Certification audit summary · Web view14-Oct-13 The following summary has been accepted by the...

Seaview Park Limited

CURRENT STATUS: 14-Oct-13

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

GENERAL OVERVIEW

Seaview is privately owned and operated. Seaview cares for up to 35 residents requiring rest home level care. On the day of the audit there were 20 residents including three on short term respite care.

This audit was undertaken to establish the level of preparedness of the prospective provider to provide a health and disability service and to assess conformity prior to a facility being purchased. The proposed new owner has a manager with aged care experience who will be moving into the role and have a quality and risk management system which they intend to implement at Seaview. At the time of the audit the proposed change of ownership date had not been established.

This audit has identified areas for improvement around the complaints register, the quality management system, performance appraisals, admission agreements, aspects of medication documentation, preventative maintenance, replacement of laundry tubs, repair to the oven, hoist servicing, the call bell system, annual review of the infection control programme, staff training around infection control and six monthly fire drills.

Seaview Retirement ParkSeaview Park Limited

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

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Seaview Park Limited

Premise Name Street Address Suburb City

Seaview Retirement Park 839 Whangarei Heads Road RD 4 Whangarei

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

Type of Audit Provisional audit and (if applicable)

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

Designated Auditing Agency

Health and Disability Auditing New Zealand Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXXX RCmpN, Health audit cert 8.00 6.00 14-Oct-13

Auditor 1 XXXXXXXX RN, Health audit cert 8.00 6.00 14-Oct-13

Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor Peer Review Auditor XXXXXXXX 2.00

Total Audit Hours on site 16.00 Total Audit Hours off site (system generated)

14.00 Total Audit Hours 30.00

Staff Records Reviewed 6 of 23 Client Records Reviewed (numeric)

5 of 20 Number of Client Records Reviewed

using Tracer Methodology

1 of 5

Staff Interviewed 5 of 23 Management Interviewed (numeric)

2 of 2 Relatives Interviewed (numeric)

Consumers Interviewed 8 of 20 Number of Medication Records Reviewed

10 of 20 GP’s Interviewed (aged residential care and residential disability) (numeric)

Declaration

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

I confirm that Health and Disability Auditing New Zealand Limitedhas in place effective arrangements to avoid or manage any conflicts of interest that may arise.

Dated this 22 day of October 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.

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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

Seaview Retirement Park

Executive Summary of Audit

General OverviewSeaview is privately owned and operated. Seaview cares for up to 35 residents requiring rest home level care. On the day of the audit there were 20 residents including three on short term respite care.This audit was undertaken to establish the level of preparedness of a prospective provider to provide a health and disability service and to assess conformity prior to a facility being purchased. The proposed new owner has a manager with aged care experience who will be moving into the role. Radius, the proposed new owner have a quality and risk management system which they intend to implement at Seaview. At the time of the audit the proposed change of ownership date had not been established.This audit has identified areas for improvement around the complaints register, the quality management system, performance appraisals, admission agreements, aspects of medication documentation, preventative maintenance, replacement of laundry tubs, repair to the oven, hoist servicing, the call bell system, annual review of the infection control programme, staff training around infection control and six monthly fire drills.

1.1 Consumer RightsThe service functions in a way that complies with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Information about the Code and services are readily available to residents and families. Policies are implemented to support residents’ rights. Residents and relatives speak positively about care provided at the facility. There is a Maori health plan in place to guide staff practice. Cultural assessment is undertaken on admission and during the review process. Policies are implemented to support resident’s rights such as privacy, dignity, abuse and neglect, culture, values and beliefs, complaints, advocacy and informed consent. Staff receive on-going education on residents’ rights. Care plans accommodate the choices of residents and/or their family/whānau. Residents and relatives confirm residents’ on-going involvement with the community. Complaints processes are implemented and complaints and concerns are managed and documented. An improvement is required to the documentation of complaints in the complaints register.

1.2 Organisational ManagementThe facility is currently being managed by the prospective purchaser under formal arrangements initiated by Northland District Health Board. The prospective purchaser has appointed a manager with experience in aged care. There is a comprehensive risk management plan that has been developed to manage the risks of transition between the current and the prospective owners. There is an established quality and risk management system in place that includes key components which supports the provision of clinical care. Adverse events are documented by staff and are reported to management who inform affected residents and families in an open manner. Information obtained through the quality and risk management system is discussed with staff at the monthly meetings which include an education session at the same time. Improvements are required to the current quality and risk system. Human resource management practices are conducted in accordance with good employment practices. Currently the business is restructuring its staffing levels to match reduced resident occupancy. Management are working with staff, the union and the DHB to agree the proposed new staffing roster. An improvement is required to ensure performance appraisals of health care assistants are completed.

