(iv) There is no documented evidence of current performance appraisals on eight of eight staff files reviewed(v) Ten of the 12 staff working in the dementia unit have not commenced or completed the dementia specific unit standards.(vi) Five of the eight registered nurses do not have current first aid certificates and unable to determine there is a staff member on each shift with a current first aid certificate.

Corrective Action:Provide evidence that: (i) an inservice education programme covering all of the core education sessions is developed and implemented for 2014 and beyond; (ii) staff involved in medicine management complete medication competencies on at least an annual basis and that records of these are kept; (iii) all staff have current performance appraisals; (iv) that all staff working in the dementia unit commence and complete the dementia specific unit standards as identified in the district health board contract (E4.5); and (v) all registered nurses have current first aid certificates and that there is at least one staff member on each shift with a current first aid certificate.


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 prospective purchaser is interviewed and reports that initially they are not proposing to make any changes to the exisiting roster and staffing levels. A ‘Staffing Levels’ policy is reviewed as part of the ‘Our People – Human Resources’ policy and is provided by the exisiting provider. This staffing levels policy is not comprehensive and the prospective purchaser states during interview they will be implementing a new policy on the staffing rationale that is based on 'SNZ:HB 8163:2005 Indicators for Safe aged-care and dementia-care for Consumers'.

The rosters for the current service provider are reviewed and the minimum cover is provided between 11pm and 7am and consists of one registered nurse and two caregivers – one in the dementia unit and one in the rest home and hospital area. The care manager is also available after hours if required. Registered nurse cover is provided 24 hours a day.

Caregivers interviewed report that there is generally enough staff on duty and they are able to get through the work allocated to them. Residents interviewed report there is generally enough staff on duty to provide them with adequate care.

The district health board requirements are met.

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:Resident information is entered in an accurate and timely manner into a register (electronic) that is appropriate to the service. Interview of the receptionist confirms resident's data is entered on the day of admission to the facility. Resident files are integrated and recent test/investigation/assessment information is located in residents' files. Approved abbreviations are listed. Residents archived records are held on site and there are systems in place for retrieving these if required.

A visual inspection of the facility evidences that residents' information is stored in the staff office and is held securely and is not on public display. Clinical notes are accessible to all clinical staff. The resident's NHI number, name, and date of birth are used as the unique identifier. Improvements are required to the entries staff make in residents progress notes as staff are not recording their full names when making these entries (see criterion 1.2.9.9).

Care staff interviewed report they know how to maintain confidentiality of resident information. Historical records are held on site, and are secure.

With the exception of D7.1 the district health board requirements are met.

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:Resident files are reviewed and staff are recording their first name and designation when the staff member makes an entry in the resident’s progress notes.

Finding:Staff are not recording their full names when making entries in resident’s progress notes

Corrective Action:Provide confirmation that staff are documenting their first and last names and their designation when making entries in records.


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:All prospective residents must be assessed by FOCUS (the local support needs assessment service) prior to admission to the service. Roseneath Care Services works closely with FOCUS to ensure that residents’ level of care is identified and documented (verified in four of four care plans). The CCM confirms on interview that when individual approaches are made about admission, the prospective resident/family is advised that they must contact FOCUS first. The application for admission forms contains a statement that all residents must be assessed through FOCUS prior to admission. Completed admission forms are sighted in four of four resident files.

Prospective residents are provided with an admission pack. This includes comprehensive information about aspects of day to day living, the philosophy of the service, the open disclosure policy and protocol, complaints and concerns, and resident rights and responsibilities. They are also encouraged to visit the facility prior to admission, and staff are able to provide any further information they may require, especially in relation to the support needs assessment processes.

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:The CCM advises that the service works closely with FOCUS and the Wairarapa District Health Board to ensure that only residents who can safely and appropriately be cared for by the service are admitted. She cannot recall the service declining entry, but if this situation did arise, the service would work FOCUS to support the person and their family to find appropriate care/placement.

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:A RN is responsible for undertaking all the nursing assessments of new admission and then subsequent re-assessments within appropriate timeframes (confirmed in five of five resident files). Initial care plans are developed within 48 hours of admission (confirmed in two of two residents’ files) and a long-term care plan developed within three weeks of admission (confirmed in two of two residents’ files). There is evidence of ongoing clinical assessments, such as pressure area risk and falls risk, being undertaken on a three-monthly and as-required basis.

