certification audit summary · web viewthese relate to hazard monitoring, post incident recordings...

Kaikohe Aged Care Centre Limited

CURRENT STATUS: 20-Aug-13

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

GENERAL OVERVIEW

Kaikohe Aged Care continues to provide rest home, dementia and hospital services to a total of 55 residents. There have been no changes to management or the environment since the last audit. Processes regarding care and support remain unchanged and meet the needs of residents. Occupancy on the day of the audit is 39.

At the previous audit, five required improvements were identified. At this unannounced audit, four of the previous required improvements are noted to have been addressed and four new areas for improvement are required. These relate to hazard monitoring, post incident recordings and essential notifications, closure of treatment plans and individual supplies of medication.

AUDIT SUMMARY AS AT 20-AUG-13

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short fallsStandards applicable to this service fully attained

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

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

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights Day of Audit

20-Aug-13

Assessment

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

Standards applicable to this service fully attained

Organisational Management Day of Audit

20-Aug-13

Assessment

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


Continuum of Service Delivery Day of Audit

20-Aug-13

Assessment

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


Safe and Appropriate Environment Day of Audit

20-Aug-13

Assessment

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


Restraint Minimisation and Safe Practice Day of Audit

20-Aug-13

Assessment

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


Infection Prevention and Control Day of Audit

20-Aug-13

Assessment

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


Kaikohe Care CentreKaikohe Care Centre Limited

Surveillance audit - Audit Report

Audit Date: 20-Aug-13

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Kaikohe Care Centre Limited

Premise Name Street Address Suburb City

Kaikohe Care Centre 22 Bissett Road Kaikohe

Proposed changes of current services (e.g. reconfiguration):

Type of Audit Surveillance audit and (if applicable)

Date(s) of Audit Start Date: 20-Aug-13 End Date: 21-Aug-13

Designated Auditing Agency

Health Audit (NZ) Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXX RN, LA, 8086 12.00 6.00 20-Aug-13 to 21-Aug-13

Auditor 1 XXXXXXXRGON, BA, Reg. Lead Auditor RABQSA

12.00 4.00 20-Aug-13 to 21-Aug-13

Auditor 2

Auditor 3

Auditor 4

Auditor 5

Auditor 6

Clinical Expert

Technical Expert

Consumer Auditor

Peer Review Auditor XXXXXXX

RN, BN, Lead Auditor

1.00

Total Audit Hours on site 24.00 Total Audit Hours off site (system generated)

11.00 Total Audit Hours 35.00

Staff Records Reviewed 7 of 36 Client Records Reviewed (numeric)

5 of 39 Number of Client Records Reviewed

using Tracer Methodology

3 of 5

Staff Interviewed 14 of 36 Management Interviewed (numeric)

1 of 1 Relatives Interviewed (numeric)

2

Consumers Interviewed 5 of 39 Number of Medication Records Reviewed

10 of 39 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

I, (full name of agent or employee of the company) XXXXXXX (occupation) Director of (place) Auckland hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf ofHealth Audit (NZ) Limited, an auditing agency designated under section 32 of the Act.

I confirm that Health Audit (NZ) Limitedhas in place effective arrangements to avoid or manage any conflicts of interest that may arise.

Dated this 17 day of August 2013

Please check the box below to indicate that you are a DAA delegated authority, and agree to the terms in the Declaration section of this document.

This also indicates that you have finished editing the document and have updated the Summary of Attainment and CAR sections using the instructions at the bottom of this page.

Click here to indicate that you have provided all the information that is relevant to the audit:

The audit summary has been developed in consultation with the provider:

Electronic Sign Off from a DAA delegated authority (click here):

Services and Capacity

Kinds of services certified

Hospital Care Rest Home Care

Residential Disability Care

Premise Name Total Number of Beds

Number of Beds Occupied on Day of Audit

Number of Swing Beds for Aged Residen-tial Care

Kaikohe Care Centre 55 39

Executive Summary of Audit

General Overview

Kaikohe Aged Care continues to provide rest home, dementia and hospital services to a total of 55 residents. The have been no changes to management or the environment since the last audit. Processes regarding care and support remain unchanged and meet the needs of residents. Occupancy on the day of the audit is 39.

At the previous audit, five required improvements were identified. At this unannounced audit, four of the previous required improvements are noted to have been addressed and four new areas for improvement are required. These relate to hazard monitoring, post incident recordings and essential notifications, closure of treatment plans and individual supplies of medication.

1.1 Consumer Rights

Open communication channels between the organisation and residents is effective and maintained. Residents and relatives are advised on entry to the facility of the complaint process and demonstrate a good understanding of this process. There is evidence that all expressed concerns and/or formal complaints are taken seriously and acknowledged by the service, and then investigated and managed in ways that facilitates resolution.

1.2 Organisational Management

Systems are established and maintained by the senior management. Business/strategic planning clearly defines the scope, direction and goals of the facility and monitoring and reporting processes against these. The facility is managed by a suitably qualified and experienced person at all times. The required policies, procedures and work instructions are documented and available to all staff. Key quality goals are monitored and, where variation occurs, remedial actions are implemented.

Adequate human resource management and employment policies are in place. There is a system for validating professional qualifications and vetting new prospective staff members. An orientation/induction programme is available and all new staff. Staffing levels are adequate to meet the staffing guidelines for rest home, hospital and dementia residents over the 24 hours. There is an in-service education programme that exceeds requirements and covers relevant aspects of care and support. Staff performance is monitored. 1.3 Continuum of Service Delivery

The service provides appropriate service provision for residents who need rest home, hospital or secure dementia care. Each stage of service provision is undertaken by suitably qualified and experienced nursing and care staff. The assessment, planning, provision and review of care is provided in time frames that meet the residents' needs and complies with contractual requirements. The residents and family interviewed report satisfaction with the quality of care provided at the service. The facility is in the process of implementing the InterRAI assessment system and using it as the basis for long term care planning. Care plans are comprehensive and evidence input from the resident and family as able. Residents with disturbed behaviour have behaviour management plans but an improvement required following the last audit relating to ensuring that residents in the dementia unit have care plans that identify behaviour patterns and management strategies across 24 hours has been partly implemented. Further improvement is required. Where there are temporary changes in

a resident's condition, for example a wound needing care, the service uses short term care plans to document the resident's needs, treatment and progress. Improvement is required to ensure that the record includes a final evaluation and sign off by the registered nurse when treatment is no longer required.