1.3 Continuum of Service DeliveryResident files reviewed include service coordination centre assessment forms. The facility information pack includes all relevant aspects of service , and this is provided to residents and/or family/whanau prior to entry. There is an improvement required around admission agreements. Care plans are developed in consultation with relevant people including residents and where appropriate family / whanau or Enduring Power of Attorney. A registered nurse assessment, including a variety of risk assessments are completed on admission and reviewed six monthly following admission. The consumers' needs, and goals are clearly identified and interventions clearly guide staff. Residents and/or family have input into the development of care plans. Communication with family is well documented. Planned activities are appropriate to the residents' interests. Residents interviewed confirm their satisfaction with the programme. Residents' files evidence activity care plans included in the long term care plan identify goals, and interventions and are evaluated at least six monthly. Individual activities are provided either within group settings or on a one-on-one basis. Activities are planned monthly. An appropriate medicine management system is implemented. Policies and procedures detail service provider's responsibilities. Caregivers, an enrolled nurse and the registered nurses are responsible for medicine management have attended in-service education for medication management and complete a medication competency annually. Medication charts sighted evidence documentation of consumers' allergies/sensitivities and three monthly medication reviews completed by general practitioners. There are no residents who are self-medicating. There is compliance with respective legislation, regulations and guidelines. The service has transfer and discharge procedures The staff interviewed are knowledgeable of their responsibility of safe exit or discharge to another facility or hospital. A dietitian is available to provide dietetic assessment for residents and arrange special authority's as required. All food is cooked on site and kitchen staff have attained safe food handling certificates. Residents and families interviewed, all confirmed satisfaction with food services. There are improvements required around PRN medication prescribing, medication administration and replacing the seal on the oven.

1.4 Safe and Appropriate EnvironmentThe service has implemented policies and procedures for fire, civil defence and other emergencies. There are staff on duty with a current first aid certificate. The building holds a current warrant of fitness. Rooms are individualised. External areas are safe and well maintained. The facility has a van available for transportation of residents. Those transporting residents hold a current first aid certificate. There is a large spacious lounge on each level and two dining areas. There are adequate toilets and showers. Fixtures fittings and flooring is appropriate and toilet/shower facilities are constructed for ease of cleaning. Cleaning and laundry services are well monitored through the internal auditing system. is an approved evacuation scheme and emergency supplies for at least three days. Chemicals are stored securely. Appropriate policies are available along with product safety charts. The temperature of the facility is comfortable and constant and able to be adjusted in residents rooms to suit individual resident preference. There are emergency plans in place. There is a civil defence kit and evidence of supplies in the event of an emergency in line with Civil Defence guidelines. There are improvements required around surfaces of tubs, preventative maintenance, hoist servicing, six monthly fire drills and the call bell system.

2 Restraint Minimisation and Safe PracticeThere is a restraint policy in place to guide staff and staff are aware of the content of the policy and have attended refresher education on restraint minimisation this year. There are no residents using enablers or restraints.

3. Infection Prevention and ControlThe infection control policies and procedures are documented. Staff meetings are conducted with infection control noted as a regular agenda item. Regular infection control audits, hazard documented and incident monitoring of infection prevention and control practices are performed and the results are communicated to staff at meetings. Staff receive training in infection control at orientation. The infection control coordinator (the registered nurse) takes overall responsibility for ensuring that the surveillance programme is well implemented with review trends and implementation of any recommendations.All surveillance activities are the responsibility of the infection control coordinator who is the registered nurse/manager with assistance from all staff through the bi monthly staff meeting. There is an infection register in which all infections are documented monthly. There are improvements required around an annual review of the infection control programme and staff training in infection control.

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 PA Low 0 1 1 0 0 3

Consumer Rights Standards (of 12): N/A:0 CI:0 FA: 11 PA Neg: 0 PA Low: 1 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:22 PA:1 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 PA Moderate 0 5 3 0 0 9Standard 1.2.4 Adverse event reporting FA 0 2 0 0 0 4

Standard 1.2.7 Human resource management PA Low 0 3 1 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: 5 PA Neg: 0 PA Low: 1 PA Mod: 1 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

1.3 Continuum of Service Delivery

Attainment CI FA PA UA NA ofStandard 1.3.1 Entry to services PA Low 0 0 1 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 FA 0 1 0 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 FA 0 1 0 0 0 3Standard 1.3.8 Evaluation FA 0 2 0 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 PA Moderate 0 3 1 0 0 7Standard 1.3.13 Nutrition, safe food, and fluid management PA Moderate 0 2 1 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 9 PA Neg: 0 PA Low: 1 PA Mod: 2 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 PA Low 0 2 1 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 PA Moderate 0 3 2 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: 6 PA Neg: 0 PA Low: 1 PA Mod: 1PA 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 1 3Standard 2.2.2 Assessment Not Applicable 0 0 0 0 1 2Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 3 6Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 2 3Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 1 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 PA Low 0 2 1 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 PA Low 0 1 1 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: 3 PA Neg: 0 PA Low: 2 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: 35 PA Neg: 0 PA Low: 6 PA Mod: 4 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: 80 PA: 13 UA: 0 N/A: 8

Corrective Action Requests (CAR) Report

Provider Name: Seaview Park LimitedType of Audit: Provisional audit

Date(s) of Audit Report: Start Date:14-Oct-13 End Date: 14-Oct-13DAA: Health and Disability Auditing New Zealand LimitedLead Auditor: XXXXXXXX

Std Criteria Rating Evidence Timeframe1.1.13 1.1.13.3 PA

LowFinding:There is no current up-to-date complaints register which contains a list of all complaints, dates and actions taken.

Action:Ensure all resident complaints and relevant dates and actions taken are recorded in the complaints register.

3 months

1.2.3 1.2.3.1 PALow

Finding:The quality plan in use is overdue for review.

Action:Ensure there is a current quality and risk management plan in place to guide practice.

3 months

1.2.3 1.2.3.7 PALow

Finding:There is no current system in place to measure achievements against the quality and risk management plan.

Action:Ensure there is an implemented system that measures achievement against the objective outlined in the quality and risk management plan.