The GP is responsible for completing a medical assessment on admission, and then on a regular, agreed and as-required basis (confirmed in five of five resident files). On interview the GP reports his satisfaction with staff skills and knowledge, and that he is contacted in a timely and appropriate manner when medical events occur outside of his scheduled weekly visits.

Four of four residents, and four of four family members, confirm their inclusion in the initial and ongoing assessment and care planning process (although this is not well documented in the resident records). The four family members also confirm they are kept informed of any changes to the resident’s condition, and examples of this are noted on family communication sheets in five of five resident files.

The CCM, RNs and two team leaders coordinate service delivery across the facility. The CCM is on-call Monday-Friday and a senior RN is on-call over the weekends. The owner is on site each week day.

All caregiving staff are given a handover sheet at the start of their shift and attend a verbal handover. Entries are made in residents’ progress notes each shift. A communication book is also used to keep staff informed of events such as resident appointments and tests.

Tracer One (Stage III dementia care):XXXXXX This information has been deleted as it is specific to the health care of a resident.

Tracer Two (rest home): XXXXXX This information has been deleted as it is specific to the health care of a resident.

Tracer Three (hospital level care:)XXXXXX 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:A range of clinical assessments are undertaken as part of the initial assessment (including continence, pressure area risk, and falls risk) and these are reassessed on a regular (usually three monthly) and on an as-required basis (sighted in eight of eight resident files). Resident's preferences are identified in the personal communication profile and inform care plan development. The service also utilises the information provided by FOCUS, the interRAI assessment, and referral information from the WDHB and other providers.

An appropriate initial care plan format is completed for residents within 48 hours of admission (sighted in three of three care plans). A detailed long term care plan is developed for residents within three weeks of admission (confirmed in three of three current care plans). In the eight resident files reviewed, all the long term care plans are current, and on archived files reviewed there is evidence that long term care plans were reviewed within the appropriate time frames (three of three care plans).

Five of five residents and four of four family members confirm they are satisfied that residents’ needs, support requirements and preferences are assessed and recorded. The service does not currently have any staff who are trained in interRAI assessment, and no interRAI assessments have been undertaken within the service.

Refer to criterion 1.3.13.1 re nutritional assessments and areas identified for improvement.

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:Although individualised service delivery plans are developed for each resident and all resident files reviewed contain a current long-term care plan, these plans do not consistently contain sufficient detail to ensure that outcomes are achieved. This is identified as an area for improvement.

The current care plan format used for residents in the Stage III dementia unit does not meet the requirements of the age related residential care services contract and this is identified as an area for improvement.

Service delivery plans are integrated.

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:The lifestyle care plans policy establishes the timeframes for initial and ongoing assessments, the developments of initial and long term plans, the frequency of GP review, and the types of clinical assessments to be routinely undertaken (including pressure area and falls risk, continence, function assessment and activities). Although the CCM reports that residents/families are involved in the development of service delivery plans, this is not recorded in the current care plan format. Four of four family members and two of two residents confirm their involvement in the care plan development. Five of the eight care plans reviewed do not describe fully the support/interventions required to achieve desired outcomes

On review, the three care plans of residents receiving specialist dementia services do not include all of the inclusions required in Section E4.3 ii, iii and iv of the Age Residential Care Contract. The following criteria are missing - strategies for minimising episodes of challenging behaviours, descriptions of how the behaviour of the resident is best managed over a 24 hour period, or a description of the activities to meet their diversional, motivational and recreational therapy needs during the 24 hour period. These residents have an activities plan, but this does not specifically address their needs over the 24 hour period.

Refer also to Criterion 2.2.3.4

Finding:Service delivery plans do not describe the required support and interventions.

Service delivery plans for residents receiving specialist dementia care do not include all of the information required under section E4.3 ii and iii (care planning) in the age related residential care services agreement.

Corrective Action:(a)There is evidence that all care plans describe the required support and interventions necessary to achieve desired resident outcomes.(b) There is evidence that the care plans of all residents in the Stage III dementia unit comply with the requirements of the age related residential care services agreement.


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:A range of clinical policies guide the provision of service delivery. At least one RN is on duty 24 hours a day to lead service delivery and the CCM (also a RN), is available on week days. The GP visits the facility weekly and as-required, and is available for consultation after-hours.