The activities programme supports the interests, needs and strengths of the residents in rest home, hospital and specialist dementia services. The residents and families interviewed express satisfaction with the activities provided. A documented medicine management system is in place. Improvement is required to the documented policy to include a process for managing alternative therapies such as supplements and rongoa. Improvement is also required in relation to managing discrepancies in controlled drugs supplies. including appropriate notifications. The registered nurses and designated senior caregivers responsible for medicine management are assessed as competent to do so. Improvement is required to ensure that administration of liquid medications to rest home residents complies with medicines regulations and that the process for documenting medication discrepancies is consistently followed. Residents express satisfaction with meals and confirm that additional snacks and drinks are available on request. The menus are appropriate to the resident group and have been reviewed by a dietician. The previous improvements required relating to dating of food in the fridge / freezers, and monitoring of fridge / freezer temperatures have been effectively addressed.

1.4 Safe and Appropriate Environment

The current Building Warrant of Fitness is displayed at the entrance to the facility. The required improvement regarding maintenance and calibration of equipment and monitoring hot water temperatures has been adequately addressed.

2 Restraint Minimisation and Safe Practice

The facility does not currently have any residents using enablers. Relevant training in the use of restraint and enablers has been provided for staff in the last two years. Staff interviewed demonstrated understanding of the safe use of enablers should they be required. The previous improvement required relating to de-escalation training for non-clinical staff has been addressed.

3. Infection Prevention and Control

The facility maintains procedures for the prevention and control of infections. Incidence of infections and use of antibiotics are surveyed monthly. Staff are informed and results used to improve infection c control practices. There have been no outbreaks of infection since the last audit.

Summary of Attainment

1.1 Consumer Rights

Attainment CI FA PA UA NA ofStandard 1.1.1 Consumer rights during service delivery Not Applicable 0 0 0 0 0 1

Standard 1.1.2 Consumer rights during service delivery Not Applicable 0 0 0 0 0 4

Standard 1.1.3 Independence, personal privacy, dignity and respect Not Applicable 0 0 0 0 0 7

Standard 1.1.4 Recognition of Māori values and beliefs Not Applicable 0 0 0 0 0 7

Standard 1.1.6 Recognition and respect of the individual’s culture, values, and beliefs Not Applicable 0 0 0 0 0 2

Standard 1.1.7 Discrimination Not Applicable 0 0 0 0 0 5

Standard 1.1.8 Good practice Not Applicable 0 0 0 0 0 1

Standard 1.1.9 Communication FA 0 2 0 0 0 4

Standard 1.1.10 Informed consent Not Applicable 0 0 0 0 0 9

Standard 1.1.11 Advocacy and support Not Applicable 0 0 0 0 0 3

Standard 1.1.12 Links with family/whānau and other community resources Not Applicable 0 0 0 0 0 2

Standard 1.1.13 Complaints management FA 0 2 0 0 0 3

Consumer Rights Standards (of 12): N/A:10 CI:0 FA: 2 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Criteria (of 48): CI:0 FA:4 PA:0 UA:0 NA: 0

1.2 Organisational Management

Attainment CI FA PA UA NA of

Standard 1.2.1 Governance FA 0 2 0 0 0 3

Standard 1.2.2 Service Management FA 0 1 0 0 0 2

Standard 1.2.3 Quality and Risk Management Systems PA Low 0 7 1 0 0 9

Standard 1.2.4 Adverse event reporting PA Moderate 0 0 2 0 0 4

Standard 1.2.7 Human resource management FA 0 4 0 0 0 5

Standard 1.2.8 Service provider availability FA 0 1 0 0 0 1

Standard 1.2.9 Consumer information management systems Not Applicable 0 0 0 0 0 10

Organisational Management Standards (of 7): N/A:1 CI:0 FA: 4 PA Neg: 0 PA Low: 1 PA Mod: 1 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.3 Continuum of Service Delivery


Standard 1.3.1 Entry to services Not Applicable 0 0 0 0 0 5

Standard 1.3.2 Declining referral/entry to services Not Applicable 0 0 0 0 0 2

Standard 1.3.3 Service provision requirements FA 0 3 0 0 0 6

Standard 1.3.4 Assessment Not Applicable 0 0 0 0 0 5

Standard 1.3.5 Planning Not Applicable 0 0 0 0 0 5

Standard 1.3.6 Service delivery / interventions PA Moderate 0 0 1 0 0 5

Standard 1.3.7 Planned activities FA 0 1 0 0 0 3

Standard 1.3.8 Evaluation PA Low 0 1 1 0 0 4

Standard 1.3.9 Referral to other health and disability services (internal and external) Not Applicable 0 0 0 0 0 2

Standard 1.3.10 Transition, exit, discharge, or transfer Not Applicable 0 0 0 0 0 2

Standard 1.3.12 Medicine management PA High 0 3 1 0 0 7

Standard 1.3.13 Nutrition, safe food, and fluid management FA 0 3 0 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:6 CI:0 FA: 3 PA Neg: 0 PA Low: 1 PA Mod: 1 PA High: 1PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.4 Safe and Appropriate Environment


Standard 1.4.1 Management of waste and hazardous substances Not Applicable 0 0 0 0 0 6