6 months

1.2.3 1.2.3.8 PALow

Finding:The system of identifying corrective actions and addressing them is not fully implemented.

Action:Ensure there is a system of identifying corrective actions requiring improvement that is fully documented and implemented.

3 months

1.2.7 1.2.7.5 PALow

Finding:Appraisals for HCAs were due in June 2013 and have yet to be completed.

Action:Ensure performance appraisals are completed annually for all staff.

3 months

1.3.1 1.3.1.4 PALow

Finding:Two of the five files sampled do not have a signed admission agreement. One of these is a long term resident who has a short term agreement but no long term agreement.

Action:Ensure all residents have a signed admission agreement.

3 months

1.3.12 1.3.12.6 PAModerate

Finding:(i)Three of ten medication charts sampled have regular non-packaged medications that have not been signed as administered regularly. (ii) Six of ten medication charts have PRN medication prescribed with no documented indication for use.

Action:(i)Ensure that medications are administered as prescribed. (ii) Ensure PRN medications document a reason for use.

1 month - immediately

1.3.13 1.3.13.5 PAModerate

Finding:The oven seal is damaged and the formica surface under the oven has scalded.

Action:Ensure the oven is safe.

3 months

1.4.2 1.4.2.1 PALow

Finding:(i)There is a tub in the main laundry and another in the upper Manaia laundry that have rust and damaged paint. (ii) There are no records for preventative maintenance since February 2013. (iii) There is no record of the hoist having been serviced.

Action:(i)Ensure all surfaces are intact and can be adequately cleaned. (ii) Ensure preventative maintenance is completed. (iii) Ensure the hoist is serviced according to manufacturer's directions.

6 months

1.4.7 1.4.7.1 PALow

Finding:The last trial evacuation that there is documented evidence for occurred in December 2012.

Action:Ensure trial evacuations occur six monthly.

3 months

1.4.7 1.4.7.5 PAModerate

Finding:The call system does not interconnect throughout the facility. The second and third floor call bell systems are able to alert staff members located on the upper floor but a call bell rung on floor one (Seaview) cannot be received on the second or the third floors. Should the staff member located on the upper floor during the night period be required to provide assistance to the residents located on the second floor, a call bell rung by any resident on the upper floor to summons a staff member’s assistance cannot be heard on the second floor.

Action:Ensure there is a call bell system that is interconnected throughout the facility.

3 months

3.1 3.1.3 PALow

Finding:There has been no annual review of the infection control programme.

Action:Ensure there is an annual review of the infection control programme.

6 months

3.4 3.4.1 PALow

Finding:There has been no staff training in infection control since March 2012.

Action:Ensure infection control training is provided to staff at least annually.

6 months

Continuous Improvement (CI) Report

Provider Name: Seaview Park LimitedType of Audit: Provisional audit Date(s) of Audit Report: Start Date:14-Oct-13 End Date: 14-Oct-13DAA: Health and Disability Auditing New Zealand 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: FAStaff are aware of the Code of Health and Disability Services Consumers’ Rights (the Code) and can articulate examples of how they incorporate the rights of residents into their practise (confirmed in interview with three of three HCAs, one enrolled nurse, one registered nurse and the nurse manager). There are policies and procedures in place requiring staff to implement the requirements of the Code (sighted). Internal audits occur to ensure staff comply with the Code (last internal audit conducted 13 March 2013). The service provides families and residents with information on entry to the service and this information contains details relating to the Code. Staff receive training on the Code at orientation and in on-going professional development (staff last received training on the Code on 30 November 2012 (12 attended) and on 22 August 2013 (22 attended). Residents believe that services are provided in accordance with their rights (confirmed in discussions with eight of eight residents).

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: FAResidents are informed of their rights in the information pack, which is given to all prospective residents (sighted). Information on the Code is displayed throughout the facility (sighted). Residents and relatives are provided with explanations on the Code and the nationwide health and disability advocacy service when the initial discussions on entry occur and thereafter as the need arises (confirmed in discussions with three of three health care assistants (HCAs), one enrolled nurse (EN), the nurse manager, eight of eight residents and two of two relatives). D6.2 and D16.1b.iii New subsidised residents and/ or their nominated representatives receive a copy of the Code on entry to the facility.

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: FAStaff respect the privacy of residents. Staff knock on resident’s bedroom doors prior to entry (observed during audit). Staff maximise resident independence by providing information on choices. Each resident has their own bedroom to maximise privacy. Discussions of a private and confidential nature are held either in the resident’s bedroom or in the office depending on the preference of the resident (and or their family).Residents are able to store their possessions in their own bedroom. D3.1b, d, f, i The service has a philosophy that promotes quality of life, involves residents in decisions about their care, respects their rights and maintains privacy and individualityD14.4 There are clear instructions provided to residents on entry regarding responsibilities of personal belonging in their admission agreement. Personal belongings are documented and included in resident files. D4.1a Five of five resident files reviewed identified that cultural and /or spiritual values, individual preferences are identified. The service has policy in place that requires staff to report all instances of suspected or actual resident abuse.