An individualised care plan is developed for each resident (refer to criterion 1.3.5.2). Although some details of the required interventions may not be documented, on

interview, the GP confirms that adequate and appropriate services are provided to residents. Five of five residents and four of four residents’ families express their satisfaction with the services provided.

Refer to criterion 1.3.5.2.

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:A qualified diversional therapist, with eight years’ experience, leads the activities programme at Roseneath Lifecare, five days per week. She is supported by a recently appointed recreation officer.

There is a comprehensive and well-documented system for identifying resident activity preferences and requirements, planning these activities, and evaluating outcomes on a six monthly basis (confirmed in seven of seven resident files). The personal history form and the recreation questionnaire are used as the basis for identifying resident preferences and interests. Comprehensive records are maintained of resident participation in activities and all eight of eight resident files reviewed demonstrate regular and ongoing evaluation of resident activities plans.

A monthly recreation programme is developed, and distributed to residents. The programme includes entertainers, outings, quizzes and crosswords, exercises and celebration of festive events. Residents are encouraged to participate in the organised activities, but their wishes not to participate are respected. One-on-one activities such as hand massages are also offered to residents who are not able to attend group activities. Five of five residents and two of two family members confirm their satisfaction with the range of activities offered to residents.

The service has a dedicated mobility van, with a current warrant of fitness and registration, and is in regular use.

Bi-monthly diversional therapist meetings are held at the facility, and the diversional therapist confirms that she feels well-supported to access on-going education, including conference attendance.

Refer to criterion 1.3.5.2 re activities plans for residents in the Stage III dementia unit.

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

Attainment and Risk: UA Moderate

Evidence:Although care plans are reviewed and updated regularly and there is evidence of ongoing assessments in all of the eight residents’ files reviewed, there is no formal process used to document the evaluation of these plans. This is confirmed on interview with the CCM, and is identified as an area for improvement.

There is limited evidence that care plans are changed when progress is different from expected. This is identified as an area for improvement.

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.

Attainment and Risk: UA Moderate

Evidence:None of the eight care plans reviewed contain evidence that evaluation of these plans was/had been undertaken. Although there is some evidence in those current plans and archived long term care plans (three of three) that plans have been updated, there is currently no section in the care plan format for documenting resident progress against goals. It is recommended that the format of these care plans is reviewed to facilitate the documentation of evaluations.

Finding:There is no evidence that evaluations are being undertaken in a comprehensive and timely manner.

Corrective Action:Provide evidence that service delivery plans are evaluated in a timely and comprehensive manner.


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:There is limited evidence that service delivery plans are updated when progress is different from expected.

Finding:There is limited evidence that service delivery plans are changed when progress is different from expected.

Corrective Action:Provide evidence that service delivery plans are updated when progress is different from expected.


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:On interview, the CCM confirms that residents are support to access other health and disability services. In three of three care plans reviewed there is evidence of referral to other providers, such as an assessment for wheelchair modifications, and a referral to the palliative care service. On interview, two of two family members confirm that residents are support to access other health and disability services.

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:The service has a facility transfer form that is completed when a resident is discharged or transferred. This was sighted in one of two files of residents who had been transferred to WDHB. A copy of the second transfer form could not be located, but the resident’s archive file was not searched. On interview the CCM confirms that this information always accompanies the resident.

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:Comprehensive and current medicine management policies and procedures guide medicine management in the service. Residents receive medicines in a safe and timely manner that generally complies (see exceptions below) with current legislative requirements and safe practice guidelines.

The facility is currently implementing the Medichart electronic charting system. Hard copy medication charts printed from the Medichart system which are then signed by the GP are used as the basis for medication administration, and are updated whenever the medications are changed. This system means that updated medication charts are available to staff almost immediately, minimising the potential for confusion.

Medications are received monthly from the pharmacy (Packette system), and with the exception of medications requiring refrigeration (refer 1.3.12.1) are stored safely and securely. Although the CCM confirms medications are checked by an RN on arrival, there is no documented evidence to support this. This is identified as an area for improvement.

A medication round is observed, and medication is administrated in a safe and timely manner consistent with practice guidelines. With the exception of the Stage III dementia unit, all medication is administered by an RN. There is no evidence of medication competency assessment for staff involved in medication administration, including the staff administering medication in the Stage III unit, and this is identified as an area for improvement.