Standard 1.4.2 Facility specifications FA 0 2 0 0 0 7

Standard 1.4.3 Toilet, shower, and bathing facilities FA 0 0 0 0 0 5

Standard 1.4.4 Personal space/bed areas Not Applicable 0 0 0 0 0 2

Standard 1.4.5 Communal areas for entertainment, recreation, and dining Not Applicable 0 0 0 0 0 3

Standard 1.4.6 Cleaning and laundry services Not Applicable 0 0 0 0 0 3

Standard 1.4.7 Essential, emergency, and security systems Not Applicable 0 0 0 0 0 7

Standard 1.4.8 Natural light, ventilation, and heating Not Applicable 0 0 0 0 0 3

Safe and Appropriate Environment Standards (of 8): N/A:6 CI:0 FA: 2 PA Neg: 0 PA Low: 0 PA Mod: 0PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


2 Restraint Minimisation and Safe Practice


Standard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6

Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3

Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2

Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 0 6

Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3

Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 0 1

Restraint Minimisation and Safe Practice Standards (of 6): N/A: 5 CI:0 FA: 1 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


3 Infection Prevention and Control


Standard 3.1 Infection control management Not Applicable 0 0 0 0 0 9

Standard 3.2 Implementing the infection control programme Not Applicable 0 0 0 0 0 4

Standard 3.3 Policies and procedures Not Applicable 0 0 0 0 0 3

Standard 3.4 Education Not Applicable 0 0 0 0 0 5

Standard 3.5 Surveillance FA 0 2 0 0 0 8

Infection Prevention and Control Standards (of 5): N/A: 4 CI:0 FA: 1 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


Total Standards (of 50) N/A: 32 CI: 0 FA: 13 PA Neg: 0 PA Low: 2 PA Mod: 2 PA High: 1 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 0 FA: 35 PA: 6 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Kaikohe Care Centre LimitedType of Audit: Surveillance audit

Date(s) of Audit Report: Start Date:20-Aug-13 End Date: 21-Aug-13DAA: Health Audit (NZ) LimitedLead Auditor: XXXXXXX

Std Criteria Rating Evidence Timeframe1.2.3 1.2.3.5 PA

LowFinding:Although hazards are identified and discussed at quality meetings, there is no clear link with the health and safety committee and no evidence the hazard register is reviewed and/or monitored.

Action:Review and monitor hazards (as required) through the health and safety meetings.

6 months

1.2.4 1.2.4.3 PALow

Finding:Records of immediate post fall observations have not been maintained.

Action:Maintain records of immediate post fall observations.

6 months

1.3.6 1.3.6.1 PAModerate

Finding:Residents in the dementia unit do have behaviour management plans but the plans do not provide an overview of behaviour patterns and relevant management strategies over 24 hours.No action has been taken to investigate and reverse persistent weight loss of 1kg - 1.5kg per month shown by a rest home resident over the last six months..There is no evidence that neurological observations are done on residents following unwitnessed falls.

Action:Develop and implement behaviour management plans for residents in the dementia unit that provide an overview of behaviour patterns and relevant management strategies over 24 hours.Implement processes to monitor the results of monthly weighs and ensure that action is taken to Investigate and reverse adverse trends.Ensure that neurological observations are done for residents who hit their head in a fall, or who have an unwitnessed fall.

3 months

1.3.8 1.3.8.2 PALow

Finding:According to staff and resident interviews, the wound of a rest home resident reviewed u healed in June but this is not documented in progress notes nor on the wound management plan.

Action:Improvement is required to ensure that a final evaluation and sign off by the RN is recorded on wound management plans when no further treatment is required.

6 months

1.3.12 1.3.12.1 PAHigh

Finding:1. The documented medicine management policy does not include a process for managing alternative therapies, such as homeopathic medicines and rongoa.2. Liquid Paracetamol elixir is administered to individual residents from a stock bottle in both the rest home and the dementia unit.3.There is no evidence that the discrepancy in the Controlled Drug Register of 14 tablets of morphine sulphate 30mgm tabs noted on 24-Sept-12 has been documented on an incident or medication error form, investigated or reported to the DHB or the police.4. There are no guidelines for essential notifications in the event of missing controlled drugs.

Action:1. Revise the medicine management policy to include processes for managing alternative therapies such as homeopathic medicines and rongoa.2. Ensure that liquid medications are only administered from individually prescribed and named supplies.3. Ensure that the process documented in the medicine management policy for addressing medication errors is consistently followed and that guidelines are documented in relation to essential notifications to be made in the case of missing controlled drugs.4. Provide written guidelines for essential notifications in the event of missing controlled drugs.

1 month.

Continuous Improvement (CI) Report

Provider Name: Kaikohe Care Centre LimitedType of Audit: Surveillance audit

Date(s) of Audit Report: Start Date:20-Aug-13 End Date: 21-Aug-13DAA: Health Audit (NZ) LimitedLead Auditor: XXXXXXX

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS

OUTCOME 1.1 CONSUMER RIGHTSConsumers 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 1.1.9 CommunicationService 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

Evaluation methods used: D SI STI MI CI MaI V CQ SQ STQ Ma L

How is achievement of this standard met or not met? Attainment: FA

There is a policy on Open Disclosure. Incidents and adverse events are managed in an open manner and there is clear evidence of family contact in incident records sampled. Residents and family member interviewed state they have the opportunity to talk to management or staff and are able to request changes if needed. Family member also state they are contacted if there are changes in a resident's health status. Residents speak English and/or Maori. A number of staff speak Te Reo. In addition, the services of an interpreter can be accessed through the Northland District Health Board if required.

The remaining related ARC requirements are met. Residents receive adequate information regarding the services they are provided. All residents (or family) sign a resident agreement which outlines subsidies and services that are provided .There is a process for advising non-subsidised residents of their eligibility and the process to become a subsidised resident should they wish to do so. This information is included in the admission pack. There are currently three non-subsidised residents. A copy of the Ministry of Health “Long-term residential care in a rest home or hospital – what you need to know 2012 ” is provided. All residents sign a consent form and service agreement on admission.

Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers.

Audit Evidence Attainment: FA Risk level for PA/UA:

Finding Statement

Corrective Action Required:

Timeframe:

Criterion 1.1.9.4 Wherever necessary and reasonably practicable, interpreter services are provided.


Finding Statement


Timeframe:

STANDARD 1.1.13 Complaints ManagementThe 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


How is achievement of this standard met or not met? Attainment: FAThe complaints policy meets the requirements of right 10 of the Code of Health and Disability Services Consumer Rights. All residents receive information on the complaints process on admission, including the right to access independent advocacy services. Complaint forms are also easily accessible throughout the facility. Residents interviewed confirm they are aware of the complaints process and feel confident they would make a complaint if required.Records of complaints sampled confirm the result of investigations and detail any remedial actions taken. An analysis of complaints is included at the monthly quality meetings. The complaints register is current and includes all complaints, dates and actions taken. There have no complaints to the Health and Disability Commissioner since the last certification audit, however there have been two complaints to the District Health Board (DHB). One in November 2012 and one in March 2013. Records sighted confirm that these have been adequately addressed, investigated and closed to the satisfaction of the complainant and/or DHB.

The ARC requirements are met.

Criterion 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.


Finding Statement


Timeframe:

Criterion 1.1.13.3 An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.


Finding Statement


Timeframe:

OUTCOME 1.2 ORGANISATIONAL MANAGEMENTConsumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.

STANDARD 1.2.1 GovernanceThe 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


How is achievement of this standard met or not met? Attainment: FAThe Directors are responsible for developing the purpose, scope, mission and goals of the organisation. The vision of the Directors is documented in the current strategic and business plan. The business plan (2013) is sighted and reflects current goals regarding sustainability and customer focus.

Organisational performance is monitored. One Director is on site frequently and receives copies of the quality (CQI) and nursing meeting minutes. The Facility Manager and Director meet monthly and minutes of senior management meetings are sighted.The Facility Manager is interviewed. The Facility Manager has been employed in the role since February 2012. Her staff file is sighted and confirms appropriate clinical and management experience. She is a registered nurse and has a graduate diploma in Business Management. She was the previous Facility Manager from 1994-2004. The Facility Manager job description includes authorities, responsibilities and accountability. The Facility Manager has exceeded the required eight hours professional development per annum and is actively involved in the aged care sector.

The remaining relevant ARC requirements have been met.

Criterion 1.2.1.1 The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.


Finding Statement


Timeframe:

Criterion 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.


Finding Statement


Timeframe:

STANDARD 1.2.2 Service Management

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


How is achievement of this standard met or not met? Attainment: FAA senior registered nurse performs the role of the Facility Manager in her absence. The senior nurse who is currently delegated this role was the previous Facility Manager, prior to 2004, and has adequate management experience. Delegation to senior nursing staff in the absence of the Facility Manager is defined in the 'On Call Policy' and reporting lines are documented in the current organisational flowchart.

The ARC requirements are met. The service philosophy is commensurate with the needs of the older person and management strategies include safety obligations.

Criterion 1.2.2.1 During a temporary absence a suitably qualified and/or experienced person performs the manager's role.


Finding Statement


Timeframe:

STANDARD 1.2.3 Quality And Risk Management SystemsThe 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


How is achievement of this standard met or not met? Attainment: PA Low

There are policies and procedures that identify quality outcomes for key components of service delivery, including quality and risk management. These comply with standards. The Facility Manager ensures that the current version of all policies, procedures and work instructions are available to staff. Review dates are sighted on the footer of all documents. All obsolete documents are identified as such, removed from circulation and a copy maintained. Staff interviewed are aware of the process for implementing new policies and procedures and are required to sign an acknowledgement that they have read and understood new policies. Policies sighted reflect ARC requirements and best practice. The organisation has a quality programme that is implemented in practice. There is a documented annual Quality and Risk Management plan (January 2012 - 2013) with goals and objectives identified. Each goal has associated key tasks and identified outcomes. Achievement towards quality targets is reviewed at CQI meetings. The CQI team includes representation from each service area. Quality improvement data is analysed to identify trends and themes. This includes incidents, infections, audits, complaints and restraint. Meeting minutes and staff interviews provide evidence that the information is communicated to staff, and residents and family wherever appropriate. Feedback from the annual family and resident satisfaction surveys is also used to improve services.There is an internal audit schedule that is implemented. Audits are scheduled at regular intervals to cover the scope of the quality system. Examples of internal audits are sighted and confirm audits are conducted as scheduled, include required corrective actions, which are then communicated to staff through the CQI and registered nurse meeting minutes. A risk management plan is documented and includes all risk management activities and makes reference to hazard monitoring. Risks and hazards are discussed at CQI meetings. There is a health and safety committee and it is noted that health and safety meetings are required to be conducted every three months, however only one meeting has occurred thus far for the year 2013. There is no clear link with the health and safety committee to the CQI committee and no evidence the hazard register is reviewed and/or monitored. An improvement is required.

The remaining relevant ARC requirements have been met. The organisation has an appropriate accounting system. Finances are managed by the administrator and the Facility Manager. The Facility Manager reports variance to the Board.

Criterion 1.2.3.1 The organisation has a quality and risk management system which is understood and implemented by service providers.


Finding Statement


Timeframe:

Criterion 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.


Finding Statement


Timeframe:

Criterion 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.


Finding Statement


Timeframe:

Criterion 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system.This shall include, but is not limited to:

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.

Audit Evidence Attainment: PA Risk level for PA/UA: Low

There is evidence of new hazards being discussed at the CQI meeting, if identified through the accident and incident reporting process. There is also a hazard register. The Health and Safety committee is currently required to meet every three months. The committee has not been meeting as frequently as required (once thus far in 2013) and there is no evidence that hazards have been reviewed and/or monitored.

