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Craigweil House Care Limited

CURRENT STATUS: 14-Oct-13

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

GENERAL OVERVIEW

Craigweil House is certified to provide rest home, hospital and dementia level care for up to 65 residents including 20 designated dementia beds. The current occupancy is 15 hospital, 20 rest home including one respite client and 11 residents requiring dementia level care. The general manager has been appointed since 07 January 2013 and has 23 years experience in aged care (16 years operational management). Support is provided by a clinical manager who has 20 years nursing experience. There are registered nurses on each shift and caregivers are described by residents, family and the doctor as being caring and competent. Training is provided annually relevant to all roles and responsibilities. The service implements a quality programme that includes management of incidents, complaints, hazards and the implementation of an internal audit programme. Family and residents interviewed spoke positively about the care and support provided. Improvements are required to assessments, review of care plans, review of menu and to the activities programme.

AUDIT SUMMARY AS AT 14-OCT-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

Indicator Description Definition

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

14-Oct-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

14-Oct-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

14-Oct-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

14-Oct-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

14-Oct-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

14-Oct-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.


AUDIT RESULTS AS AT 14-OCT-13

Consumer Rights

Residents at Craigweil House receive services in line with the Code of Health and Disability Services Consumer Rights (the Code). Systems are in place to ensure residents are provided with appropriate information to assist them to make informed choices and give informed consent. The general practitioner (GP) is involved in the consent process with regard to assessing competence. Staff interviewed demonstrate a good understanding in relation to informed consent and informed consent processes. Residents and family members interviewed report that they are kept well informed. The service ensures opportunities for discussions on the Code and advocacy services.

Management and staff communicate in an open manner and residents are kept up to date when changes occur. The provider has documented procedures and work instructions to guide staff if concerns or difficulties in communicating with residents occurs. Privacy is maintained and any personal belongings treated with respect. Complaints information complies with requirements and is readily available. A complaints register is maintained.

There are documented procedures regarding the identification and management of abuse and neglect. Staff boundaries are monitored and the adverse event reporting system ensures any identified breach in boundaries is investigated.

There is a documented Maori Health Plan which acknowledges the principles of the Treaty of Waitangi and is aimed at reducing barriers to access. Links have been made with the Maori community and individual care plans include any cultural needs identified by residents and/or their family.

Organisational Management

Systems are established and maintained which define the scope, direction and objectives of the service and the monitoring and reporting processes. The general manager is qualified to perform this role and is responsible for the overall service delivery of the rest home, hospital and the dementia unit and the business administration, quality systems and human resource management. The service has developed and implemented quality and risk management systems. Ouality outcomes data is analysed to improve service delivery. An audit schedule for 2013 is in place. The adverse event reporting system is planned with staff documenting any incidents.

The human resource management system provides the implementation of staff and on-going training processes. There is a clearly documented rationale for determining staff levels and staff mix in order to provide safe service delivery in the rest home, hospital and the dementia unit. Rosters and staff interviews demonstrate that an appropriate number of skilled and experienced staff are allocated each shift. Careerforce training modules are encouraged. The education programme is available for 2013 and education records are well maintained.

Continuum of Service Delivery

The service has systems and processes implemented to assess, plan and evaluate the care needs of the residents in the rest home, hospital and the dementia unit. Staff provide an integrated and multidisciplinary approach to service delivery. A team approach is encouraged and continuity of care is promoted. The registered nurses are responsible for developing, implementing, reviewing, updating and evaluating the individual care plans for the residents at least six monthly or more often if required as the needs of the resident changes. The family/whanau are kept well informed of any significant changes.

An activities programme is implemented for rest home and dementia unit residents. Hospital residents are invited to attend group activities that involve visits by volunteers/entertainers. An actiivites program to meet the needs of all hospital residents is to be implemented from 28 October 13.

Food services policies and procedures are appropriate to the service settings. Residents` individual dietary needs are clearly identified, documented and reviewed on a regular basis. Residents and family/whanau interviewed report satisfaction with the food service. A dietitian is scheduled to visit the facility on the 26 October 13 to provide menu reviews and education on the diet requirements and guidelines for diabetics.

The medication management systems reflect current legislation and guidelines. An appropriate medicine management system is implemented with policies and procedures detailing service providers` responsibilities. Staff responsible for medicine management have attended relevant in-service education and have current medicine competencies.

An improvement is required to assessment, review of care plans, the activities programme and review of the menu.

Safe and Appropriate Environment

There is an older building for rest home residents and a purpose built dementia unit and hospital. The facilities provide residents with a safe, appropriate environment for each area

of service. Emergency planning, policies and processes are implemented by the service to ensure residents, visitors and staff are protected from harm. There are processes for managing waste or exposure to hazardous substances. Emergency and security reaponses are well documented and understood by staff. Six monthly fire evacuations and education occurs. The service has an approved fire evacuation plan. There are adequate emergency supplies available in each area of service. Food is available and water replacement has been arranged.

The building has a current building warrant of fitness. There is an appropriate system in place for reactive maintenance. There is equipment for heating and ventilation inside the facilities. There are suitable outdoor areas that have seating and sheltered areas for residents use. The facility is smoke free.

Restraint Minimisation and Safe Practice

The service has clearly described restraint minimisation and safe practice policies and procedures which comply with the standard. There are two enablers in use at the time of audit. Staff have received training in de-esculation techniques for managing challenging behaviour and education about the service policy, regulations and safe and effective alternatives to restraint. Staff interviewed understand that the use of enablers is a voluntary process along with approval and informed consent processes. Safety is promoted at all times.

Infection Prevention and Control

The Craigweil House organisational infection prevention and control policies and procedures implemented by the service reflect accepted good practice and infection prevention and control principles of care delivery. There are adequate resources to allow for a managed environment which minimises the risk of infection to residents, staff and visitors. The infection control programme is relevant to the size and scope of the service and is monitored by the infection control co-ordinator (the clinical manager). The infection control co-ordinator ensures the process of surveillance is adhered to and monthly infection surveillance data is recorded, collated, and reported to management. The co-ordinator analysis and evaluation of data is used to identify areas for improvement.

Craigweil HouseCraigweil House Care Ltd

Certification audit - Audit ReportAudit Date: 14-Oct-13

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Craigweil House Care Ltd

Premise Name Street Address Suburb City

Craigweil House 143-147 Parkhurst Road Parakai Helensville

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

Type of Audit Certification audit and (if applicable)

Date(s) of Audit Start Date: 14-Oct-13 End Date: 15-Oct-13

Designated Auditing Agency

HealthShare Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXXXX

RN with APC, B. Nursing, RABQSA Lead Auditor

16.00 8.00 14-Oct-13 to 15-Oct-13

Auditor 1 XXXXXXXXX

RN, RM, Dip HSM, PG Cert Neurosurgical Nursing,NZQA 8086

16.00 8.00 14-Oct-13 to 15-Oct-13

Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor

Peer Review Auditor XXXXXXXXX

MBA, MN, B Ed, Adv Dip Child and Family, RGON, Dip Tchg, Lead Auditor

4.00 2-November 2013

Total Audit Hours on site 32.00 Total Audit Hours off site (system generated)

20.00 Total Audit Hours 52.00

Staff Records Reviewed 8 of 54 Client Records Reviewed (numeric)

8 of 46 Number of Client Records Reviewed

using Tracer Methodology

3 of 8

Staff Interviewed 9 of 54 Management Interviewed (numeric)

1 of 1 Relatives Interviewed (numeric)

5

Consumers Interviewed 3 of 46 Number of Medication Records Reviewed

16 of 46 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

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

I confirm that HealthShare Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise.

Dated this 13 day of November 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

Craigweil House 65 46 5

Executive Summary of Audit

General OverviewCraigweil House is certified to provide rest home, hospital and dementia level care for up to 65 residents including 20 designated dementia beds. The current occupancy is 15 hospital, 20 rest home including one respite client and 11 residents requring dementia level care. The general manager has been appointed since 07 January 2013 and has 23 years experience in aged care (16 years operational management). Support is provided by a clinical manager who has 20 years nursing experience. There are registered nurses on each shift and caregivers are described by residents, family and the doctor as being caring and competent. Training is provided annually relevant to all roles and responsibilities. The service implements a quality programme that includes management of incidents, complaints, hazards and the implementation of an internal audit programme. Family and residents interviewed spoke positively about the care and support provided. Improvements are required to assessments, review of care plans, review of menu and to the activities programme.

1.1 Consumer Rights

Residents at Craigweil House receive services in line with the Code of Health and Disability Services Consumer Rights (the Code). Systems are in place to ensure residents are provided with appropriate information to assist them to make informed choices and give informed consent. The general practitioner (GP) is involved in the consent process with regard to assessing competence. Staff interviewed demonstrate a good understanding in relation to informed consent and informed consent processes. Residents and family members interviewed report that they are kept well informed. The service ensures opportunities for discussions on the Code and advocacy services.

Management and staff communicate in an open manner and residents are kept up to date when changes occur. The provider has documented procedures and work instructions to guide staff if concerns or difficulties in communicating with residents occurs. Privacy is maintained and any personal belongings treated with respect. Complaints information complies with requirements and is readily available. A complaints register is maintained.

There are documented procedures regarding the identification and management of abuse and neglect. Staff boundaries are monitored and the adverse event reporting system ensures any identified breach in boundaries is investigated.

There is a documented Maori Health Plan which acknowledges the principles of the Treaty of Waitangi and is aimed at reducing barriers to access. Links have been made with the Maori community and individual care plans include any cultural needs identified by residents and/or their family.

1.2 Organisational Management

Systems are established and maintained which define the scope, direction and objectives of the service and the monitoring and reporting processes. The general manager is qualified to perform this role and is responsible for the overall service delivery of the rest home, hospital and the dementia unit and the business administration, quality systems and human resource management. The service has developed and implemented quality and risk management

systems. Ouality outcomes data is analysed to improve service delivery. An audit schedule for 2013 is in place. The adverse event reporting system is planned with staff documenting any incidents.