On each of the sixteen medication charts reviewed (eight hospital, four rest home and four dementia unit) the resident’s photos and any sensitivity to medication is included, and medications are charted appropriately.

All stock medication is current (checked monthly), and all medication, such as eye drops, have the date of first use recorded on them. The controlled drugs register

demonstrates that a weekly stock take of all controlled medicines is undertaken.

There are currently no residents who are self-medicating, but there are established processes to ensure resident safety with self-medication that can be implemented should this be required, and this is confirmed on interview with the CCM.

Several other areas of improvement related to medication are identified: the temperature of the medication fridge is not being monitored or recorded; standing orders do not include the contraindications to administration and there are missing entries in two of sixteen medication administration records.

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:A comprehensive medication policy provides a detailed framework for safe medicines management across the service, and on interview two of two RNs demonstrate their understanding of, and familiarity with the policy and its requirements.

Several aspects of the medicines management system require further improvement. A detailed and current standing orders protocol is in place, which complies with all requirements except for including the contra-indications for administration. There is no evidence that the temperature of the medication fridge is being monitored. In sixteen of the medication administration records reviewed, there are missing entries in two records. The CCM reports that all medications are checked by a RN on arrival from the pharmacy, but there is no documentation that this checking has been undertaken.

Finding:(i)Standing orders do not include contraindications for administration (ii) There is no evidence that the temperature of the medication fridge is being monitored(iii) There are missing entries in two of sixteen medication administration records (iv) There is no evidence that medications are checked on arrival from the pharmacy.

Corrective Action:(i)Standing orders include contraindications for administration.(ii)Provide evidence that the temperature of the medication fridge is monitored daily.(iii)Provide evidence that medication administration records are complete.(iv)Provide evidence that medications are checked on arrival from the pharmacy.


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:All medications are administered by a RN, with the exception of the Stage III dementia unit, where medications are administered by the Team Leader. Observation of one medication round demonstrates compliance with good practice. The CCM reports that she has recently personally supervised each of the staff administering medications to monitor their competency in this role. There is however no documented evidence that all staff involved in the administration of medicines have been assessed as competent to undertake this role.

Finding:There is no evidence that staff involved in the administration of medicines have been assessed as competent to undertake this role.

Corrective Action:Provide evidence that all staff involved in medication management have been assessed as competent to undertake this role. .


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:

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:An experienced and qualified (NZQA US 167) Food Services Team Manager is responsible for food service delivery. A second cook, and two kitchen hands, have also completed food handling training. Food is prepared on a four week cycle, and there are summer and winter menu plans.

On admission residents complete a copy of their dietary preferences and a copy of this is retained in the kitchen. There is evidence of resident meals being tailored to accommodate their dietary preferences, such as for a resident who requires a gluten-free diet. The nutritional needs of residents requiring diabetic or moulied diets, or those with restrictions related to other medications can also be accommodated.

The food services manager reports that six monthly surveys of resident satisfaction with meals are undertaken, but the results of these surveys were not available. On interview, eight of eight residents confirm their satisfaction with their meals.

Food is available in the main kitchen on a 24-hour basis for residents receiving specialist dementia services, and a very small amount of food is also kept in the unit itself.

There are detailed policies and procedures related to food services provision, including refrigeration guidelines, stock control, food storage, food preparation, serving food, and cleaning schedules. Although on inspection the kitchen is observed to be maintained in a hygienic condition, some of the weekly and monthly cleaning schedule documentation is incomplete. This is identified as an area for improvement. There is documentation of full compliance with testing that fridge and freezer temperatures, are maintained within appropriate ranges. Food is stored appropriately and there is evidence of stock rotation.

There is no evidence that residents’ weights are being monitored regularly, or evidence of a menu review by a registered dietician, and these are identified as areas for improvement. The food services manager reports that staff advise her verbally when a resident’s diet needs to be adjusted if they are losing or gaining weight inappropriately.

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:Breakfast is provided to residents in their individual rooms, but residents are encouraged to have their main meal of the day (lunch) in the dining room. On interview, four of four residents, and one of one family member, express their satisfaction with the food being offered to them. The lunchtime meal in the dining room is observed on both days of the audit, the atmosphere is calm, meals are attractively presented, and fluids are provided. Residents also have fluid in their rooms, and there are regular morning tea, afternoon tea and supper rounds. Although the Food Services Manager and the owner report on interview that the menu has been reviewed by a dietician within the past two years, they were unable to find evidence of this review.