Finding StatementAlthough hazards are identified and discussed at quality meetings, there is no clear link with the health and safety committee and no evidence the hazard register is reviewed and/or monitored.

Corrective Action Required:Review and monitor hazards (as required) through the health and safety meetings.

Timeframe:6 months

Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.


Finding Statement


Timeframe:

Criterion 1.2.3.7 A process to measure achievement against the quality and risk management plan is implemented.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

Criterion 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.


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STANDARD 1.2.4 Adverse Event ReportingAll 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


How is achievement of this standard met or not met? Attainment: PA ModerateIndividual incident and accident reports are required to be completed for each incident/accident with immediate action noted and any follow up action required. The Facility Manager signs off each incident form and a copy of the incident forms are kept in each resident file and an individual register maintained. The service collates incidents, accidents, unplanned or untoward events monthly and provides feedback to the service and staff. Incidents and accidents are benchmarked with five other local providers. Benchmarking includes statistics on falls, skin tears, challenging behaviours and near misses (per 100 bed days). Minutes of the August 2013 CQI meeting provides evidence of discussion on incidents/accidents and actions taken. There is evidence that deficits are remedied and improvements are made. Incidents are also categorised in order to determine essential notifications. All level one and level two incidents are notified to the Directors ad District Health Board and the Ministry of Health. Incident reports sighted included essential notifications to family and the general practitioner (as required), however it is noted that the required essential notification was not made following a medication incident in 2012 and an improvement is required (refer # 1.3.12.1). Four recent incidents are sampled and tracked by the auditor to ensure investigation, appropriate actions and closure. The related incident reports and resident files are sighted. Two incidents were unwitnessed falls and records of immediate (and post fall) observations have not been recorded and an additional improvement is required. All four sampled incidents have been reported at the CQI meeting.

The remaining ARC requirements are met

Criterion 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.

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateRefer to criterion 1.3.12.1 regarding essential notifications following medication incident.

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Criterion 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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowFour incident reports are tracked. Two of these are unwitnessed falls. The required first aid was provided, however records of immediate post falls observations have not been maintained. One incident report states that immediate 'observations' were taken, however these were not recorded. This resident was transferred to hospital in the ambulance. The other made no mention of observations/or immediate post fall recordings.

Finding StatementRecords of immediate post fall observations have not been maintained.

Corrective Action Required:Maintain records of immediate post fall observations.

Timeframe:6 months

STANDARD 1.2.7 Human Resource ManagementHuman 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


How is achievement of this standard met or not met? Attainment: FAThere are written policies and procedures in relation to human resource management which comply with current good employment practice. Seven staff files are sampled. The sample is stratified and includes two registered nurses, ancillary staff and care givers. The sample includes two staff on permanent night shift.The skills and knowledge required for each position within the service is documented in job descriptions which outline accountability, responsibilities and authority. The more recent staff files sampled have the required recruitment screening including references (the others have been employed for over 20 years). There is a system for the validation of professional qualifications for both employed and external health professionals.All new staff receive an orientation to the facility and to their respective job The orientation programme includes the essential components of service delivery, including philosophy and best practice, resident rights, training requirements, managing challenging behaviour, abuse and neglect, emergency procedures. Completed orientation records are sighted in files sampled.There is a planned programme of on-going education. The provision of training is provided to meet contract requirements. Individual training records are maintained and attendance at training is monitored. Training records of permanent night staff confirm attendance at training.The improvement required regarding dementia training for staff working in the protected living environment (PLE) has been adequately addressed. A sample from the current roster confirms staff working in the PLE have either completed or commenced the ACE dementia training (two are yet to commence but have not been employed for six months yet and are overseas trained registered nurses).Performance is monitored and an annual appraisal is completed for all staff.

The remaining relevant ARC requirements are met

Criterion 1.2.7.2 Professional qualifications are validated, including evidence of registration and scope of practice for service providers.


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Criterion 1.2.7.3 The appointment of appropriate service providers to safely meet the needs of consumers.


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Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided.


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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.


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STANDARD 1.2.8 Service Provider AvailabilityConsumers 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


How is achievement of this standard met or not met? Attainment: FAThe facility employs 36 staff. This includes registered nurses, enrolled nurses, care givers, ancillary, maintenance and administration staff. There is a documented rationale for determining service provider levels and skill mixes. The 'Annual Leave and Rostering Policy' defines rostering guidelines and takes into account the lay out of the facility. The appropriate skill mix is reflected on the roster. A registered nurse is on duty at all times, and there are three registered nurses who live permanently on site. There are two care givers on each duty in the PLE and the hospital area and one care giver rostered per shift in the rest home. In addition, the diversional therapist and Facility Manager are on site each day (Monday to Friday). There are three permanent night staff. The Facility Manager is also available on call 24 hours a day. In times of sickness or annual leave, staffing resources are accessed from the current team, as there is no access to agency staff in the area. Orientation and training records confirm that staff are suitably qualified and the PLE is staffed by care givers who have, or are completing, the ACE dementia training. There have been no reported incidents or complaints which relate to staffing levels. Resident, family and the GP interviewed state that they have access to staff as required.The remaining related ARC requirements are met. A copy of registered nurses annual practicing certificates is maintained and scope of practice is defined.

Criterion 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.