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 has a Maori health plan policy and procedure in operation to guide staff in order to ensure that the specific needs of Maori residents are met, which is due for review in November 2013. Staff endeavour to assist residents in a culturally appropriate manner that reflects the principles of the Treaty of Waitangi, by mutual respect and understanding of the residents' and staffs' individual values and beliefs, and by taking into account the cultural, spiritual, social and ethnic needs and in particular the role of Maori people within the community. The service has a relationship with a local Kaumatua and has a relationship with the Anglican Maori Ministry in Onerahi. In addition staff endeavour to establish and maintain communications with the local Maori health providers through the services at the Whangarei Base Hospital thus reducing barriers to current and potential residents. Staff have training in Treaty of Waitangi and related issues of respect values (last training occurred on 28 June 2012 with 13 staff attending). Staff acknowledge that Maori have special beliefs, skills, and knowledge about health issues. Staff practice a holistic approach to healthcare which incorporates the four cornerstones of Maori health (confirmed in discussions with one of the eight residents who identifies as Maori).A3.2 There is a Maori health plan that includes a description of how staff will achieve the requirements set out in A3.1 (a) to (e)D20.1i The nurse manager liaises with management of the Maori health directorate employed by Northland DHB.

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.

Finding Statement

Timeframe:

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

Finding Statement

Timeframe:

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

Finding Statement

Timeframe:

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: FAThe service has a culturally safe care policy to ensure a culturally appropriate service is provided by staff. Staff endeavour to assist all residents in a culturally appropriate manner by mutual respect and understanding of the residents' and staffs' individual values and beliefs, and by taking into account the cultural, religious social and ethnic needs in all aspects of their lives (confirmed in discussions with three of three HCAs, one EN, one RN and the nurse manager). This policy does not stand alone but compliments all other policies and procedures in place. On admission all residents are fully assessed and a care plan is developed in partnership with the resident and family/whanau/significant other that will include all aspects of the policy and address all aspects of care and life needs. An interpreter and/or advocate for the resident is made available as needed. Local ethnic/Iwi or other relevant community groups will be resourced as required and/or requested by resident and/or family/whanau. Residents have access to a spiritual advisor/minister of their choice who may visit regularly. Staff receive training in cultural issues and the Treaty of Waitangi (last occurred 28 June 2012).In the event of a death of a resident, their bedroom is later blessed usually by the Anglican Minister of religion. There is a Maori health plan in place. Residents are satisfied that their cultural and individual values were being met (confirmed in discussions with eight of eight residents). Family are involved in assessment and the care planning process (confirmed in discussions with two of two relatives). Information gathered during assessment including residents cultural, beliefs and values is used to develop a care plan which the resident (if appropriate), and/or their family/whānau are asked to consult on. Agreement is reached by all parties involved in the consultation process and the care plan is implementation within the service delivery.

D3.1g The service provides a culturally appropriate service. D4.1c Care plans reviewed included the resident’s social, spiritual, cultural and recreational needs.

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.

Finding Statement

Timeframe:

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 abuse and neglect policy guides practice to ensure that residents will be free from discrimination, coercion, harassment, sexual, financial or other exploitation. Staff are provided with training during orientation and in on-going in-service (last session provided 22 August 2013 (22 staff attended). Staff are taught to understand any aspects of abuse and neglect and to report any abusive or neglectful behaviour carried out by other staff or the residents’ family/whanau. Staff are required to be mindful of the ability of families/whanau to abuse their relatives in care and putting in place safeguards to prevent and manage these occurrences whilst giving due attention to the Privacy Act and the Personal Protection of Property Act. There have been no instances of abuse reported to the nurse manager (confirmed in discussions with the nurse manager).

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.

Finding Statement

Timeframe:

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 has policies to guide good practice that align with the health and disability services standards and industry practice. There are quality and risk management practices in place. Staff are encouraged to complete training following orientation. Staff are paid additional money on completion of courses. Approximately 26 percent of HCAs have completed their initial ACE training and two HCAs have completed training on providing care to residents with dementia. A training plan is in place and an internal in-service training programme is implemented. Staff are paid to attend internal training and the training is held at the same time as the monthly staff meeting to maximise attendance. Attendance is compulsory.

A2.2 Services are provided that adheres to the health & disability services standards. There is an implemented quality improvement programme in place. Staff performance is monitored by the nurse manager.D1.3 All approved service standards are adhered to (with the exception of the CARs identified during this audit).D17.7c There are implemented competencies for clinical staff and HCAs who carry out delegated clinical tasks (i.e. medicine administration) which must be completed prior to conducting the tasks, procedure or treatment and policies and associated procedures and forms are in place to guide safe practice. There are clear ethical and professional standards and boundaries within job descriptions.

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: FAAn adverse event and open disclosure policy is in place. An accident / incident /unwanted events reporting system is maintained (sighted). Staff are trained on the policy and associated procedure and forms (last training occurred 10 October 2013 attended by 12 staff). Resident’s records evidence communication with their family about any significant changes that have occurred to the resident and a record of family communication is documented. Residents and relatives report good communication with staff and management (confirmed in discussions with eight of eight residents and two of two relatives). Resident meetings are conducted (consumers' meeting minutes sighted). Interpreter services are able to be accessed through the nationwide health and disability advocacy service if needed. The nurse manager has an open door policy.

D12.1 Non-subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so in the service agreement, which is provided to all residents on entry. D16.1b.ii Residents and family are informed prior to entry of the scope of services and any items they have to pay for that are not covered by the agreement and this information is included in the service agreement (which is based on the Aged Care Association template document) (see CAR 1.3.1).D16.4b Two of two relatives stated that they are always informed when their family members health status changes.D11.3 The information pack can be made available in large print if needed and can be read to residents if necessary.