In eight of eight resident files reviewed, there is no evidence that the resident’s weight is being monitored on a regular basis. In two of two files, the weight at the time of admission is also not recorded.

Finding:(i)There is no evidence that resident’s weight is monitored regularly. (ii) There is no evidence that a registered dietician has reviewed the menu.

Corrective Action:(i)Provide evidence that residents are weighed on a regular basis. (ii) Provide evidence that the menu is reviewed by a registered dietician.


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:Detailed cleaning schedules are available. Although there is full documentation of compliance with the daily cleaning schedule, the documentation relating to weekly and monthly cleaning is not complete. There is no evidence that the dishwasher machine is checked regularly, or the date it was last serviced. On inspection, the kitchen is observed to be maintained in a hygienic condition.

Finding:Although there is documented evidence of daily kitchen cleaning being completed as scheduled, the documentation related to weekly and monthly cleaning is more sporadic. There is also no evidence that the dishwasher machine is checked regularly.

Corrective Action:Provide evidence that all cleaning is undertaken in accordance with the cleaning schedule.


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:There are documented processes for the management of waste and hazardous substances in place. Policies and procedures specify labelling requirements. Material safety data sheets are available and are accessible for staff. Staff interviewed report they receive training and education to ensure safe and appropriate handling of waste and hazardous substances although there is no evidence of ongoing education having been provided (refer to criterion 1.2.7.5)

A visual inspection of the facility provides evidence that protective clothing and equipment that is appropriate to the risks associated with the waste or hazardous substance being handled are provided and is being used by staff. For example, goggles/visors, gloves, aprons, and masks are viewed in sluice rooms.

Visual inspection of the facility provides evidence that hazardous substances are correctly labelled, and the container is appropriate for the contents including container type, strength and type of lid/opening. Sluice rooms are available for the disposal of waste and hazardous substances.

The district health board requirement is met.

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 prospective purchaser advises during interview they have no plans to to make environmental changes to the facility. A maintenance person is employed for 40 hours a week and is interviewed during this audit. There is a second person employed for 18 hours a week who assist with maintenance as required and is responsible for maintenance of the grounds. During interview the maintenance person confirms there is a maintenance programme in place that ensures buildings, plant and equipment are maintained to an adequate standard. This finding is confirmed during visual inspection and review of maintenance documentation.

Planned and reactive maintenance systems are in place and are reviewed during this audit along with current calibration / performance verified stickers in place on medical equipment. Service provider's documentation and visual inspection evidences current Building Warrant of Fitness that expires 28 June 2014.

A visual inspection of the facility provides evidence of safe storage of medical equipment although storage space is limited and hoists and other equipment is observed stored in corridors.

Corridors are of various widths and allow residents to pass each other safely; safety rails are secure and are appropriately located.

The external areas are safely maintained and are appropriate to the resident group and setting, although there has been two recent events where residents have left the dementia facility. The care manager described the investigations and review processes following these adverse events, although the investigations, including corrective action plans, have not been documented (refer criterion 1.2.3.8). The care manager advises that staff are now more vigilant with ensuring doors are when staff and visitors are coming in and out of the dementia unit and when using the community hall. Residents are protected from risks associated with being outside (eg, provision of adequate and appropriate seating; provision of shade; and ensuring a safe area is available for recreation or evacuation purposes).

Staff report they receive education in the safe use of medical equipment by suitably qualified personnel, although there is limited documented evidence to support this (refer criterion 1.2.7.5). Care staff interviewed confirm that they have access to appropriate equipment; equipment is checked before use; and they are competent to use the equipment.

Residents 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.

The district health board requirements are met.

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:All bedrooms provide single accommodation and the majority have wash hand basins and toilets. There is an adequate number of communal toilet and shower facilities available throughout the facility. Five of the bedrooms have full ensuite facilities.

Visual inspection provides evidence that toilet, shower and bathing facilities are of an appropriate design and number to meet the needs of the residents. The fixtures, fittings, floors and wall surfaces are constructed from materials that can be easily cleaned. Hot water temperatures are monitored at monthly intervals and are two of the areas recorded exceed the recommended temperature range contained in BIA Approved Document G12 Water Supplies as determined by the Building Regulations 1992 (Acceptable Solutions). A plumber was contacted during this audit and visited to adjust the tempering valve so that water is delivered in line with the recommended temperatures. There is no evidence corrective action had been taken to address this issue prior to the auditor raising it during this audit (see link criterion 1.2.3.8). The temperatures for these areas were retested durng this audit and meet the required standard.