The human resource management system provides the implementation of staff and on-going training processes. There is a clearly documented rationale for determining staff levels and staff mix in order to provide safe service delivery in the rest home, hospital and the dementia unit. Rosters and staff interviews demonstrate that an appropriate number of skilled and experienced staff are allocated each shift. Careerforce training modules are encouraged. The education programme is available for 2013 and education records are well maintained.

1.3 Continuum of Service Delivery

The service has systems and processes implemented to assess, plan and evaluate the care needs of the residents in the rest home, hospital and the dementia unit. Staff provide an integrated and multidisciplinary approach to service delivery. A team approach is encouraged and continuity of care is promoted. The registered nurses are responsible for developing, implementing, reviewing, updating and evaluating the individual care plans for the residents at least six monthly or more often if required as the needs of the resident changes. The family/whanau are kept well informed of any significant changes.

An activities programme is implemented for rest home and dementia unit residents. Hospital residents are invited to attend group activities that involve visits by volunteers/entertainers. An actiivites program to meet the needs of all hospital residents is to be implemented from 28 October 13.

Food services policies and procedures are appropriate to the service settings. Residents` individual dietary needs are clearly identified, documented and reviewed on a regular basis. Residents and family/whanau interviewed report satisfaction with the food service. A dietitian is scheduled to visit the facility on the 26 October 13 to provide menu reviews and education on the diet requirements and guidelines for diabetics.

The medication management systems reflect current legislation and guidelines. An appropriate medicine management system is implemented with policies and procedures detailing service providers` responsibilities. Staff responsible for medicine management have attended relevant in-service education and have current medicine competencies.

An improvement is required to assessment, review of care plans, the activities programme and review of the menu.

1.4 Safe and Appropriate Environment

There is an older building for rest home residents and a purpose built dementia unit and hospital. The facilities provide residents with a safe, appropriate environment for each area of service. Emergency planning, policies and processes are implemented by the service to ensure residents, visitors and staff are protected from harm. There are processes for managing waste or exposure to hazardous substances. Emergency and security reaponses are well

documented and understood by staff. Six monthly fire evacuations and education occurs. The service has an approved fire evacuation plan. There are adequate emergency supplies available in each area of service. Food is available and water replacement has been arranged.

The building has a current building warrant of fitness. There is an appropriate system in place for reactive maintenance. There is equipment for heating and ventilation inside the facilities. There are suitable outdoor areas that have seating and sheltered areas for residents use. The facility is smoke free.

2 Restraint Minimisation and Safe PracticeThe service has clearly described restraint minimisation and safe practice policies and procedures which comply with the standard. There are two enablers in use at the time of audit. Staff have received training in de-esculation techniques for managing challenging behaviour and education about the service policy, regulations and safe and effective alternatives to restraint. Staff interviewed understand that the use of enablers is a voluntary process along with approval and informed consent processes. Safety is promoted at all times.

3. Infection Prevention and ControlThe Craigweil House organisational infection prevention and control policies and procedures implemented by the service reflect accepted good practice and infection prevention and control principles of care delivery. There are adequate resources to allow for a managed environment which minimises the risk of infection to residents, staff and visitors. The infection control programme is relevant to the size and scope of the service and is monitored by the infection control co-ordinator (the clinical manager). The infection control co-ordinator ensures the process of surveillance is adhered to and monthly infection surveillance data is recorded, collated, and reported to management. The co-ordinator analysis and evaluation of data is used to identify areas for improvement.

Summary of Attainment

1.1 Consumer Rights

Attainment CI FA PA UA NA ofStandard 1.1.1 Consumer rights during service delivery FA 0 1 0 0 0 1Standard 1.1.2 Consumer rights during service delivery FA 0 2 0 0 0 4Standard 1.1.3 Independence, personal privacy, dignity and respect FA 0 4 0 0 0 7Standard 1.1.4 Recognition of Māori values and beliefs FA 0 3 0 0 0 7

Standard 1.1.6 Recognition and respect of the individual’s culture, values, and beliefs FA 0 1 0 0 0 2Standard 1.1.7 Discrimination FA 0 1 0 0 0 5Standard 1.1.8 Good practice FA 0 1 0 0 0 1Standard 1.1.9 Communication FA 0 2 0 0 0 4Standard 1.1.10 Informed consent FA 0 3 0 0 0 9Standard 1.1.11 Advocacy and support FA 0 1 0 0 0 3Standard 1.1.12 Links with family/whānau and other community resources FA 0 2 0 0 0 2Standard 1.1.13 Complaints management FA 0 2 0 0 0 3

Consumer Rights Standards (of 12): N/A:0 CI:0 FA: 12 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:23 PA:0 UA:0 NA: 0

1.2 Organisational Management

Attainment CI FA PA UA NA ofStandard 1.2.1 Governance FA 0 2 0 0 0 3Standard 1.2.2 Service Management FA 0 1 0 0 0 2Standard 1.2.3 Quality and Risk Management Systems FA 0 8 0 0 0 9Standard 1.2.4 Adverse event reporting FA 0 2 0 0 0 4

Standard 1.2.7 Human resource management FA 0 4 0 0 0 5Standard 1.2.8 Service provider availability FA 0 1 0 0 0 1Standard 1.2.9 Consumer information management systems FA 0 4 0 0 0 10

Organisational Management Standards (of 7): N/A:0 CI:0 FA: 7 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


1.3 Continuum of Service Delivery

Attainment CI FA PA UA NA ofStandard 1.3.1 Entry to services FA 0 1 0 0 0 5Standard 1.3.2 Declining referral/entry to services FA 0 1 0 0 0 2Standard 1.3.3 Service provision requirements FA 0 3 0 0 0 6Standard 1.3.4 Assessment PA Low 0 0 1 0 0 5Standard 1.3.5 Planning FA 0 2 0 0 0 5Standard 1.3.6 Service delivery / interventions FA 0 1 0 0 0 5Standard 1.3.7 Planned activities PA Low 0 0 1 0 0 3Standard 1.3.8 Evaluation PA Low 0 1 1 0 0 4Standard 1.3.9 Referral to other health and disability services (internal and external) FA 0 1 0 0 0 2Standard 1.3.10 Transition, exit, discharge, or transfer FA 0 1 0 0 0 2

Standard 1.3.12 Medicine management FA 0 4 0 0 0 7Standard 1.3.13 Nutrition, safe food, and fluid management PA Low 0 2 1 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 8 PA Neg: 0 PA Low: 4 PA Mod: 0 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.4 Safe and Appropriate Environment

Attainment CI FA PA UA NA ofStandard 1.4.1 Management of waste and hazardous substances FA 0 2 0 0 0 6Standard 1.4.2 Facility specifications FA 0 3 0 0 0 7Standard 1.4.3 Toilet, shower, and bathing facilities FA 0 1 0 0 0 5Standard 1.4.4 Personal space/bed areas FA 0 1 0 0 0 2Standard 1.4.5 Communal areas for entertainment, recreation, and dining FA 0 1 0 0 0 3Standard 1.4.6 Cleaning and laundry services FA 0 2 0 0 0 3Standard 1.4.7 Essential, emergency, and security systems FA 0 5 0 0 0 7Standard 1.4.8 Natural light, ventilation, and heating FA 0 2 0 0 0 3

Safe and Appropriate Environment Standards (of 8): N/A:0 CI:0 FA: 8 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

Attainment CI FA PA UA NA ofStandard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 0 6Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3Standard 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

Attainment CI FA PA UA NA ofStandard 3.1 Infection control management FA 0 3 0 0 0 9Standard 3.2 Implementing the infection control programme FA 0 1 0 0 0 4Standard 3.3 Policies and procedures FA 0 1 0 0 0 3Standard 3.4 Education FA 0 2 0 0 0 5Standard 3.5 Surveillance FA 0 2 0 0 0 8

Infection Prevention and Control Standards (of 5): N/A: 0 CI:0 FA: 5 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: 5 CI: 0 FA: 41 PA Neg: 0 PA Low: 4 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0Total Criteria (of 219) CI: 0 FA: 89 PA: 4 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Craigweil House Care LtdType of Audit: Certification audit

Date(s) of Audit Report: Start Date:14-Oct-13 End Date: 15-Oct-13DAA: HealthShare LimitedLead Auditor: XXXXXXXXXStd Criteria Rating Evidence Timeframe1.3.4 1.3.4.2 PA

LowFinding:Three of eight resident assessments did not include relevant information provided by NASC and hospital services on admission. Four of eight resident admission assessments did not demonstrate completion of the cultural and spiritual needs section.

Action:i) Ensure the assessment utilises information provided by the NASC and/or previous provider of health and personal care services along with observations and examinations carried out by the facility. ii) Ensure that all assessments include completion of the cultural and spiritual needs section.

3 months

1.3.7 1.3.7.1 PALow

Finding:There is no planned activities programme implemented for residents in the hospital and dementia unit.

Action:Ensure a planned activities programme that meets the needs of all residents is implemented in the hospital and dementia unit.

3 months

1.3.8 1.3.8.3 PALow

Finding: i) Four of eight long term care plans are not evaluated within a six month time frame. Ii) Two residents care plans are not amended to reflect the current care requirements for those residents.

Action:i) Complete six monthly review of all care plans. ii) Update the care plan as changes in required care occur.

6 months

1.3.13 1.3.13.1 PALow

Finding:An improvement is required to review the menu.

Action:Ensure the winter and summer menu is reviewed by a dietician.

6 months

Continuous Improvement (CI) Report

Provider Name: Craigweil House Care LtdType of Audit: Certification audit

Date(s) of Audit Report: Start Date:14-Oct-13 End Date: 15-Oct-13DAA: HealthShare LimitedLead Auditor: XXXXXXXX

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 1.1.1 Consumer Rights During Service DeliveryConsumers receive services in accordance with consumer rights legislation.