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 Consent

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

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: FAWritten informed consent is gained for do not resuscitate or resuscitation orders appropriately for five of five files sampled. Five files were reviewed and found to have valid consents. It was stated by the registered nurse that family involvement occurs with the consent of the resident. Other forms of written consent included; consent to share information, consent for photographs and consent for transportation. A review of five files found all consents were present and signed by the resident or their EPOA. EPOA documents are kept on the resident's file. Eight residents interviewed confirm that they are given good information to be able to make informed choices. Three health care assistants, one enrolled nurse and the registered nurse interviewed confirm information was provided to residents prior to consents being sought and they were able to decline or withdraw their consent. Staff received training around obtaining informed consent by the Health and Disability Advocates in November 2012 and August 2013. D13.1 There were three of five admission agreements sighted (see CAR 1.3.1).D3.1.d Discussion with two family identified that the service actively involves them in decisions that affect their relatives lives.

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: FAResidents have access to advocacy services through the nationwide advocacy service. A brochure on the service is provided to residents on entry to the facility and additional information is on display within the facility. D4.1d; Two of two relatives identified that the service provides opportunities for the family/EPOA to be involved in decisions affecting their relative.ARC D4.1e, Resident’s records contain information on the resident’s family/whanau and chosen social networks.

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: FAResidents are actively encouraged by staff to maintain their community links. They are encouraged to be involved in community activities (eg, the local church, the RSA, and to interact with children from the local schools, attend local arts and crafts events and attend local fairs that are held at the school, and to attend local churches). Residents are encouraged to maintain links to their family and friends (confirmed in discussions with three of three HCAs, one EN, one RN, the nurse manager, eight of eight residents, and two of two relatives). Links are recorded in plans of care (confirmed in review of five of five resident’s records). Residents have access to visitors of their choice (observed and confirmed in discussions with eight of eight residents). The facility encourages open visiting at any reasonable hour. D3.1h; Family are encouraged to be involved with the service and careD3.1.e Residents are supported and encouraged to remain involved in the community and external groups.

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: PA LowStaff are aware of residents rights to make a complaint and staff can correctly articulate the process which complies with Right 10 of the Code should a resident wish to complain (confirmed in discussions with the nurse manager, three of three HCAs, one enrolled nurse and one RN). Residents and their next of kin understand that they have a right to complain and they are aware of the process they should follow (confirmed in discussions with eight of eight residents and two of two relatives). There is a complaint policy in place. All consumer complaints are recorded individually. However a record of more recent complaints and the dates and actions taken in relation to those complaints have not been maintained in the complaints register and an improvement is required. There have been no complaints involving the Health and Disability Commissioner.D13.3h. The admission agreement and entry pack includes information on the complaints procedure and a form is provided to residents within the information pack at entry.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowComplaints related to residents and their next of kin are documented individually.

Finding StatementThere is no current up-to-date complaints register which contains a list of all complaints, dates and actions taken.Corrective Action Required:Ensure all resident complaints and relevant dates and actions taken are recorded in the complaints register.

Timeframe:3 months

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: FA

Seaview cares for up to 35 residents requiring rest home level care. On the day of the audit there were 20 residents including three on short term respite care. The organisation is currently owned by Ideal Nurses Limited who trade as Seaview Retirement Park. Ideal Nurses Limited are in discussions with Radius Residential Care Limited to purchase the service. Northland DHB entered into a formal arrangement with Radius Residential Care Limited to manage the business on behalf of Ideal Nurses Limited from September 2013. Radius Residential Care Limited appointed a nurse manager to manage the business on a day-to-day basis with support from the wider organisation. The nurse manager has since resigned and her last day of employment is 25 October 2013. She has a current practising certificate and has 15 months experience as a facility manager within Radius. She has completed at least eight hours of professional development within the last 12 months directly related to managing a rest home and has a current first aid certificate.Radius Residential Care Limited has appointed another manager to the role and this person will commence on 23 October 2013. This person is reported to be an experienced assistant facility manager who has been employed within Radius for a number of years. She will be supported by the regional manager and the two delegated facility managers who are employed by Radius at its two other facilities located in Whangarei. The regional manager visits the area weekly from her base in Auckland. The regional manager is supported by the general manager who reports to the CEO. Ideal Nurses Ltd has a business plan dated 2011 to guide business operation. The plan ceased to be applied when the business governance arrangement changed in September (sighted). The plan includes their strategies, actions and who was responsible for implementing the actions. the purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.The prospective purchaser has developed a risk management (transition) plan dated October 2013 which outlines the current risks and the risks going forward the business. RRCL operates under a business plan dated April 2012 to March 2015 which includes purpose, values (ie,vision), scope, direction and goals of the organisation (sighted). The intention is that this business plan will apply to the business following purchase.

ARC,D17.3di The manager has maintained at least eight hours of professional development activities within the last year related to managing a rest home.

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: FAIf the manager is temporarily absent then the registered nurse assumes the responsibilities of the role on a temporary basis. Depending on the length of absence and the reasons for the absence, and the wishes of the registered nurse employed at the time, Radius Residential Care Limited may choose to make alternate arrangements (confirmed in discussions with the regional manager).D19.1a; A review of the documentation, policies and procedures and from discussions with staff identified that the service operational management strategies and the quality programme, which includes culturally appropriate care, are designed and implemented to minimise the risk of unwanted events occurring to residents and to enhance quality.