All toilets have appropriate access for residents based on their needs and abilities. There are clearly identified toilet/shower and wash basin facilities that meet specifications for people with disabilities that are large enough for manipulation of mobility aids and where practicable, provide working space for up to two service providers. Communal toilet/shower/bathing facilities have a system that indicates if it is engaged or vacant. Appropriately secured and approved handrails are provided in the toilet/shower/bathing areas, and other equipment/accessories are made available to promote resident independence


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:Visual inspection provides evidence that adequate personal space is provided in bedrooms to allow residents and staff to move around within the room safely. This finding was confirmed during interviews of staff and residents. The majority of bedrooms have double leaf doors and are large enough to allow for easy access for mobility aids.


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:Visual inspection provides evidence that adequate access is provided to lounges and dining rooms. Residents are observed moving freely within these areas. Residents interviewed confirm there are alternate areas available to them if communal activities are being run in one of these areas and they do not want to participate in them


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:Cleaning policy and procedures, and laundry policy and procedures are available. There are policies and procedures for the safe storage and use of chemicals / poisons.

All linen is washed on site and although the laundry is narrow in parts, there is adequate dirty / clean flow. The laundry person is interviewed in the laundry and describes the management of laundry including the transportation, sorting, storage, laundering, and the return of clean laundry to the residents.

Visual inspection of the facility provides evidence of implementation of appropriate cleaning and laundry processes. The effectiveness of the cleaning and laundry services is audited via the internal audit programme and completed audits for laundry and cleaning are reviewed for 2014.

Visual inspection of the facility provides evidence that: safe and secure storage areas are available and staff have appropriate and adequate access to these areas as required; chemicals are labelled and stored safely within these areas; chemical safety data sheets or equivalent are available; appropriate facilities exist for the disposal of soiled water/waste (ie, sluice room, convenient hand washing facilities are available, and hygiene standards are maintained in storage areas).

Residents interviewed state they are satisfied with the cleaning and laundry service.


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 are available. There are also policy/procedures for the safe and appropriate management of unwanted and/or restricted visitors.

New Zealand Fire Service letter (dated 23 October 2012) advising evacuation scheme approval is sighted. The last trial evacuation was held on 9 October 2013 as a result of a false alarm. The owner/manager advises that they are scheduling another trial evacuation within the next two weeks (refer criterion 1.2.7.5)

Not all registered nurses, vehicle drivers and activities personnel have completed first aid training and improvements are required (refer criterion 1.2.7.5). During interview care staff report they can not recall receiving emergency and security management education (refer criterion 1.2.7.5).

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; oxygen is maintained in a state of readiness for use in emergency situations.

A visual inspection of the facility evidences emergency lighting, torches, gas and BBQ for cooking, extra food supplies, emergency water supply (potable/drinkable supply and non-potable/non drinkable supply), blankets, and cell phones.

There is a call bell system in place that is used by the resident or staff member to summon assistance if required and is appropriate to the resident group and setting. Call bells are accessible / within reach, and are available in resident areas (eg, bedrooms, ablution areas, ensuite toilet/showers). Residents interviewed confirm they have a call bell system in place which is accessible and staff generally respond to it in a timely manner.


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:There are procedures to ensure the service is responsive to resident feedback in relation to heating and ventilation, wherever practicable. Heating is provided by heat pumps and panel heaters. Residents interviewed confirm the facility is maintained at an appropriate temperature.

Visual inspection evidences that the residents are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature. There are two bedrooms (rooms 11 and 12) that have had their views and the provision of natural lighting affected as a result of the new extension to the dementia unit. Room 11 has had another small window installed on another wall to compensate for this but this is not possible for room 12. The view from these rooms is to the dementia wall which is approximately 750mm away. The owner/manager advises the resident in room 12 spends very little time in this room and they have consented to being in this room. The owner/manager also advises building consent was granted by the local authority for this addition and it’s subsequent impact on the view and lighting from rooms 11 and 12.