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OUTCOME 1.3 CONTINUUM OF SERVICE DELIVERYConsumers 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 1.3.3 Service Provision RequirementsConsumers 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


How is achievement of this standard met or not met? Attainment: FAEach stage of assessment, planning, provision of care, review/evaluation is undertaken by suitably qualified staff who are competent to perform their role. Five of five residents' files reviewed (one dementia unit resident, two rest home and two hospital residents) confirm that the registered nurse (RN) conducts the initial assessment and initial care plan on admission to the service, develops the long term care plan within three weeks of admission and reviews and evaluates the plan at least six monthly. Plans are developed with input from the resident and family who sign the plan as they are able. The facility is in the process of introducing the InterRAI assessment process. To date 14 of the 39 residents have been entered into the system and the assessments used as the basis for planning their care. The care givers (CGs) provide most of the direct care under the direction of the RN. There is a detailed orientation, on-going education programme and competency assessment process that ensures the care staff are suitably qualified to perform their role. The care plan identifies the need, desired outcome or goal, level of support required and the interventions and support. The evaluation records if the desired outcomes or goals are met and progress towards achievement of outcomes (confirmed in five of five residents' files reviewed (one resident with dementia, two rest home and two hospital residents). The multi-disciplinary review is conducted at least six monthly and has input from nursing, pharmacy, recreational therapist, dietician, key caregiver, GP and other allied health services applicable to the resident (also involves resident and family) to review the resident’s needs. The five residents’ files reviewed evidence the initial medical review is conducted within two days of admission (where required). On-going medical reviews are conducted monthly or at least three monthly when the resident is assessed as stable (more frequently when required for the residents changing needs). The doctor interviewed was satisfied with the level of communication from the staff and with the standard of care provided to his patients.

The service is co-ordinated in a manner that promotes continuity of care. Progress notes are updated each shift (confirmed in the five residents' files reviewed). A documented handover and verbal report are provided at the start of each shift (witnessed). CGs interviewed report that adequate information is provided at handover, in resident progress notes, and on the communication sheet. The five residents interviewed (one dementia unit resident, two rest home and two hospital residents) and two family members interviewed (one rest home, and one hospital) report the residents receive care that meets their needs.

Tracer # 1 - Dementia Unit: XXXXXX This information has been deleted as it is specific to the health care of a resident.

Tracer # 2 - Hospital: XXXXXX This information has been deleted as it is specific to the health care of a resident. Tracer # 3- Rest Home: XXXXXX This information has been deleted as it is specific to the health care of a resident. Other ARC requirements are met.

Criterion 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.


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Criterion 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.


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Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.


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STANDARD 1.3.6 Service Delivery/InterventionsConsumers 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


How is achievement of this standard met or not met? Attainment: PA ModerateThe five care plans reviewed (two rest home, two hospital and one dementia unit resident) have interventions based on the residents' needs. The service has paper based assessment and care planning records. The care plan records the identified need, level of assistance required, desired outcomes or goals that are individualised to the resident’s needs. The resident living in the dementia unit reviewed has a behaviour assessment with specific interventions recorded to identify preventive and de-escalation techniques. The previous improvement required in relation to 24 hour behaviour management plans for residents in dementia unit has been partly implemented. Improvement is required to ensure that all residents have behaviour management plans that identify their behaviour patterns and appropriate management strategies over 24 hours. The hospital resident reviewed has interventions for wound care recorded on the wound assessment plan. The rest home resident reviewed does not have specific interventions for the management of the resident's weight loss. Neither is there evidence that neurological observations have been done following three un-witnessed falls. Improvement is required to ensure that the results of monthly weighs are monitored and action taken to investigate and reverse unwanted trends.

Each resident file reviewed includes a behaviour management assessment and plan. The plan identifies behaviour triggers and management strategies but does not detail the behaviour pattern over 24 hours. An improvement required following the last audit relating to ensuring that residents in the dementia unit have care plans that identify behaviour patterns and management strategies across 24 hours has been partly addressed. Further improvement is required to ensure that the behaviour plan contains sufficient detail to provide a 24 hour overview of behaviour patterns and appropriate management strategies.Six CGs and two RNs interviewed, (from rest home, hospital and dementia unit and who work all shifts), report the hand over reports, progress notes and care plans provide accurate information regarding the individual needs and care required for the residents. Five residents and two family members interviewed report satisfaction with the care provided and commented on the friendly and homelike nature of the service. Each resident file reviewed includes a behaviour management assessment and plan. An improvement required following the last audit under 1.3.5.1 relating to ensuring that residents in the dementia unit have care plans that identify behaviour patterns and management strategies across 24 hours has been partly addressed. Further improvement is required to ensure that the behaviour plan contains sufficient detail to provide a 24 hour overview of behaviour patterns and appropriate management strategies.The ARC requirements are met.

Criterion 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.

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateThe resident living in the dementia unit reviewed has a behaviour assessment with specific interventions recorded to manage challenging behaviour. However the behaviour management plan does not provide an overview of behaviour patterns and relevant management strategies over 24 hours. (Refer to 1.3.3.3).The rest home resident reviewed does not have specific interventions for the management of the resident's weight loss. Neither is there evidence that neurological observations have been done following three un-witnessed falls.

Finding StatementResidents in the dementia unit do have behaviour management plans but the plans do not provide an overview of behaviour patterns and relevant management strategies over 24 hours. No action has been taken to investigate and reverse persistent weight loss of 1kg - 1.5kg per month shown by a rest home resident over the last six months.There is no evidence that neurological observations are done on residents following un-witnessed falls.

Corrective Action Required:Develop and implement behaviour management plans for residents in the dementia unit that provide an overview of behaviour patterns and relevant management strategies over 24 hours. Implement processes to monitor the results of monthly weighs and ensure that action is taken to Investigate and reverse adverse trends.Ensure that neurological observations are done for residents who hit their head in a fall, or who have an un-witnessed fall.