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

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: FAThe service provider policies and procedures were reviewed for informed consent, privacy, resident’s safety, abuse and neglect, cultural safety, sexuality and intimacy and spiritual health of the older person. Staff receive education during orientation and ongoing training on these topics is included in the staff annual training schedule sighted. Staff interviewed (general manager, clinical manager, registered nurse, two of two care staff, physiotherapist) are able to articulate knowledge of the code of Health and Disability Services Consumers' Rights (the Code) and how to apply this as part of their everyday practice. Staff interviewed confirm they have received education on the Code (27 February 13 and 13 March 13) as documented on in-service education records sighted. Visual observations during the audit indicate that staff are respectful of residents and incorporate the principals of the Code in their practice. The service provides information on the Code to families and residents on admission. Three of three residents (two rest home and one hospital) and five of five family members (one rest home, two hospital and two dementia) interviewed states that they receive services as per the Code. The requirements of the ARC service agreement are met.

Criterion 1.1.1.1 Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.

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

Finding Statement

Corrective Action Required:

Timeframe:

STANDARD 1.1.2 Consumer Rights During Service DeliveryConsumers are informed of their rights.

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


How is achievement of this standard met or not met? Attainment: FAInformation on the code of rights and the Nationwide Health and Disability Advocacy Service (NHDAS) are displayed in the entrance area of the rest home and in the resident’s rooms. Brochures are also provided in the admission information pack. Staff interviewed (clinical manager, RN and two of two care staff) confirms that the content of the information pack is discussed with the relatives and residents on admission.Three of three residents (two rest home and one hospital) and five of five family members (one rest home, two hospital and two dementia) interviewed confirm that the Code, the advocacy service and the complaints process was discussed and explained to them on admission along with the informed consent process. The GP is involved in the consent process with regard to assessing competence of a resident when signing consents (sighted for one dementia resident). The information pack provided to residents and families on entry includes how to make a complaint. The requirements of the ARC service agreement are met.

Criterion 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.


Finding Statement


Timeframe:

Criterion 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.


Finding Statement


Timeframe:

STANDARD 1.1.3 Independence, Personal Privacy, Dignity, And RespectConsumers 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


How is achievement of this standard met or not met? Attainment: FAThe service provider policies and procedures were reviewed for informed consent, privacy, residents safety, abuse and neglect, cultural safety, sexuality and intimacy and spiritual health of the older person. Staff receive education during orientation and ongoing training on these topics is included in the staff annual training schedule sighted. Recent training includes informed consent 27 February 2013, open disclosure 13 March 13, communication 10 April 13 and challenging behaviour 14 February 13. The resident’s admission agreement provides instructions to residents regarding responsibilities of personal belongings. Personal belongings are documented and included in resident files. Staff interviewed (clinical manager, two of two care staff) confirm residents wear their own clothing. Staff confirm they provide residents with privacy by shutting doors prior to cares being given, knocking on doors before entering residents' rooms, keeping all information regarding the resident in the resident's file and holding discussions in either their bedrooms or a quiet room as evident by observation during the day. The residents interviewed confirm their privacy is respected and that they wear their own clothing and have appropriate storage facilities in their rooms. There are documented procedures and guidelines regarding the identification and management of abuse and neglect. Staff interviewed (two of two care staff, cook and kitchen hand) are able to describe the process for reporting suspected or actual abuse. Three of three residents interviewed confirm they are receiving services appropriate to their needs, that staff treat them with dignity and respect and are caring, helpful and encourage them to be as independent as they are able to be. Two of two relatives interviewed from the dementia unit state that their family member was welcomed into the unit and personal

pictures put up in their rooms to assist in orientating them. The family members confirm their relatives in the dementia unit are treated with kindness and respect.Staff interviewed confirm they respect residents' spiritual and cultural needs. Three of three residents and five of five family members interviewed state that staff assist residents to attend church services either in the community or in the facility if required. Visual inspection of the facility provides evidence that residents have dedicated areas to keep their personal property and possessions and the rooms are personalised. Communal hygiene facilities display appropriate signage and a safe locking system. There are quiet, low stimulus areas that provide privacy for residents in the dementia unit. The requirements of the ARC service agreement are met.

Criterion 1.1.3.1 The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.


Finding Statement


Timeframe:

Criterion 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.


Finding Statement


Timeframe:

Criterion 1.1.3.6 Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer.


Finding Statement


Timeframe:

Criterion 1.1.3.7 Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.


Finding Statement


Timeframe:

STANDARD 1.1.4 Recognition Of Māori Values And BeliefsConsumers 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


How is achievement of this standard met or not met? Attainment: FAThe service provider policies and procedures were reviewed for cultural safety and cultural responsiveness and terminal care and death of a Maori resident. The service provider documentation reviewed includes appropriate Māori protocols and provides guidelines for staff in care provision for Maori residents. The

documentation is referenced to the Treaty of Waitangi and includes guidelines on partnership, protection, participation and equality with the inclusion of Te Whare Tapa Wha. Staff interviewed (clinical manager, RN and two of two care staff) confirm an understanding of cultural safety in relation to care. There are staff working at that facility, including the general manager that identify as Māori. Cultural safety education is provided in the orientation programme and annually through the in-service program (October 2014). Education records and audit schedule 2013 are sighted. There are currently two residents who identify as Māori. One resident agreed to be interviewed and confirms their cultural needs are met. The cultural needs for both Māori residents are reflected in their assessment and care planning documents reviewed (refer 1.3.4.2). Access to Māori support and advocacy services is available if required. A volunteer advocate visits the facility every Tuesday. Systems are in place to allow for review processes including input from family/whanau as appropriate, for residents who identify as Māori. Links have been made with the Māori community including local marae and Te Ha Oranga Ngati Whatua.The requirements of the ARC service agreement are met.

Criterion 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.


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Criterion 1.1.4.3 The organisation plans to ensure Māori receive services commensurate with their needs.


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Criterion 1.1.4.5 The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.


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STANDARD 1.1.6 Recognition And Respect Of The Individual's Culture, Values, And BeliefsConsumers 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


How is achievement of this standard met or not met? Attainment: FAThere are policies and procedures around cultural safety, cultural responsiveness - other cultures, interpreter services and spiritual health of the older person. The service provider documentation provides evidence that appropriate, culturally safe practices are implemented, including respect for residents' cultural and spiritual values and beliefs. The service provider’s cultural responsiveness - other cultures policy has guidelines for interacting with residents of differing ethnicity and/or culture. Staff interviewed (clinical manager, RN and two of two care staff) confirm an understanding of cultural safety in relation to care and that processes are in place to ensure residents have access to appropriate services to ensure their cultural and spiritual values and beliefs are respected. The resident and their family/whanau are involved in the assessment process on admission. This includes assessment of their individual values and beliefs which are then documented in the care plan. Four of the eight resident admission assessments reviewed did not demonstrate completed sections relating to cultural and spiritual needs (refer 1.3.4.2).Two of eight residents' assessments identify food preferences relating to cultural beliefs. These preferences are included in the residents care plans.Three of three residents and five of five family members interviewed confirm that their values and beliefs are respected by staff. The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 1.1.7 DiscriminationConsumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e


How is achievement of this standard met or not met? Attainment: FAThe service provider policies and procedures were reviewed for complaints, cultural safety, cultural responsiveness - other cultures and spiritual health of the older person. The service provider policies and procedures in place outline the safeguards to protect residents from abuse, including discrimination, coercion, harassment, and exploitation, along with actions to be taken if there is inappropriate or unlawful conduct. Policies reviewed include complaints policies and procedures. Expected staff practice is outlined in job descriptions. Eight of eight staff files reviewed contain job descriptions and employment contracts detailing staff responsibilities and boundaries. Three of three residents and one GP interviewed report that staff maintain appropriate professional boundaries. Two of two care staff interviewed demonstrate an awareness of the importance of maintaining boundaries and processes they are required to adhere to.The clinical manager and RN states that care staff working in the dementia unit are trained to provide a supportive relationship based on a sense of trust, security and self-esteem. Interviews with two family members from the dementia unit confirm that staff assist them to understand dementia.

Criterion 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.


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STANDARD 1.1.8 Good PracticeConsumers 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


How is achievement of this standard met or not met? Attainment: FAThe service provider’s policies and procedures are reflective of evidence based practice and have all been reviewed this year to ensure they are up to date. Management and staff have access to and demonstrate knowledge of relevant legislation and approved service standards. The policies and procedures, evidence based guidelines, treatment protocols, reference material and resources are available and utilised by staff.The education programme sighted for the year 2013 covers all mandatory requirements for staff and other significant clinical aspects of care delivery. Staff have access to mentoring and peer supervision and there is evidence of professional networking. Demonstrated competencies are recorded. Staff interviewed (clinical manager, RN, two of two care staff, activities co-ordinator, cook and kitchen assistant) confirm that the facility provides a resourceful, learning and supportive environment. Implementation of the quality improvement and quality management strategies are reflected across all services. The internal quality system and internal audits provides evidence of outcomes which are fed back to staff at the staff meetings (minutes sighted). Clinical record reviews and care delivery audits by the RN and medication system audits completed by the pharmacist is evident. There is a communication diary which staff interviewed (clinical manager, RN, two of two care staff, activities co-ordinator, cook and kitchen assistant) states 'works very well'. This diary is updated with resident’s appointments, staff messages and rostering changes to alert staff. Infection control and laboratory results are monitored closely by the clinical manager and are available for the doctor’s rounds. The GP interviewed commented on the effective communication of the clinical manager and the RNs. Specialised dementia services are provided by appropriately selected, trained and competent staff. Staff interviewed (clinical manager, RN) states that support and care to residents in the dementia unit is flexible and individualised, promotes quality of life and minimises restrictive practices through the management of challenging behaviour. Two of two family members interviewed confirm they are happy and satisfied with the care provided to their relatives living in the dementia unit.The requirements of the ARC service agreement are met.

Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice.


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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


How is achievement of this standard met or not met? Attainment: FAThe service provider has a communication policy, interpreter policy and an open door policy. The service provider has adequately documented procedures and work instructions to guide staff if concerns or difficulties in communicating with residents occur. All residents have English as their first language. There is access to interpreter services and advocacy support services if required. A volunteer advocate visits the facility every Tuesday and was observed visiting on the day of audit. Resident meetings are conducted monthly (minutes sighted). Information is provided in a manner that the resident can understand. Three of three residents (two rest home and one hospital) interviewed report that they are kept well informed, that management and staff communicate in an open manner, that visitors are welcome at any time and that they attend resident meetings. A service information package is provided to residents and their family/whanau on admission. Information on resident rights, advocacy and interpreter services is provided in the pack and is also displayed in residents rooms. The incident and accident forms have an area to document if the relatives have been contacted. This is sighted as being completed on the seven of seven incident and accident forms audited. Five of five family members (two hospital, one rest home and two dementia) interviewed confirm they received an information pack on admission, that they are advised immediately if there is a change in their family member's health status and that they are involved in every aspect of care delivered to their relative. Staff interviewed (general manager, clinical manager, RN, GP, physiotherapist and two of two care staff) state that relatives and residents can call and discuss issues at any time.The requirements of the ARC service agreement are met.

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


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


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STANDARD 1.1.10 Informed ConsentConsumers 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


How is achievement of this standard met or not met? Attainment: FAThe service provider has an informed consent policy in place. This includes recording requirements for general consents such as resident outings, photo consent, access to health information and treatment interventions. Staff interviewed (general manager, clinical manager, RN and two of two care staff)

demonstrate an understanding of informed consent processes. Staff interviewed (clinical manager, RN and GP) confirm that information on informed consent is discussed with the relatives and residents on admission and appropriate forms are shown to them at this time. Eight of eight residents' files reviewed demonstrate written and verbal discussions on informed consent have occurred. Seven of eight resident files reviewed contain signed and dated consent forms. On the one occasion where consent is not signed by the resident or a family member, the GP has recorded a discussion is held with the resident and the resident (dementia) is assessed as being incapable to make an informed choice. This resident has no contact with family. Three of three residents (two rest home and one hospital) interviewed confirm they have been made aware of and understand the principles of informed consent and confirm that their choices and decisions are acted on. Staff interviewed (general manager and clinical manager) states that residents have the choice to make an advanced directive. An advance directive is completed by the resident with the GP. Of eight resident files reviewed, two residents had chosen to have an advance directive in place. These are signed and dated by the resident and the GP.Eight of eight residents files reviewed contain signed and dated admission agreements. One residents (dementia) admission agreement is signed by the residents EPOA.The requirements of the ARC service agreement are met.

Criterion 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.


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Criterion 1.1.10.4 The service is able to demonstrate that written consent is obtained where required.


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Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid.


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STANDARD 1.1.11 Advocacy And SupportService 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


How is achievement of this standard met or not met? Attainment: FAThere are appropriate policies regarding advocacy and/or support services. Staff interviewed (general manager, clinical manager, RN and two of two care staff) states that a volunteer advocate visits the facility weekly and that advocates can also be accessed through the Nationwide Health and Disability Advocacy Service or through the District Health Board if required. The Nationwide Health and Disability Advocacy Service brochure is provided to the resident and their family/whanau on admission. These brochures are also displayed in the entrance foyer of the facility. Training on advocacy and support (code of rights) is provided to staff during orientation and in the ongoing in-service programme (sighted). Training was last held in February and March 13.The assessment process identifies the residents/family/whanau chosen support networks. The residents' and family support networks are recorded in eight of eight residents files reviewed. Resident meetings are held three monthly. Three of three residents (two rest home and one hospital) interviewed confirm their attendance at resident meetings and that a volunteer advocate visits the facility every Tuesday.

The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 1.1.12 Links With Family/Whānau And Other Community ResourcesConsumers are able to maintain links with their family/whānau and their community.

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


How is achievement of this standard met or not met? Attainment: FAThere is a visitors' policy and guidelines available to ensure resident safety and well-being is not compromised by visitors to the service. Staff interviewed (clinical manager, two of two care staff and activities coordinator) states that access to community support/interest groups is facilitated for residents as appropriate. The activities coordinator is available to take residents on community visits and out to appointments. The activities programme includes visiting entertainers, community outings and daily newspaper reading. There are television sets in resident’s rooms and in lounge areas that allow for viewing current affairs.During the audit, visitors are seen to be welcomed by staff. Staff acknowledge, value and encourage the involvement of families/whanau in the provision of care for their relative. Care intervention that includes family participation is recorded in the residents care plans sighted.Three of three residents (two rest home and one hospital) confirm they can have access to visitors of their choice at any time. Five of five family members (two hospital, one rest home, two dementia) interviewed confirm their relative is supported to access services within the community if the family are unable to do so. The requirements of the ARC service agreement are met.

Criterion 1.1.12.1 Consumers have access to visitors of their choice.


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Criterion 1.1.12.2 Consumers are supported to access services within the community when appropriate.


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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 management policy and procedure is clearly documented. The complaints procedure is explained by the registered nurses as part of the admission process. It is fully described in policy and shown in the information folder in the dementia unit, the hospital and the rest home. Time frames relating to receiving a complaint, acknowledgement of a complaint, review/feedback and appeal process comply with Right 10 of the Code. Any complaints or

situations are reported to the general manager. The complaints register sighted is maintained by the general manager and is current and up to date. There are five complaints documented in the register which is closed out effectively and one complaint received February 2013 was followed through by the Waitemata District Health Board health services for older people and was unsubstantiated. All timeframes documented in the policy and procedure for complaints management and as mentioned in the Code was effectively met. The complaints/compliment/concerns forms are accessible for residents, family, staff and are located on the table in the reception area. A lockable box is provided for completed forms. Complaints are managed fairly and are used to improve service delivery. Feedback is provided to staff at the staff meetings held regularly. Staff, residents and families interviewed have a good understanding of the complaints process.The requirements of the ARC service agreement 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.


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


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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 service`s quality plan and business plan identify the purpose, values and priorities and goals for the service. A full review undertaken 11 October 2013 by the owner/directors has occurred and all relevant details were updated. The mission statement remains the same. This is framed and displayed in the office. The mission statement is also documented in the information booklet in the admission folder. The quality and risk management action plan documents the organisations commitment to the provision of quality support and care in all areas of service delivery. The general manager is responsible for ensuring services are planned, coordinated, and appropriate to meet the needs of the residents. The general manager interviewed is well supported by the administrator.Policies and procedures and associated documents implemented along with a systems approach to service delivery provides a good level of assurance that the service is meeting accepted good practice and adhering to relevant standards relating to the Health and Disability Services (Safety) Act 2001.The services offered include rest home, hospital and dementia services. The dementia unit has twenty beds, the hospital twenty and the rest home twenty five beds. The total beds are sixty five with five swing beds being available. The occupancy on the day of the audit is forty five.A set agenda sighted is available for team executive meetings held weekly with the owner directors, the general manager and the administrator. The general manager presents a weekly report. The contracted medical service and the general manager have met together on three occasions and the minutes of the meetings dated 24 Jan 13, 12 Feb 13 and 07 Mar 13 were sighted.The service is managed by an experienced facility general manager with relevant aged care and quality management experience. The general manager has twenty four years’ experience in the aged care sector and previously owned her own rest home. The general manager works full time. Educational requirements are met and the general manager completes ongoing education. The personal record sighted and reviewed evidences relevant training and professional development such as employment law / 90 day disciplinary meetings 15 April 13, communication and documentation 5 Aug 13 and management training 7 October 13.The requirements of the ARC service agreement are met.

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


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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.


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STANDARD 1.2.2 Service ManagementThe 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: FADuring the temporary absence of the general manager a clinical manager is available and experienced to cover this service. The clinical manager is a registered nurse currently employed for thirty hours a week and has a current annual practising certificate which was sighted.The clinical manager is an experienced registered nurse who has worked extensively in the aged care sector in rest home, dementia and hospital level care. The clinical nurse`s personal file sighted evidences relevant education and professional development has been undertaken. All compulsory mandatory training

has been completed for this role and for the organisation. The clinical manager has also completed a Careerforce training module on dementia care and a certificate was sighted.The general manager interviewed stated that the owner/directors would be very supportive in her absence and would be available to the clinical manger if required.The requirements of the ARC service agreement are met.

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


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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: FAThe quality and risk management plan for 2013/2014 identifies objectives for the service. The quality plan covers aspects of service delivery with actions shown on how to minimise identified risks. The business risk management plan recently reviewed covers being a good provider, responsible planning, safe environment, internal audits and the schedule reviewed is developed and implemented. The policies are reviewed annually by Care Association New Zealand by the quality and risk consultant and/or the general manager as per the schedule sighted. The archived system is set up and the storage area sighted. There is also a document trolley which is stored in a locked area for documents to be destroyed as part of the controlled document policy. Policies and procedures are maintained electronically by the general manager but hard copy manuals are available and accessible for staff.