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: PA ModerateThere is a quality/risk management policy and plan (which was intended to be reviewed in 2011) and an improvement is required. Although overdue for review, this plan is in operation. The plan still refers to Radius Residential Care Limited who operated the facility prior to Ideal Nurses Ltd. There is a system operating in practice which includes key components of a quality and risk management system. The system includes but is not limited to: (a) incident and accident event reporting; (b) compliments and complaints management; (c) infection prevention and control; (d) health and safety; and (e) restraint minimisation. There is a system of internal audit in place (internal audit timetable sighted) and an on-going system of staff education (programme sighted). Staff are aware of the quality and risk management system (confirmed in discussions with the nurse manager, one EN and three of three HCAs).Residents meetings occur 2 monthly and staff attend to hear resident feedback (meeting minutes sighted of meetings held 6 May 2013 and 20 September 2013). Residents and relatives are comfortable in talking to the nurse manager between meetings (confirmed in discussions with eight of eight residents and two of two relatives).

Ideal Nurses Limited has developed and implemented a limited suite of policies, associated procedures and forms that are aligned with current good practice and service delivery, meet the requirements of legislation. They are continuing to use some policies from the previous owner and have purchased a numbers of policies and procedures and associated forms from a contractor that have yet to be implemented in practice (sighted). Ideal Nurses Limited review its documents two yearly and they are next due for review in October 2013. Radius Residential Care Limited as current operator and prospective purchaser has developed a risk management plan for the transition process which links to their business plan (sighted). Radius Residential Care Limited intends to implement its quality and risk management system and associated suites of specific policies and procedures by the end of December 2013. The system includes a system of document control which is managed by the support office. All documents are reviewed mostly two yearly or earlier if needed. Some documents are reviewed five yearly. Document control is managed by a dedicated team of staff which includes the general manager, regional managers and facility managers. Quality improvement data are collected in hard copy format and are processed at the time the event is reported by staff. Data are summarised on a quality indicator data form which includes incidents, accidents and infection prevention and control data. Results are discussed at staff meetings (minutes sighted for 22 August 2013 although prior to August 2013 the system was inactive). There is no process in place to measure achievement against Ideal Nurses Limited quality and risk management plan and an improvement is required.

Corrective action reports are individually grouped and developed according to the identified quality improvement activity. CARS are then grouped into a summary form. The summary form of corrective actions is not up-to-date making it difficult to understand the current plan of action. An improvement is required. There is a hazard management system in place that identifies actual and potential risks to residents, visitors and staff. Current risks are identified by Radius Residential Care Limited who in their dual role of current operator and prospective purchaser have developed a risk management plan to manage the current risks to the business and the transition risks.D5.4 The range of policies and procedures specified in the ARC agreement exist to support service delivery. D19.3 There are implemented risk management, and health and safety policies and procedures in place including accident and hazard managementD19.2g There are falls prevention strategies in place to reduce the risk that residents may fall (eg, minimising or removing trip hazards, careful placement of furniture and mobility aids, on-going reviews of a resident’s medicine management programme, and on-going medical reviews of residents to ensure their health and independence is promoted. One resident who is known to fall frequently has a sensor mat system in place by her bed to assist in preventing her falling (refer 1.3.3).

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowIdeal Nurse Limited has a quality plan which outlines its quality and risk management system. Key components of the system are known to staff and implemented in practice. The prospective purchaser has developed a transition risk management plan, which is linked to its business plan. The plan includes revision of the existing quality and risk management system by the end of December 2013.

Finding StatementThe quality plan in use is overdue for review. Corrective Action Required:Ensure there is a current quality and risk management plan in place to guide practice.

Timeframe:3 months

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe prospective purchaser has developed a transitional risk management plan that aligns with their business plan and has systems that it uses within its facilities to measure achievements against their plans.

Finding StatementThere is no current system in place to measure achievements against the quality and risk management plan.

Corrective Action Required:Ensure there is an implemented system that measures achievement against the objective outlined in the quality and risk management plan.

Timeframe:6 months

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.

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

Corrective action report forms are used by staff to identify quality improvement activities (forms sighted). A number of related actions may be identified that relate to the overall quality improvement activity and there is a sign off process included in the form. These individual corrective action forms are then intended to be documented on a (summary) corrective action plan form which lists all corrective actions by number. Information on progress is being reported back to staff at the staff meeting (minutes sighted)

Finding StatementThe system of identifying corrective actions and addressing them is not fully implemented.

Corrective Action Required:Ensure there is a system of identifying corrective actions requiring improvement that is fully documented and implemented.

Timeframe:3 months

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: FAThere are policies and procedures and forms in place for the managing of all adverse, unplanned or untoward events. Staff record details of the incident or accident and notify the RN and or the nurse manager of the event. The event is investigated by the RN and or nurse manager and a copy of the form is made and stored in the incident/accident folder with the completed original being filed in the resident’s clinical record. A record of incidents and accidents is entered into an electronic database by administration staff for data analysis and reporting purposes. The nurse manager and area manager understand their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required (confirmed in discussion with the nurse manager and regional manager on the day of audit). Staff are aware of the need to document such events using the incident/accident form (forms sighted and confirmed in discussions with three of three HCAs and one EN). All forms are reviewed by the manager at the time of the event or the next working day. There is an open disclosure policy included in the adverse events reporting and open disclosure policy to guide practice. The nurse manager will telephone family if appropriate (confirmed in discussions with two of two relatives). A record of this communication is documented and indicated on the form and/or the clinical records. D19.3b; There is a health and safety policy called accident/incident/near miss policy that includes incident reporting. It includes definitions and outlines responsibilities including immediate action, reporting, monitoring and corrective action to minimise and debriefing.