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:‘Restraint Minimisation and Safe Practice’ policy is reviewed as well as ‘Managing Challenging Resident Behaviour’ policy and these record the assessment, monitoring and evaluation processes required.

There are currently seven residents using restraint and no residents using an enabler. This is confirmed during an interview of the care manager and review of the restraint/enabler register. Review of documentation provides evidence that residents are experiencing services that are the least restrictive. Documentation reviewed, including resident files, provides evidence of assessment, monitoring (refer criterion 2.2.3.4) and evaluation of restraint use for each resident.


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:Responsibilities and accountabilities for restraint are outlined in the restraint minimisation and safe practice policy that includes responsibilities for key staff at an organisational level and the service level and is reviewed during this audit. The restraint co-ordinator is a senior registered nurse but they are not available during this audit. The care manager who oversees the restraint co-ordinator is interviewed during this audit and they are able to describe the role and responsibilities of the position.

The restraint co-ordinator does not have a job description on their personal file (refer criterion 1.2.7.3). There is no restraint approval group for the facility (refer criterion 2.2.5.1) but each resident has a group of people who are responsible for approving the restraint they are using as well as reviewing the restraint/s used every two months. This group includes but is not limited to the resident’s GP, the care manager, a registered nurse and the resident and a family member.

There is no documented evidence that staff have received challenging behaviour and restraint minimisation and safe practice education in any of the staff files reviewed (refer criterion 1.2.7.5). ‘Understanding dementia’ education was provided by the owner/manager on 12 July 2012 and was attended by 15 members of staff. Two staff interviewed report they have received dementia awareness education in February 2014 but no documentation is available to support this.

The care manager advises during interview that restraint use is discussed during the clinical/registered nurse meetings.


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:Assessment processes are described in the restraint policies. Assessments are completed for residents using restraint and are sighted in two residents' files reviewed. One of the files is for a hospital resident who is using bedrails and the other is for the rest home resident who is using a lap belt. The care plans reviewed indicate the assessments are undertaken by suitably qualified and skilled staff in partnership with the resident and their family. The consent form documents that the RN, family and GP are involved. A ‘Checklist for ensuring safe and appropriate use of restraint’ is reviewed and includes the considerations when using restraint and what to do following restraint use.


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:Monitoring forms are reviewed for two residents using restraint and improvements are required to the monitoring of restraint use and the documentation of risks associated with restraint use in resident files (see criterion 2.2.3.4 and refer also to criterion 1.3.5.2)

The restraint checklist includes the considerations when using restraint and what to do following restraint use. A ‘Restraint Monitoring Form’ is reviewed and states the frequency of the monitoring is to be recorded in the resident’s care plan. The policy states a ‘Restraint Minimisation Evaluation Form’ is to be completed two monthly or sooner if indicates and covers the aspects of safe use of restraint.

There is an assessment process and it includes consultation with the resident and family. A restraint register is maintained that records the seven restraint users.

The district health board requirement D5.4n is met.

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:Monitoring forms for two residents are reviewed and the forms for the hospital are not comprehensive and do not include the time the restraint (lap belt) is applied and released. The restraint monitoring form records the time on as ‘am’. The care plan does not identify the duration the restraint should be used for (refer criterion 1.3.5.2.)

Finding:(i) Monitoring Forms for the hospital are not comprehensive and do not include the time the restraint (lap belt) is applied and released. (ii) The care plan does not include the risks associated with the restraint used (lap belt) including the duration the restraint should be used for (Refer also criterion 1.3.3.3.)

Corrective Action:Provide evidence that (i) comprehensive monitoring of restraint use is occurring, including the actual time the restraint is applied and released and the duration of restraint use; and (ii) the care plans identify the risks associated with the restraint being used.


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:Restraint evaluation processes are documented in the restraint minimisation and safe practice policy. Residents' documentation provides evidence that restraint is being evaluated at least two monthly. Restraint practices are discussed at each individual resident’s restraint approval meetings.


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:There is no restraint approval group for the facility and improvements are required to this aspect of service delivery (refer criterion 2.2.5.1).

Approved restraint for each resident is reviewed at least two monthly. This review is conducted with the family and resident. A basic challenging behaviour audit is reviewed that was completed on 12 February 2014 as well as a restraint audit that was completed in April 2014.