The internal audit system and practices are audited as per the documented and implemented schedule sighted. The dates the audits are performed is accurately recorded. The quality and risk system is closely linked with the health and safety, event reporting, the infection prevention and control programme, restraint minimisation and safe practice and the complaints management for the organisation. The general manager completed a kitchen food quality control Aug 13 and continues to monitor each area of service as per the quality schedule.The general manager completed a kitchen food quality control Aug 13 and continues to monitor each area of service as per the quality schedule. The general manager reports weekly to the owner/directors. Satisfaction surveys have been distributed to residents and staff and when returned will be collated and analysed by the general manager and feedback given to staff at staff meetings and residents at the resident`s meetings held monthly as part of the activities programme. A corrective action form is used if any issues or quality improvements are identified with evidence of resolution of issues. Records are maintained by the administrator on the number of admissions, transfers and/or deaths/discharges. The training schedule is documented for 2013 and a record is maintained in the education folder with the planned dates and number of staff in attendance.Minutes of the executive team meetings, team leader meetings dementia unit meetings and staff meetings are all recorded in the minute’s folder. Records of the set agenda, attendance records and the details of the meetings are recorded accurately and are accessible for staff. The risk register is maintained by the general manager. The risk register is maintained for each area of service. A flow chart is available to demonstrate the hazard management process. The service has adequate insurance cover for public liability, employee liability, professional indemnity, rest home liability, building and contents cover and motor vehicle cover for the two vans utilised by the service. The asset register is reviewed annually by the owner/directors. Financial records and held and managed professionally by an accounting firm as per the ARC agreement. Any enduring power of attorney (EPOA) forms are also kept in the same files if available. Confidentiality is maintained and the filing cabinet sighted is secure.The requirements of the ARC service agreement are met.

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


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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.


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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.


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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.


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


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


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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.


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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: FAForms, policy and procedures are up to date and cover all required aspects of adverse event reporting. Any use of data when collated and analysed is used to improve service delivery. The general manager and the administrator are available for interview. Both have a good understanding of the statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority to contact if and when required. The accident compensation corporation (ACC) defines clearly the meaning of serious harm and sentinel events. Waitemata District Health Board and HealthCert would be notified for a significant event or change in the service provided as required in the ARC agreement. The medical officer of health is to be informed of any outbreak management for infection control notifiable diseases or illnesses. There has been no adverse or unplanned or untoward events identified or trends reported for this organisation.The requirements of the ARC service agreement 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.


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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.


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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: FAThe human resources documents and policies sighted meet contractual requirements. Job descriptions are sighted in eight of eight staff records sighted. The files sighted include three caregivers, one cook, the general manager, the clinical manager RN and two registered nurses The files contained and employee checklist, 90 day trial forms, reference checking, induction pack given, contract, copy of drivers licences, registered nurse annual practising certificates and administration details of employment such as kiwi saver. The orientation programme included all components of service delivery and work book completed are available for restraint minimisation and infection control. The orientation programme is also relevant to the dementia unit and includes a session on how to implement activities and therapies. All staff interviewed two healthcare assistants, one clinical manager, one administrator, activities co-ordinator, one cook, one kitchen-hand and one registered nurse received a full orientation at commencement of employment.The staff training records are available and the schedule for 2013 is clearly documented and implemented. Staff interviewed two healthcare assistants felt they are provided with lots of opportunities for in-service education and registered nurses to further professional development to meet their individual needs and scope of practice. Education this year has covered 14 February 2013 challenging behaviour with thirteen participants and this was repeated 10 April 2013 with eighteen participants. On the 13 March eleven staff attended an in-service on open disclosure. On the 20 March the topic delirium was presented by the WDHB nurse specialist with eight attendees, 10 April 2013 communication and this was repeated 14 August 2013 with person centred care with fourteen in attendance. On the 12 June 2013 depression with nine attendees recorded and 26 June 2013 restraint minimisation and safe practice with fifteen attendees. The clinical manager presented to staff 05 September 2013 the topic of communication and on the 18 September and the 25 September manual handling training and hoist management was delivered by a registered physiotherapist and all staff attended. Fifteen staff have completed the first aid training and four additional staff are due to complete this course as soon as a date is confirmed.Registered nurse are supported and encouraged to maintain their professional competency and are given allocated study days annually and can attend study days and/or conferences relevant to aged care and for meeting the requirements of their annual practising certificates. Performance appraisals are completed for all staff both clinical and non-clinical by the general manager and the clinical manager. Evidenced in the eight of eight staff records reviewed.Should any agency staff be contracted they would receive an orientation that includes the physical layout, emergency protocols, and contact details should an emergency arise.The registered nurses and senior care staff responsible for medication management have to complete the medication competencies. Records sighted evidence these have been completed. The clinical manager is responsible for maintaining these records.There is a system in place for verifying the professional qualifications of the registered nurses. The general manager is responsible for checking the professional qualifications annually. There are two general practitioners who visit on a regular basis and two other doctors from the same practice in

Helensville. All annual practising certificates (APCS) have been validated, scopes of practice checked and recorded. Other allied health professionals for example the podiatrist, occupational therapist and physiotherapist have valid APCs.The requirements of the ARC service agreement 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: FAThere is a human resource management policy available and reviewed which relates to determining provider levels and skill mix to ensure safe service delivery. The general manager interviewed is committed to ensuring that at all times adequate numbers of suitable staff are on duty, to provide safe support and care to ensure achievement of quality resident support and outcomes. The daily staff mix is consistent with the following staff being on duty, the facility general manager, the administrator, the clinical manager, caregivers, cook/kitchen hand, cleaner, laundry staff and two maintenance men. The general manager when interviewed stated that there has been stability of staff over this last year. The activities co-ordinator works in a dual role as a caregiver 7am

until 10am and then 10am until lunchtime as an activities co-ordinator in the rest home. The general manager interviewed is currently employing an activities co-ordinator for the hospital and the dementia unit.Staff interviewed across all shifts and across all areas of the service stated that the staffing is adequate. There is an on-call system for after hours to cover this service. The general manager and the clinical manager cover this aspect of the service.A staff member completes the roster two weeks ahead and this is overseen by the general manager. Factors taken into consideration include the ability to meet the facility goals and objectives, acuity and assessed needs of the residents, resident support and care levels, clinical indicators, safety and security of staff and residents as per the ARC service agreement. There are three rosters sighted one for the dementia unit, hospital and the rest home. The rosters sighted evidence coverage for all service streams each shift seven days per week. Casual staff are available to cover as required. Staff/residents/families interviewed felt the services are covered adequately.The requirements of the ARC service agreement are met.

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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STANDARD 1.2.9 Consumer Information Management SystemsConsumer 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


How is achievement of this standard met or not met? Attainment: FAReview of the eight of eight residents` records three rest home, three hospital and two dementia unit demonstrate that all residents have been assessed by the Needs Assessment Service Co-ordinators at Waitemata District Health Board prior to admission. The detail is adequate and records information important for ongoing care and support being provided to the individual residents.

The progress records are clearly documented each shift by the caregivers and/or registered nurse. The date, time, signatures and designation of those entering into the records is legible, accurate and timely. The assessments and care plans are signed off by the registered nurse. Records are integrated and there are coloured dividers between each section. The general practitioner contracted to this service was interviewed by phone and is pleased with the communication with staff by phone and in person when he visits the residents. All records are maintained confidentially. The resident records are stored in a locked cupboard in the nurse`s station. The resident fire register is maintained and kept at reception. The resident register is maintained with appropriate detail for this aged residential care setting. Photo identification is on all individual resident records on the front cover and on the medication record and medication signing sheet. Consent is obtained to place the residents name on the doorway to their room. No resident information boards or records on visual inspection are in view of the public.The requirements of the ARC service agreement are met.

Criterion 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.


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Criterion 1.2.9.7 Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.


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Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable.


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Criterion 1.2.9.10 All records pertaining to individual consumer service delivery are integrated.


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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 1.3.1 Entry To ServicesConsumers' 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


How is achievement of this standard met or not met? Attainment: FAThere are currently 46 residents admitted to the facility. Documented processes are implemented to ensure residents' entry into the service has been facilitated in a competent, equitable, timely and respectful manner. An information package and brochure is developed for residents and their family/whanau that explains the entry criteria, assessment process and scope of services provided. Information on the philosophy and practices particular to the dementia unit is included in the information package. Three of three residents (two rest home and one hospital) and five family members (two hospital, one rest home and two dementia) interviewed confirm that during admission, staff explain the information and allow time for discussion.The admission agreement defines the scope of service and includes all of the contractual requirements. Eight of eight resident files (three hospital, three rest home, two dementia) reviewed contain signed and dated admission agreements. Staff (general manager, clinical manager) interviewed states the needs assessors at the District Health Board are informed of the levels of service available at this facility and relevant community agencies are also informed. Eight of eight residents' files (three hospital, three rest home, two dementia) reviewed confirms all residents have been referred by NASC. The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 1.3.2 Declining Referral/Entry To ServicesWhere 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


How is achievement of this standard met or not met? Attainment: FAA process to decline resident entry to the service is documented which states that the referral source, resident, their family/whanau and their GP will be informed of the reason for this. Staff interviewed (general manager and clinical manager) interviewed state residents' will be declined entry if a bed is not available at the time. If a resident is declined entry, support is provided to the resident and their family/whanau to access alternative services.

Criterion 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.


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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: FAThe facility operates 24/7. Service delivery is overseen by the clinical manager.Staff interview and review of resident files identified that an assessment and initial care plan is completed on admission by the clinical manager and RNs. Desired outcomes and goals are recorded in the care plan. A GP medical review is within two days of admission and evident as one to three monthly thereafter. Identified need and appropriate intervention as a result of the medical consultation is recorded in the care plan.

A full care plan is completed within three weeks of admission by the RN with input by care staff, the resident and their family. Staff (clinical manager, RN and two of two care staff) confirm care plans provide appropriate guidelines for care intervention. Three of three residents (two rest home and one hospital) five of five family members (two hospital, one rest home and two dementia) interviewed confirm their input into service delivery planning and assessments. Eight of eight residents' files reviewed provide evidence that assessment, planning, provision and evaluation occurs (refer to 1.3.4.2 and 1.3.8.3). Policies and protocols are in place to ensure cooperation between service providers and to promote continuity of service delivery. Family/whanau communication is recorded, clinical and allied health/medical progress notes are recorded and the authors are identified. Care staff handover notes and verbal handover occurs between shifts in the rest home, hospital and dementia unit.The requirements of the ARC service agreement are met.Tracer Methodology: Rest home: XXXXXX This information has been deleted as it is specific to the health care of a resident. Tracer Methodology: Hospital:XXXXXX This information has been deleted as it is specific to the health care of a resident. Tracer Methodology: Dementia Unit:XXXXXX This information has been deleted as it is specific to the health care of a resident.