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: PA LowEach position has a job description which includes the authority, accountabilities, responsibilities, qualifications and expectations of the position (confirmed in review of six of six employee records (one of which was the nurse manager and the other five of the six being HCAs). The nurse manager holds hard copy current records of staff and contractors who hold professional qualifications who practise at the facility (practising records sighted for the RNs, ENs, physiotherapist, the general practitioners, the contracted pharmacist). Staff are appointed to safely meet the needs of residents. Newly appointed HCAs undergo a period of orientation and buddying to ensure they are competent to carry out their duties (confirmed in review of six of six personnel records and confirmed in discussions with three of three HCAs and one EN). There is a skills mix policy in place that meets the expectations for staffing of rest homes (as specified in ARC D17.3a,ii). Two registered nurses currently job share the role of registered nurse. One of the two RNs are on call if they are not physically on site. Depending on the HCA’s previous training, all caregivers are encouraged and have financial incentives to participate in the ACE career force development programme and in the mandatory training programme. There is a training plan which was amended in August 2013 to reflect statutory and ARC contractual topics of education. A range of topics are identified for training (training plan sighted). The training plan is displayed in the clinical office. Training sessions coincide with the monthly staff meetings. The nurse manager records staff attendance and the content of the education session and a record is kept on the staff member’s employment records (sighted in review of six of six personnel records). Staff receive feedback on performance. However formal feedback through the performance appraisal system for HCAs is overdue as feedback was expected to occur in July 2013. An improvement is required.

D17.7d: There are implemented competencies for registered nurses related to specialised procedure or treatment including (but not limited to); medicine management.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe performance management system of annual appraisals is used to identify on-going education needs for staff. The appraisal system is used to identify opportunities for education and these are incorporated into the annual training plan.

Finding StatementAppraisals for HCAs were due in June 2013 and have yet to be completed.Corrective Action Required:Ensure performance appraisals are completed annually for all staff.

Timeframe:3 months

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 skills mix policy in place that meets the expectations for staffing of rest homes (as specified in ARC D17.3a, ii). Staffing is currently being restructured to match occupancy. A proposed draft roster was released on 18 September 2013 which is being implemented on 17 October 2013.The new proposed roster will be as follows: Registered nurse cover will be provided by two RNs who job share the role. When they are not onsite, one of them will be on call.There will be two HCAs on every morning shift. 1 HCA will work from 6.45 am till 3 pm (i.e., 7.75 hours) and the other will work from 7 am to 1pm (i.e., 5.5 hours). On the weekends both HCAs will be paid an extra 30 minutes for no meal break as they cannot leave the premises and residents unattended.In the afternoons Monday to Friday 1 HCA starts at 2 45 pm and finishes at 11pm (i.e., 7.75 hours) The second HCA will start at 4.30 pm and finish at 9.30 pm (i.e., 5 hours). The late start is covered by existing staff on the premises (eg, the nurse manager or the RNs), In the afternoons on Saturday and Sunday 1 HCA starts at 2 45 pm and finishes at 11 pm (i.e., 7.75) The second HCA will start at 4 pm and finish at 9.30 pm (i.e., 5.5 hours).In the weekends there will be one staff on duty from 3pm to 4pm. The night shift is currently covered by two night staff on duty 10.45 pm to 7am (i.e., 8.25 hours as they are paid for no meal break).

The proposed roster is to have 1 HCA on duty between the hours of 10.45 pm to 7am and one caregiver off site but on-call. The HCA on duty will be competent to administer medicines and will have a current first aid certificate. The on-call person will be someone who can be available onsite within 20 minutes and if coming from the other Radius facilities (i.e., Rimu Park and Potter Home) this will not compromise their staffing cover. Both of the other Radius facilities have a registered nurse on site 24 hours a day, seven days a week and more than one HCA on duty overnight. The facility manager is on call and could respond in person if needed in the night.The rostering system is flexible and dependent on resident acuity. Staffing levels in the proposed roster meet the expectations for staffing of rest homes (as specified in ARC D17.3a, ii).

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: FAResident information is stored primarily in hard copy clinical records. A limited amount of information is stored electronically to manage care and to ensure records of occupancy can be maintained. Information is entered into both systems in an accurate and timely manner. Hard copy resident information is held securely to ensure privacy and is stored in the nursing station. Electronic information is stored in the nurse manager’s office. Hard copy records are integrated. All records are legible and the name and designation of the service provider is identifiable (confirmed in review of five of five resident records).D7.1 Entries are legible, dates and signed by the relevant caregiver or RN including designation.

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: PA LowPrior to entry to Seaview potential residents have a needs assessment, completed by the needs assessment and co-ordination service to assess suitability for entry to the service. The service has an admission policy, admission agreement and a resident information pack available for residents/families at entry. The information pack includes all relevant aspects of service and residents and/or family are provided with associated information such as the health and disability code of rights, how to access advocacy and the complaints process.Three of the five files sampled have a signed admission agreement. One other long term resident has a short term agreement but no long term agreement. This is an area requiring improvement.D13.3 The admission agreements reviewed in three resident files align with a) -k) of the ARC contract.