Timeframe:3 months

STANDARD 1.3.7 Planned Activities

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


How is achievement of this standard met or not met? Attainment: FAThere is a qualified diversional therapist who provides recreational activities in the rest home / hospital and in the dementia unit for 25 hours per week. She also works 17.5 hours per week as a care giver and so knows the residents well. A social profile is completed with each resident and family as available and able on admission and the activities plans are individualised to the resident’s needs and interests. Care givers in the dementia unit are trained by the divisional therapist to continue the activities in her absence, e.g. over the weekend. There is a monthly activities programme that includes special occasions, reflects events outside the facility, and includes trips out and visits from external groups into the home. Five of five activities assessments sighted in the residents' files are up to date and reflect the individualised interests of the residents where practicable. The activities assessment includes social pursuits, intellectual interests, creative pursuits, physical activity, and outdoor interests. The diversional therapist maintains a participation record for each resident.The diversional therapist participates in the six monthly multidisciplinary evaluation, review and update of each resident's goals and reports that where residents have a specific need, the service endeavours to provide the resources for this. Where possible residents' independence is encouraged to maintain links with family and community groups. Residents in the rest home, hospital and the secure unit are provided with one to one outings on a routine basis. One to one activities are planned to meet the resident’s interests. Five of five residents interviewed and two family members report there is a good range and variety of planned activities. The results of the 2012 resident satisfaction survey record that the majority of respondents are satisfied to very satisfied with the activities and outings.

The ARC requirements are met.

Criterion 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.


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STANDARD 1.3.8 Evaluation

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

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


How is achievement of this standard met or not met? Attainment: PA Low

Two of five care plans reviewed (two rest home, two hospital and one dementia unit) evidence evaluations are recorded at least six monthly by the RN with input from the GP, the resident, the family and the activities coordinator. The remaining three files are of residents with admission under six months and are not yet due for the six monthly evaluation of care. The dementia unit resident reviewed has the evaluation of the interventions for management challenging behaviours documented monthly. The six monthly multidisciplinary review meetings are attended by the resident and their family as appropriate and available. The documented evaluations indicate the resident's progress in meeting goals, and the care plans have been updated to reflect progress towards meeting goals. Where progress is different from expected the service either updates the long term care plan or uses short term care plans for temporary changes. Five of five residents' files reviewed indicate they are updated to reflect changing needs of the resident. A resident living in the dementia unit has a monthly evaluation of the interventions for challenging behaviours showing that while the resident has continued episodes of the challenging behaviours the frequency is reducing. Rest home and the hospital residents reviewed both have a wound management plan that records a wound evaluation at each dressing change indicating the degree of healing achieved and any changes to the dressing regime. The wound of a hospital resident is not yet healed. According to staff and resident interviews, the wound of a rest home resident healed in June but this is not documented on the wound management plan. Improvement is required to ensure that a final evaluation and sign off by the RN is recorded when no further treatment is required.The five residents and two family members interviewed report involvement in the evaluation processes and are satisfied with the care provided. The ARC requirements are met.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe rest home and the hospital residents reviewed both have a wound management plan that records a wound evaluation at each dressing change indicating the degree of healing achieved and any changes to the dressing regime. Improvement is required to ensure that a final evaluation and sign off by the RN is recorded when no further treatment is required.The five residents and two family members interviewed report involvement in the evaluation processes and are satisfied with the care provided.

Finding StatementAccording to staff and resident interviews, the wound of a rest home resident healed in June but this is not documented in progress notes nor on the wound management plan.

Corrective Action Required:Improvement is required to ensure that a final evaluation and sign off by the RN is recorded on wound management plans when no further treatment is required.

Timeframe:

6 months

Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan.


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STANDARD 1.3.12 Medicine ManagementConsumers 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


How is achievement of this standard met or not met? Attainment: PA HighThere is a documented medication management policy that is suitable for the level of care provided at the facility. Improvement is required to the policy so it includes guidelines for managing alternative therapies such as homeopathics and rongoa.

Medicines for residents are received from the pharmacy in individual blister packs or bottles for each resident and checked for accuracy against the resident's medicine chart on receipt. A medicine reconciliation process occurs with new admissions and when the doctor changes their prescription (confirmed with the residents reviewed using tracer methodology). During observation of the medicine round on the day of the audit (RN with medicine competency administering medicines at the time of audit) it was noted that liquid Paracetamol elixir is administered to individual residents from a stock bottle in both the rest home and the dementia unit. Improvement is required to ensure that liquid medications are only administered from individually prescribed and named supplies. Medicines are stored in locked medicine trolleys in each wing and in the locked medicine cupboard in the hospital nurses station. The service's medicine fridge is monitored monthly and temperatures are within recommended guidelines. The pharmacist does a monthly stock rotation for the medicines that are not packed in Medico Packs. Controlled drugs are stored in a locked safe in the locked medicine cupboard in the hospital wing. The controlled drug register records two staff sign the register at each administration and a weekly stock count is done. A discrepancy was sighted in the records for morphine sulphate 30mgm tabs. A balance of 14 tabs was recorded on 24-Sept-2012 but there are currently no tablets in the drug safe. Interview with the RN and the Manager indicates that the discrepancy has not been recorded on either an incident form or a drug error form. There is no evidence that the discrepancy has been investigated or