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 1.3.4 AssessmentConsumers' 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


How is achievement of this standard met or not met? Attainment: PA LowResident needs are identified in the assessment process. The nursing assessments cover needs, falls risks, nutrition, pressure area risk, skin integrity, continence, pain and a social profile. Staff (clinical manager, RN and two of two care staff) interviewed confirm that the clinical manager and the RN admits new residents on the day of admission, and confirms access and entry processes are followed. Eight of eight residents' files (three hospital, three rest home and two dementia) reviewed demonstrate nursing and medical assessments for the level and type of care required. Eight of eight residents' files evidence risk assessments on admission are conducted and recorded and an individual assessment to

determine his or her individual diversional, motivational and recreational requirements. Behaviour assessments are completed for residents of the dementia unit. A physiotherapist visits the facility every Tuesday and Thursday to provide an additional assessment and care plan for residents identified as moderate to high falls risk. Five of eight residents files reviewed demonstrate a physiotherapist assessment and care plan. The GP completes a medical assessment within 48 hours of admission. Residents' needs, desired outcomes and goals are identified and recorded. As documented in residents care plans, the care staff monitor the resident daily to identify additional support requirements and these are reported in handover and directly to the RN or clinical manager as required. Staff interviewed (clinical manager, RN, two of two care staff, GP and physiotherapist) states that assessments are conducted in safe, private and appropriate settings that includes the resident's room. Three of three residents (two rest home and one hospital) interviewed confirm their involvement in their assessments, care planning, review, treatment and evaluations of care and that the assessments are conducted in the privacy of their room. Appropriate resources and equipment are available (sighted).The requirements of the ARC service agreement have not been met (D16.2.a, D16.c). There is an improvement required to assessments including the use of relevant information provided by NASC and hospital services on admission and full completion of the service provider’s assessment tool template.

Criterion 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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe service provider has processes in place to gain information from a range of sources during the admission assessment process. For example; family, GP, specialist, hospital services and referrer.

Finding StatementThree of eight resident assessments did not include relevant information provided by NASC and hospital services on admission. Four of eight resident admission assessments did not demonstrate completion of the cultural and spiritual needs section.

Corrective Action Required:i) Ensure the assessment utilises information provided by the NASC and/or previous provider of health and personal care services along with observations and examinations carried out by the facility. ii) Ensure that all assessments include completion of the cultural and spiritual needs section.

Timeframe:3 months

STANDARD 1.3.5 PlanningConsumers' 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


How is achievement of this standard met or not met? Attainment: FAInitial care plans are recorded on admission and the long term care plan is recorded within three weeks of admission. Eight of eight residents' care plans (three hospital, three rest home and two dementia) reviewed are resident focused, integrated and promote continuity of care. Each care plan demonstrates actual and potential problems/deficits with set goals for rectifying these with required interventions. Staff interviewed (clinical manager and RN) state that the goals are identified by the resident and family and service providers. Care plans developed for dementia residents also demonstrate specific behavioural management strategies with a description of activities for therapy over a 24 hour period. The clinical manager and RNs work closely with the GP regarding the residents' medical issues and concerns. Staff interviewed (clinical care manager and RN) state that input by hospital and allied health services occurs as required and may include podiatrist, physiotherapists, occupational therapists, dietitian, specialists and district health nurses. The residents' care plans reviewed reflect input by the GP, dietitian, podiatrist and physiotherapist. Staff interviewed (clinical manager, RN, two of two care staff and activities coordinator) confirm care plans are available to staff and that they use these to guide care delivery. Clinical handover between shifts occurs in the rest home, hospital (observed) and dementia unit. The verbal handover includes a physical round of residents. Eight of eight care plans reviewed evidence that residents' and their family/whanau have input into the development and review of care plans. Three of three residents' (two rest home and one hospital) and five of five family members (two hospital, one rest home and two dementia) interviewed state they have input into care planning and that they are satisfied with the care provided. The GP interviewed confirmed that prescribed treatments are followed by staff.The requirements of the ARC service agreement are met.

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.


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Criterion 1.3.5.3 Service delivery plans demonstrate service integration.


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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: FAThe service provider has documented and implemented policies and procedures that guide staff with service delivery and care interventions. Three of three residents' (two rest home and one hospital) and five of five family members (two hospital, one rest home and two dementia) interviewed state that staff are welcoming and assist residents to adapt to their new residence. Staff interviewed (clinical care manager and RN) state that family are encouraged to support the resident into their new environment. A visual inspection of the facility identified that all residents rooms are personalised with the placement of their own pictures, photos and furniture. Interview with two family members of residents living in the dementia unit confirms that photos and personal belongings helped to orientate their relative into their new environment and relieves the resident’s anxiety.Eight of eight resident files (three hospital, three rest home and two dementia) reviewed show evidence of interventions relating to the residents' assessed needs and desired outcomes. Care interventions are holistic and are provided by the multi-disciplinary team (clinical manager, RN, care staff, GP, physiotherapist and cook). Staff interviewed (clinical manager, RN, care staff, GP, physiotherapist and cook) confirms that resident information can be accessed by the multidisciplinary team members. Short term care plans are implemented for residents' acute care needs. Wound care management plans are in place for residents with wounds (sighted). Appropriate dressings and supplies used for treatments are available. A supply of continence management products are sighted.Two of two care staff and the activities co-ordinator interviewed confirm they use the resident's care plan, are directed by the clinical manager and RN and report any change or concern identified and that this is recorded. Progress notes are documented by the clinical and medical team. Daily cares are recorded by care staff. Handover notes are recorded and verbal handover occurs each shift. There is a process to identify and respond to variances/trends e.g. accident / incident reporting system. In all eight resident files reviewed there is evidence sighted of links to other services. The requirements of the ARC service agreement 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.


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STANDARD 1.3.7 Planned ActivitiesWhere 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: PA LowThe activities co-ordinator is delegated 1.5 hours for five days per week to implement an activities programme for rest home residents. Assistance is provided by care staff, physiotherapist (exercises) external entertainers (monthly) and family volunteers (outings). Activities are provided by staff in consultation with the activities co-ordinator for residents in the dementia unit.All residents have an activities assessment and social history completed on admission by the activities co-ordinator. A care plan is developed and reflects the client’s preferences and capability to participate. Attendance records and monthly evaluations of individual activities care plans is completed by the activities co-ordinator and care staff of the dementia unit. A two monthly, rotating activities plan is developed. The programme includes activities that are physical, intellectual, sensory, social and includes reminiscing. The activities co-ordinator interviewed confirmed that attendance is always voluntary. Group activities include games, outings and music with visiting entertainers. One on one activities provided includes one on one pampering, manicures and shopping. Church service occurs on Sundays. A 24 hour programme is documented with individual activities plans for residents in the dementia unit. Three of three residents (two rest home and one hospital) and three of five family members (one rest home and two dementia) interviewed report satisfaction with the activities offered. Two family members (hospital) stated that there are not enough activities provided to residents in the hospital facility. One resident and one family member (rest home) interviewed indicate that their activity needs are effectively met.

The requirements of the ARC service agreement have not been met (D16.5c.ii).

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowCurrently, hospital residents are invited to attend group activities that involve visits by volunteers/entertainers. The provider is in the process of appointing another activities co-ordinator to meet the needs of all hospital residents. An occupational therapist is contracted (31 April 13 to March 14) to train the care giver and support the activities programme across all areas of the facility. Implementation of an activities programme for hospital residents is to commence on the 28 October 13.

Finding StatementThere is no planned activities programme implemented for residents in the hospital and dementia unit.Corrective Action Required:Ensure a planned activities programme that meets the needs of all residents is implemented in the hospital and dementia unit.

Timeframe:3 months

STANDARD 1.3.8 EvaluationConsumers' 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 LowShort term care plans are developed and implemented. Short term care plans are sighted for recurrent falls, wound care, changes in mobility, changes in food and fluid intake and for skin care. These processes are clearly documented on the short term care plan, medical and nursing assessments and the resident`s progress notes. Evaluation of short term care plans occurs at frequent intervals and close off is demonstrated when the short term care need is resolved. Short term interventions that are developed into long term requirements are transferred to the resident’s long term care plan. Eight of eight residents' files (three hospital, three rest home and two dementia) reviewed provide evidence that some evaluation of long term care plans occur. The evaluation is completed by the RN. Five of five family members (two hospital, one rest home and two dementia) interviewed states they are notified of any changes in their relatives' condition. Communication with family/whanau is documented in eight of eight residents' files reviewed. Resident interviews confirm their participation in care plan evaluationsAn improvement is required to updating of care plans as changes occur and to review of care plans.

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.


Finding Statement Corrective Action Required:

Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThere is a documented process that describes the requirement for the RN to review the resident’s long term care plans at least six monthly and as required. Two residents had suffered a fall. The RN completed a falls risk assessment and pain assessment on both residents. Required intervention as a result of the assessments was noted in the progress notes and reported at handover. An assessment and plan is completed by the physiotherapist. Medical intervention included the initiation of PRN pain relief.Improvements are required to six monthly review of care plans and to updating of care plans as changes occur (refer to 1.3.8.3).

Finding Statement i) Four of eight long term care plans are not evaluated within a six month time frame. Ii) Two residents care plans are not amended to reflect the current care requirements for those residents.Corrective Action Required:i) Complete six monthly review of all care plans. ii) Update the care plan as changes in required care occur.