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:Use of restraint for each resident is monitored via ‘Restraint/Enablers Two Monthly GP Reviews 2014’ and are reviewed. The care manager advises there is a restraint approval group for each individual resident that includes but is not limited to the GP, the care manager, a registered nurse, the resident and/or their family. A basic challenging behaviour audit is reviewed that was completed on 12 February 2014 as well as a restraint audit that was completed in April 2014.

Finding:There is no restraint approval group that reviews the restraint practice for the facility to identify trends, the progress towards reducing restraint, compliance with policies and procedures, education and training needs and whether or not any changes are required to the policies and procedures.

Corrective Action:Provide evidence that a restraint approval group is established that conducts comprehensive regular reviews of restraint practices for the facility including: the identification of trends, the progress towards reducing restraint usage, compliance with the organisation’s policies and procedures, identification of education and training needs for staff, and identifies whether or not any changes are required to the policies and procedures


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:A current, comprehensive infection control management programme is in place, and was last reviewed in February 2014. The policy clearly establishes responsibility for infection control management and the lines of accountability relating to this. The policy makes clear that staff should not come to work if they are unwell and three of three staff interviewed confirm their understanding of this. A prominently displayed notice asks visitors not to enter the facility if they are unwell, and there are a number of hand sanitiser dispensers placed at central locations around the facility.

The current infection control team is the CCM, RNs and the GP. The CCM has overall responsibility for managing the infection control programme. Refer to criterion 1.2.7.3 regarding job descriptions.

Infection control matters are discussed at the weekly clinical meetings and on a daily as-required informal basis, with the facility owner. If additional information/support is required, this can be accessed from MedLab or the WDHB Infection Control team.

The CCM reports there have been no serious infection control outbreaks in the past two years.

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:Although the infection control manager has not received any education in infection control management (see criterion 3.4.1) the service has ready access to a range of infection control expertise at the WDHB and is aware of how to access this.

On interview, four of four staff report they have ready access to a range of personal protective equipment, such as gloves and plastic apron. There is a small supply of additional equipment (gloves, gowns/aprons, face masks and hand sanitiser) stored at the facility in the event of an outbreak, although the CCM is aware that these supplies would need to be supplemented quickly should an outbreak occur.

All single-use equipment, such as syringes and sterile scissors, is disposed of immediately after use.

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:A comprehensive infection control policy, last reviewed in February 2014, is in place to guide infection control prevention and management. This includes infection definitions, standard precautions, the use of personal protective equipment, the management of outbreaks and MRSA, preventing staff infections and information on infectious diseases and their management.

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:The infection control coordinator has not undertaken any training related to infection control management and this is identified as an area for improvement.Refer also to criterion 1.2.7.5 regarding staff training.

There is evidence of education being provided to residents, such as information on hand washing being displayed around the facility. Residents were also observed being reminded to wash their hands prior to going to the dining room.

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:The CCM, who is the Infection Control Coordinator, reports that she has not undertaken any training related to infection control management.

Finding:The Infection Control Coordinator has not undertaken any training related to infection control management.

Corrective Action:Provide evidence that the Infection Control Coordinator has completed appropriate education in infection control management.


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:The infection control policy establishes the types of surveillance data that is to be collected, and the surveillance data that has been collected from January 2014 is consistent with this policy. Standardised definitions are used for the identification and classification of infections. Infection reports, completed by RNs, are filed centrally, and the CCM is responsible for collating this information, and undertaking the analysis (confirmed on interview with the CCM, reports sighted).

The CCM reports that no infection surveillance data was collected in 2013. The data available from January 2014 has been collated and graphed, and copies of the graphed data are on display in each of the staff offices, but no formal analysis of the data, or identification of trends, has been undertaken. This is identified as an area for improvement.

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:The infection control policy establishes the types of surveillance data that is to be collected, and the surveillance data that has been collected from January 2014 (infections of skin and wounds, urinary tract, respiratory, ear, nose and eye, oral, gastro and systemic infections) is consistent with this policy. Surveillance data is graphed and copies of the graphed data are sighted in two nursing offices.

The surveillance data collected from January 2014 has not been analysed in a comprehensive manner, and there is no evidence of any actions being taken related to this data.

Finding:Infection surveillance is not being analysed in a comprehensive manner, and there is no evidence of actions arising from the data that is being collected.

Corrective Action:Provide evidence that infection surveillance data is analysed and appropriate actions are taken as required.


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