reported to the DHB or the police. Following the audit the manager has communicated to the auditor that the pharmacist has confirmed that the tablets were returned to the pharmacy but no evidence has been sighted to confirm this.Improvements are required to ensure that the process documented in the medicine management policy for addressing medication errors is consistently followed and that guidelines are documented in relation to essential notifications to be made in the case of missing controlled drugs.10 of 10 medicine charts reviewed have been reviewed by the doctor in the last three months; this is recorded on the individual medicine chart. All prescriptions sighted contain the date, medicine name, dose, time of administration with any allergies highlighted in red ink. All 10 medicine charts have each medicine individually prescribed. Of the 10 medicine signing sheets sighted, all are fully completed for the administration of medicines for the past four weeks. A specimen signature register is maintained on each sheet. Reasons are recorded if the medicine has not been given. Sighted documented medication competency reviews done within the last 12 months for all staff designated as responsible for medicine management. There is one resident in the rest home assessed as competent to self-administer some of their medicines. The resident has a self-administration competency in their file (reviewed by the RN and GP). On interview the resident had good understanding of what the medication is for, how and when to take it, and how to store it safely. A monitoring record is maintained by the RN (sighted). ARC requirements D 1.1g and D 19.2g are partially met. Other ARC requirements are met.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: High1. The documented medicine management policy does not include a process for managing alternative therapies, such as homeopathic medicines and rongoa. 2. During observation of the medicine round on the day of the audit it was noted that liquid Paracetamol elixir is administered to individual residents from a stock bottle in both the rest home and the dementia unit instead of from individually prescribed and named bottles.3. A discrepancy was sighted in the Controlled Drugs Register for morphine sulphate 30mgm tabs. A balance of 14 tabs was recorded on 24-Sept-2012 but there are currently no morphine sulphate 30mg tablets in the drug safe. Interview with the RN and the Manager indicates that the discrepancy has not been recorded on either an incident form or a drug error form. There is no evidence that the discrepancy has been investigated or reported to the DHB or the police. There are no guidelines for essential notifications in the case of missing controlled drugs. Following the audit the manager has communicated to the auditor that the pharmacist has confirmed that the tablets were returned to the pharmacy but no evidence has been sighted to confirm this.

Finding Statement1. The documented medicine management policy does not include a process for managing alternative therapies, such as homeopathic medicines and rongoa. 2. Liquid Paracetamol elixir is administered to individual residents from a stock bottle in both the rest home and the dementia unit.3.There is no evidence that the discrepancy in the Controlled Drug Register of 14 tablets of morphine sulphate 30mgm tabs noted on 24-Sept-12 has been documented on an incident or medication error form, investigated or reported to the DHB or the police. 4. There are no guidelines for essential notifications in the event of missing controlled drugs.

Corrective Action Required:1. Revise the medicine management policy to include processes for managing alternative therapies such as homeopathic medicines and rongoa.2. Ensure that liquid medications are only administered from individually prescribed and named supplies.

3. Ensure that the process documented in the medicine management policy for addressing medication errors is consistently followed and that guidelines are documented in relation to essential notifications to be made in the case of missing controlled drugs.4. Provide written guidelines for essential notifications in the event of missing controlled drugs.

Timeframe:1 month.

Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage.


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Criterion 1.3.12.5 The facilitation of safe self-administration of medicines by consumers where appropriate.


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Criterion 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.


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STANDARD 1.3.13 Nutrition, Safe Food, And Fluid ManagementA 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


How is achievement of this standard met or not met? Attainment: FAAll aspects of food procurement, production, preparation, storage, delivery and disposal comply with current legislation and guidelines. Fridge and freezer recordings are undertaken daily and meet requirements. All foods sighted in the fridge and freezer is in their original packing or labelled and dated if not in the original packing. Kitchen staff have all undertaken food safety education appropriate to service delivery. The previous corrective actions requested under 1.3.13.5 to ensure all food in the fridge and freezer is labelled and dated, and fridge and freezer temperatures are maintained within hygienic parameters have been effectively addressed.The four week rotating menu has been approved by a registered dietician as suitable for aged care residents. A nutritional profile and min nutritional assessment are completed for each resident on admission by the RN and this information is shared with the kitchen staff to ensure all needs, wants, dislikes and special diets are catered for. Special diets can be provided if required and nutritional snacks and fluids are available 24 hours a day for all residents. Interviews with five residents and two family/whānau members confirm they are happy with the standard and quantities of food provided. Resident satisfaction surveys provide positive feedback regarding the menu and presentation of the food. ARC requirements are met

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.


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Criterion 1.3.13.2 Consumers who have additional or modified nutritional requirements or special diets have these needs met.


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Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.


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OUTCOME 1.4 SAFE AND APPROPRIATE ENVIRONMENTServices 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.These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3.STANDARD 1.4.2 Facility Specifications

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


How is achievement of this standard met or not met? Attainment: FAThe current Building Warrant of Fitness is displayed at the entrance to the facility. The required improvement regarding maintenance and calibration of equipment has been adequately addressed. All identified maintenance requests are followed up and signed off in the maintenance book once completed. Equipment requiring calibration is sighted and confirms calibration of hoists and chair scales has been completed.

Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation.


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Criterion 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.


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2. HEALTH AND DISABILITY SERVICES (RESTRAINT MINIMISATION AND SAFE PRACTICE) STANDARDS

OUTCOME 2.1 RESTRAINT MINIMISATION

STANDARD 2.1.1 Restraint minimisationServices demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


How is achievement of this standard met or not met? Attainment: FAThe facility does not currently have any residents using enablers. Relevant training in the use of restraint and enablers has been provided for staff in the last two years. Staff interviewed demonstrated understanding of the safe use of enablers should they be required.The use of enablers is documented as the voluntary and the least restrictive option to meet the resident’s needs. Training has been provided for all staff in relation to de-escalation and the use of enablers. The two RNs and six CGs interviewed demonstrate an understanding of enablers and restraint use. The previous improvement required under 2..1.1.5 relating to de-escalation training for non-clinical staff has been addressed.

Criterion 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.


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3. HEALTH AND DISABILITY SERVICES (INFECTION PREVENTION AND CONTROL) STANDARDS

STANDARD 3.5 SurveillanceSurveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.


How is achievement of this standard met or not met? Attainment: FASurveillance is carried out in line with the service's objectives as specified in their policy. The type of the surveillance is appropriate to the size and complexity of the service. Incidence of infections and use of antibiotics are surveyed monthly. The monthly surveillance report includes the name of the resident, the date and type of infection, if a specimen was collected, the date of receiving the result, the type of the antibiotics and the period it is prescribed for and if there are any follow up requirements. Analysis of the data includes a comparison with previous months data, reasons for the increase or decrease of infections (if identifiable), required actions / recommendations. Results are discussed at monthly quality and staff meetings with feedback to the staff at the following staff meeting.

Criterion 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.


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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.


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