Timeframe:6 months

STANDARD 1.3.9 Referral To Other Health And Disability Services (Internal And External)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


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

The service provider has policies and procedures that provide staff guidelines for referral to other health and disability services. The clinical manager and RN with the GP facilitate the referral process. The clinical manager and GP interviewed confirmed residents are advised of their options to access other health and disability services. Eight of eight residents have been referred to supporting health services. Referrals evident in the residents' files reviewed include the physiotherapist, podiatrist, aged concern, dentist and specialists and mental health services.Three of three residents (two rest home and one hospital) and five of five family members (two hospital, one rest home and two dementia) interviewed confirm that assistance to transport is available for residents to attend hospital, medical and specialist appointments if required. The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 1.3.10 Transition, Exit, Discharge, Or TransferConsumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


How is achievement of this standard met or not met? Attainment: FAExit, discharge or transfer from the service is planned and co-ordinated by the clinical manager, RN and GP. There is a documented transfer policy from one service to another service. This includes a transfer form which is completed by the RN and contains all relevant information. The family/whanau, if appropriate, are kept fully informed during the process. The clinical manager and GP interviewed states that transfers are organised if the level of care required is unable to be provided by the service provider. The requirements of the ARC service agreement are met.

Criterion 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.


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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: FAAppropriate systems are in place for safe medication management. Service provider policies and procedures cover all aspects of safe medicine practice relevant to the service level. There is an implemented internal audit schedule. Medication management systems is audited yearly. The last audit was conducted in May 2013. The clinical manager and RN is responsible for the overall management of medication. Staff interviewed (clinical manager, RN and two of two care staff) states that care staff administer all medicines in the rest home and dementia unit and that the RN administers medicines in the hospital. All staff administering medications are deemed competent to do so. The RN provides the training to care staff. The clinical manager signs off RN competencies. Training records are sighted. The lunch time medication round was observed and demonstrated safe and competent administration by the care staff member.The service provider uses a blister pack system of medicine management delivered by the pharmacy in Helensville. The received medicines are checked by the RN for accuracy when the packs or medicines are delivered. Each resident has an individual medicines profile and medicine prescription form, an individually dispensed blister pack for their medicines and a medicine signing sheet. Sixteen resident’s medicine charts are reviewed. Medicines documentation is complete. Medicines are prescribed and individually signed by the GP and reviewed three monthly. Signing charts are correctly documented by staff after each administration. One signing sheet is used for non-packed items, PRN medicines and short course medicines. PRN medication is monitored by the RN. Allergies and sensitivities are clearly identified. Photo identification is sighted in all medication files.

There is a system implemented that ensures the safe, self-administration of medicines for residents. Reassessment for safety is ongoing by the RN and is also reviewed at the residents three monthly medical review. Staff interviewed understand the requirements relating to the safe management of controlled drugs. A controlled drugs register is available. Unused or expired medicines are returned to the pharmacy.The requirements of the ARC service agreement 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.


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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: PA LowFood, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines appropriate to the resident group. An individual dietary assessment is performed on each individual resident on admission to identify any special needs and preferences. Residents who have additional or modified nutritional requirements have these met by the service. Meals are provided according to individual likes and dislikes of the residents. There is a dietary profile available in the kitchen for each resident which identifies all dietary requirements (sighted). The cook maintains a record of people's likes and dislikes and endeavours to give alternative food if possible.

Three of three residents (two rest home and one hospital) interviewed express satisfaction with the meals and drinks available. Satisfaction surveys and resident meeting minutes indicate satisfaction with food services.Additional drinks and snacks are available to all residents. The care plans for residents in the dementia unit indicate that snacks are to be available 24 hours.Weight charts observed in eight of eight residents' files (three hospital, three rest home and two dementia) identify that residents' weights are monitored and stable.There is a three weekly rotating menu. The menus are due for review. A dietitian is scheduled to visit the facility on the 26 October 13 to provide menu reviews and education on the diet requirements and guidelines for diabetics (email confirmation sighted).Three cooks are employed to provide food services. One kitchen manager (40 hours per week) and two kitchen assistants (each 30 hours per week). All staff have been trained (basic food hygiene) and orientated. Training records and certificates sighted. There is a cleaning schedule implemented. Visual inspection of food storage and food preparation areas indicate food is stored in the fridges, freezers or pantry available. Food is covered and dated and stock is rotated. Fridge and freezer temperature monitoring records are maintained by the kitchen staff and these were sighted as current. There is an implemented audit schedule. Food services are audited yearly. The last audit was conducted in July 2013. The requirements of the ARC service agreement 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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowA dietitian is scheduled to visit the facility on the 26 October 13 to provide menu reviews and education on the diet requirements and guidelines for diabetics.

Finding StatementAn improvement is required to review the menu.Corrective Action Required:Ensure the winter and summer menu is reviewed by a dietician.

Timeframe:6 months

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 1.4.1 Management Of Waste And Hazardous SubstancesConsumers, 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


How is achievement of this standard met or not met? Attainment: FAThere are policies and procedures for the management of waste and hazardous substances. The policy states the service`s commitment to safe and appropriate storage and disposal of waste and hazardous substances and has a focus on risk management.Waste is mostly of a domestic-type and is managed via a recycling programme and by removal by local council contracted services. The council service collects waste every Monday, Tuesday and Friday. A separate company collects miscellaneous rubbish when the container is full. Medical hazardous waste is collected by medical waste when the yellow containers are full and a replacement is provided. Personal protective equipment is readily available such as

gloves, aprons, gumboots, masks and goggles. Adequate supplies are available for daily use and for an emergency situation. Staff interviewed kitchen, caregivers and nursing staff, confirm this is available and used by them. Cleaning and laundry chemicals are kept in a locked cupboard. Material data sheets are available on all products used. The cleaner’s trolley is locked away when not in use.The requirements of the ARC service agreement are met.

Criterion 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.


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Criterion 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.


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STANDARD 1.4.2 Facility SpecificationsConsumers 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: FAThere are two maintenance persons responsible for the internal and external areas of the facility. One of the maintenance personal interviewed works thirty hours a week and has been in this role for two years. The staff member is mostly responsible for the internal maintenance of the three services being the dementia unit, the rest home and the hospital. The other maintenance staff member is responsible for the garden and lawns and works as a caregiver as well. At interview the maintenance programme and equipment check processes were verified. The electrical checks have been completed 24 to 26 June 2013 and a record is fully maintained. A yellow tag system is currently utilised and this is able to be verified. An electrical company is contracted to provide this service. One company is contracted for calibration of medical equipment and the three hoists have also been checked appropriately. Only two hoists are used currently by staff. Training is provided by the physiotherapist.

There are handrails down each side of the corridors in all three services. The resident`s rooms are personalised and adequate in size for those with walking or mobility aides to maintain their independence and to walk freely around the room or buildings. The dementia unit is a secure unit with key padded access at the main entrance however by design of the building residents are able to move freely around the inside of the facility, most of the external area and grounds and back into the facility. There is path around the garden which leads back into the facility. There is appropriate seating in the courtyard off the rest home and a large well maintained garden is accessible for the rest home and the hospital residents. Seating is appropriate for the elderly. There is a large sunroom and two enclosed porches in the front of the rest home where residents can sit and enjoy the environment.

The Building Warrant of Fitness sighted and displayed in the entrance to the rest home is dated the 8 February 2013 and issued by Fire Security Services Ltd compliance schedule WOF/3137 Auckland Council. The service has two vans used for transporting residents. The general manager interviewed has a system for managing the vehicle warrant of finesses and current registrations which was demonstrated and records are maintained.The requirements of the ARC service agreement are met.

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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Criterion 1.4.2.6 Consumers are provided with safe and accessible external areas that meet their needs.


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STANDARD 1.4.3 Toilet, Shower, And Bathing FacilitiesConsumers 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


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

The dementia unit has four large bathroom and toilets combined and the hospital has ten shared bathrooms. In the hospital each large bathroom is situated between two resident’s rooms. Each resident has their own vanity unit and mirror in the bathroom. There is 'not in use' and 'in use' signage available and each bathroom is lockable for maintaining privacy. In the rest home four toilets and bathrooms are in close proximity to the residents rooms on visual inspection. The hot water temperature is checked regularly by the maintenance team and recorded at 42-45 degrees centigrade.The requirements of the ARC service agreement are met.

Criterion 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.



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STANDARD 1.4.4 Personal Space/Bed AreasConsumers 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


How is achievement of this standard met or not met? Attainment: FAOne resident was self-propelling her own wheelchair safely around the rest home. The rest home is an older building which is being upgraded presently. Double wardrobes are available in each resident`s room. The rooms are large in size with high ceilings. There is one shared room only occupied by a couple. There is ample room for walking aides to be used safely and for care staff when assisting with cares. The manager explained that the hospital and dementia units are purpose built and designed appropriately for caring for elderly residents. The hospital rooms have double doorways for beds and hoist access if required.The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 1.4.5 Communal Areas For Entertainment, Recreation, And DiningConsumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

ARC E3.4b ARHSS D15.3d


How is achievement of this standard met or not met? Attainment: FAOn the tour of the facilities with the general manager it is observed that there are large lounges in the dementia unit and the rest home which can be used by residents and their families. There is a small room available in the dementia unit with comfortable seating for family/visitors and group meetings. The lounges are also used for activities. There is a smaller lounge in the hospital. The dementia unit and the hospital lounges also have facilities for meeting the dining needs of residents. The rest home has a large separate dining room close to the kitchen which is going to be enlarged and decorated this year as part of the re-furbishing programme. There is a sunny enclosed sunroom and two porches on the front of the rest home with seating available. Two residents in the rest home and hospital, nine staff, five families interviewed and the general manager reported that the facilities are communal and suitable for the elderly residents.The requirements of the ARC service agreement are met.

Criterion 1.4.5.1 Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.


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STANDARD 1.4.6 Cleaning And Laundry ServicesConsumers 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


How is achievement of this standard met or not met? Attainment: FAThere are separate laundry and linen service manuals available and reviewed containing all relevant cleaning and laundry policies and procedures to guide staff. Laundry procedures for handling soiled linen, water temperatures, protective clothing, storage of chemicals, clean linen, training and resident`s clothing are available. All cleaning processes are documented clearly for each area of service and sighted. There is adequate storage for all chemicals in a locked designated area sighted. An inventory list and preferred provider services are documented for mechanical repairs, maintenance and equipment checking. There is a cleaning schedule dated Feb 2013 with documented daily cleaning tasks to be completed. The maintenance persons completed any high cleaning and extra cleaning in the kitchen area as required by the maintenance schedule sighted.There is a large laundry on site that contains commercial grade washing machines and clothes dryer. There is dirty and clean systems approach managed effectively by the laundry person on site during the audit. The care staff are responsible for the laundry in the weekends and two care staff interviewed are aware of this responsibility. There are material data sheets available for all products used for cleaning and the laundry. Five families and two residents interviewed commented on how clean the home is and the laundry is always returned to the residents folded and/or ironed if required.The requirements of the ARC service agreement are met.

Criterion 1.4.6.2 The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.


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Criterion 1.4.6.3 Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.


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STANDARD 1.4.7 Essential, Emergency, And Security SystemsConsumers receive an appropriate and timely response during emergency and security situations.

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


How is achievement of this standard met or not met? Attainment: FAAll staff have completed first aid certificates. The training programme and job descriptions for all staff are available. The health and safety officer interviewed is fully aware of the responsibilities for this role and this is signed off 27 Mar 2013 by the health and safety officer and the general manager. All electrical, heating and emergency lighting was checked 26 June 2013. There are two monthly checks of the building required and verified. A copy is retained in the maintenance records. Any findings the general manager is informed immediately. Maintenance sheets at the nurse’s stations are used if staff find anything requires attention or repair this is documented and signed off when investigated and/or repaired. There is an approved evacuation plan dated the 12 July 2012 which was sighted and a planned fire drill is due 17 October 2013. Fire drills are held six monthly and documented evidence is available. There is a sprinkler system in each service area, extinguishers and a fire blanket is visible in the kitchen. Three civil defence boxes are available in readiness for any emergency situation. The assembly point is in the courtyard near the front car park.In the event of an emergency alternative energy and utility sources are available such as emergency lighting, and spare battery lights, a gas barbecue, linen, continence products, torches and batteries, water (town supply only) supplies, three gas heaters, gas stove. Food dry stock and freezers is accessible. The service does not have a power generator. A memorandum of understanding exists with the 'Four Square shop' next to facility to supply bottled water if needed in an emergency situation.

A nurse call bell system is available at each bed site and all bathroom areas to summon assistance as required. All bells sighted and checked are in working order.Security is maintained. The hospital registered nurse holds the keys. The dementia unit if fully secured with key pad entry only. A perimeter fence is erected and is locked with key pads on two gates. Staff on the afternoon and night shifts are responsible for ensuring the facilities doors and windows are closed appropriately and doors are locked appropriately. The general manager or person on call can be contacted if staff are concerned or alternatively the New Zealand police can be contacted if needed.The requirements of the ARC agreement are met.

Criterion 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.


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Criterion 1.4.7.3 Where required by legislation there is an approved evacuation plan.


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Criterion 1.4.7.4 Alternative energy and utility sources are available in the event of the main supplies failing.


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Criterion 1.4.7.5 An appropriate 'call system' is available to summon assistance when required.


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Criterion 1.4.7.6 The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.


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STANDARD 1.4.8 Natural Light, Ventilation, And HeatingConsumers 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


How is achievement of this standard met or not met? Attainment: FAA policy document of facility specifications addresses light, ventilation and heating. There are two gas heaters in the hallway in the rest home and some residents have individual heaters in their rooms which are checked by the electrician and tagged appropriately. There is some insulation in the wall and ceilings in the rest home to promote heat. In the hospital and dementia unit each room is thermostat controlled with a ceiling heating system throughout the facility.Ventilation is adequate in all areas. The bathrooms in the hospital and dementia unit have automatic lights and heating/lights/distractor fans which work effectively. All rooms open to the outside with an external window.The requirements of the ARC agreement are met.

Criterion 1.4.8.1 Areas used by consumers and service providers are ventilated and heated appropriately.


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


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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 Craigweil House restraint minimisation and safe practice policy dated the 21 March 2013 is available and sighted. The service philosophy and commitment to promoting a restraint free environment is encouraged and staff are provided with appropriate guidelines to enable them to prevent the need for restraint. The restraint minimisation and safe practice policy and procedures are clearly documented and implemented. The clinical manager interviewed is the restraint coordinator. The definition of restraint and enablers is clearly documented and understood by healthcare assistants and registered nurses interviewed and staff are aware of an enabler as being a voluntary decision to maintain safety and independence of a resident. Two enablers are in use one bedrail and one lap belt. Enabler consent forms are documented and signed off appropriately. The use of the two enablers is recorded in the individual residents care plans sighted. Restraint is discussed at the team leader meetings and at the registered nurse meetings. There is no restraint currently used at this facility.

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 3.1 Infection control managementThere 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


How is achievement of this standard met or not met? Attainment: FAThe clinical manager is responsible for infection control (IC) matters throughout the facility. This is documented in the clinical managers job description sighted. The clinical manager is supported by the gerontology nurse and the IC nurse from the WDHB. The clinical manager were interviewed and reported that staff and visitors suffering from infectious diseases are advised not come to the facility. Staff are aware not come to work when suffering from infections. A notice is clearly displayed at the entrance requesting visitors do not enter if they are suffering from an infectious disease. Hand gel is easily accessible throughout the facility.Staff interviewed (general manager, clinical manager and two of two care staff) confirm there are infection control policies and procedures available to provide them with adequate guidance. These were sighted. There is a schedule for IC internal audits to commence in October 13. IC meetings (minutes sighted for 23/10/13 and 25/9/13) occur as part of the leadership meetings held fortnightly. There is a plan to address IC in monthly RN meetings. The IC programme implemented provides information and resources to inform staff on infection prevention and control and is appropriate to the size and scope of the services provided. Visual inspection provides evidence staff provide infection management precautions.The requirements of the ARC service agreement are met.

Criterion 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.


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Criterion 3.1.3 The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.


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Criterion 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.


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STANDARD 3.2 Implementing the infection control programmeThere are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



How is achievement of this standard met or not met? Attainment: FAThe infection control programme meets the needs of the facility and provides information and resources to inform and guide staff. The IC coordinator is the clinical manager with the relevant skills and resources necessary to achieve the requirements of this standard. The clinical manager interviewed clearly describes the role and accountabilities of IC coordinator. The RN last attended IC training in March 2012. The job description for the IC coordinator is sighted. The IC committee comprises of the clinical manager, general manager, hospital coordinator and senior care staff of the rest home and dementia unit. The IC committee has access to the DHB gerontology nurse for advice and education. Two of two care staff and three of three residents interviewed confirm the clinical manager and RN is available for management of infection control issues or advice as required.The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 3.3 Policies and procedures

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


How is achievement of this standard met or not met? Attainment: FAThe facilities IC policies and procedures include hand washing, standard precautions, transmission based precautions, isolation, outbreak management, staff issues, cleaning and disinfection and sterilisation, linen and waste management and surveillance. The policies and procedures relate to health and disability sector infection control standards and relevant reference material and are cross referenced to all relevant current accepted good practice and legislative requirements. The IC policies, procedures and guidelines reviewed are practical and safe and are available to staff. Staff interviewed (manager and clinical manager) report that IC policies and procedures are reviewed bi-annually and when required to reflect any updates in current good practice standards or changes made to the Health and Disability Sector Standards.Staff interviewed (kitchen manager and two of two care staff) confirm there are infection control policies and procedures available to provide them with adequate guidance.The requirements of the ARC service agreement are met.

Criterion 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.


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STANDARD 3.4 EducationThe organisation provides relevant education on infection control to all service providers, support staff, and consumers.



How is achievement of this standard met or not met? Attainment: FAAll staff receive training related to IC during orientation and then annually (training records sighted). The training is provided by the clinical manager, RN or DHB gerontology nurse. The training addresses the implementation of the facilities IC policies and procedures including hand washing, standard precautions, transmission based precautions, outbreak management, staff issues, cleaning and disinfection and sterilisation, linen and waste management and surveillance. Staff training for IC last occurred October 12.The clinical care manager last attended education relating to IC in March 2012 while employed in Australia.Three of three residents (two rest home and one hospital) and two of five family members could recall the RN providing some education on IC and prevention.The requirements of the ARC service agreement are met.

Criterion 3.4.1 Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.


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Criterion 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.


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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: FAThe surveillance programme implemented is relevant to the level of services provided. The clinical manager is responsible for promoting surveillance activities and ongoing monitoring. All staff are responsible for reporting infections. Surveillance activities are monitored and reported by the clinical manager as part of the internal quality system to the general manager and owners. IC internal audits are completed as part of the internal audit programme. Staff interviewed (clinical manager, RN and two of two care staff) report they are made immediately aware of any infections of individual residents by way of feedback during daily handovers and review of clinical progress notes. An infection report is completed for every infection and a copy of this report retained in the IC surveillance folder. The clinical manager completes a monthly infection control report which includes infection by type and number. Monthly summaries of infections, actions and outcomes are included in the reporting process. The collated results are reported at leadership and staff meetings. (Minutes sighted)Antibiotic use is documented in the residents' records and the monthly infection control reports (evidence is seen in the IC folder). Surveillance activities include monitoring of multi-resistant organisms and antibiotic use.

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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certification audit summary · web viewthe adverse event reporting system is planned with staff...

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