D14.1 Exclusions from the service are included in the admission agreement.D14.2 The information provided at entry includes examples of how services can be accessed that are not included in the agreement.

Criterion 1.3.1.4 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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowPrior to entry to Seaview potential residents have a needs assessment, completed by the needs assessment and co-ordination service to assess suitability for entry to the service. The service has an admission policy, admission agreement and a resident information pack available for residents/families at entry. The information pack includes all relevant aspects of service and residents and/or family are provided with associated information such as the health and disability code of rights, how to access advocacy and the complaints process.

Finding StatementTwo of the five files sampled do not have a signed admission agreement. One of these is a long term resident who has a short term agreement but no long term agreement.Corrective Action Required:Ensure all residents have a signed admission agreement.

Timeframe:3 months

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: FAThe admission policy describes the declined entry to services process. Seaview records the reason for declining service entry to residents should this occur and communicates this to residents/family/whānau and refers the resident/family/whanau back to the referral agency.

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: FAD16.2, 3, 4: The five resident files reviewed identified that an initial nursing assessment and care plan was completed within 24 hours and all files identify that the long term care plan was completed within three weeks. There is documented evidence that the care plans were reviewed by the registered nurse and amended when current health changes. Four of five care plans evidenced evaluations completed at least six monthly (one resident is on respite care). Activity assessments and the activities sections in care plans have been completed by the activity coordinator. Eight residents interviewed stated that they and/or their family were involved in planning their care plan and at evaluation. Resident files included family contact records which were completed in all resident files sampled.D16.5e: All resident files reviewed identified that the GP had seen the resident within two working days. It was noted in resident files reviewed that the GP has assessed the residents as stable and is to be seen three monthly. More frequent GP review was evidenced as occurring on review of resident’s files with acute conditions.The GP interviewed reports that a GP from her practice visits the service daily. She reports that the registered nurses are prompt to inform them about any change in a resident’s condition and that she has confidence in the clinical care provided at Seaview.A range of assessment tools where completed in resident files on admission and completed at least six monthly including (but not limited to); a) falls risk assessment b) pressure area risk assessment, c) continence assessment (and diary) where relevant. Staff could describe a verbal handover at the beginning of each duty that maintains a continuity of service delivery. Five files reviewed identified integration of allied health and a team approach is evident.

Tracer Methodology: 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: FAThe initial nursing assessment is completed within 24 hours of admission and the care plan is completed within three weeks. Personal needs information is gathered during admission. The data gathered is then used to plan consumer goals and outcomes. This includes cultural and spiritual needs and likes and dislikes. Assessments are conducted in an appropriate and private manner. Assessments and care plans are detailed and include input from a general practitioner, support services and medical specialists as appropriate. Assessment tools such as pressure area risk, falls risk, continence and dietary assessments are completed on admission. Family members (two) and eight residents interviewed are very satisfied with the support provided.

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.

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STANDARD 1.3.5 Planning

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

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

How is achievement of this standard met or not met? Attainment: FAA review of five resident files identifies the use of short term and long term care plans. These reflect variances in resident health status. They are current and there is evidence of six monthly reviews which is signed a registered nurse.The care plan is completed within three weeks of admission by the registered nurse providing a holistic approach to care planning with resident and family input ensuring a resident focussed approach to the whole process. This is supported by other allied health care professionals providing input such as physiotherapist, dental health services and podiatrist. Care plans include clear direction for staff and are reflected in the progress notes. File of resident with a diagnosis of dementia documented the distraction techniques and regular routines that staff could use to assist the resident to manage their anxiety levels and behaviours such as wandering.File of a resident assessed as a high falls risk reviewed contained a falls risk assessment and interventions documented in the care plan to assist with the reduction of potential for falls include directions such as; ensuring that walking frame is placed within residents easy reach, that call bell is placed within reach and the use of a sensor mat.D16.3f: Residents and relatives interviewed confirm care delivery and support by staff is consistent with their expectations. All five resident files reviewed identified that family were involved. Family contact sheets located at the front of residents' files demonstrated communication with family/EPOA. All needs identified in the assessment process were included in the care plans.D16.3k: Short term care plans are in use for changes in health status.

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: FAFive resident files were reviewed. The care being provided is consistent with the needs of residents. This is evidenced by discussions with residents, families, caregivers, and one registered nurse. A review of short term care plans, long term care plans, evaluations and progress notes demonstrates integration. There is evidence of three monthly medical review. The nurse manager is responsible for the education programme and ensures staff have the opportunity to receive updated information and follow best practice guidelines. Residents' care plans are completed by the registered nurse. Care delivery is recorded and evaluated by caregivers at least weekly (evidenced in all five residents' progress notes sighted). When a resident's condition alters, the registered nurse initiates a review and if required, arranges a GP visit or a specialist referral. The three HCA’s and one enrolled nurse interviewed stated that they have all the equipment referred to in care plans and necessary to provide care, including transfer belts, wheelchairs, continence supplies, gowns, masks, aprons and gloves and dressing supplies. All staff report that there are always adequate continence supplies and dressing supplies. It is noted that in the past adequate supplies have been an issue but under the Radius temporary management this is no longer an issue. On the day of the audit supplies of these products were sighted. Eight residents and two family members interviewed were complimentary of care received at the facility.D18.3 and 4 Dressing supplies are available and stored in a locked cupboard in the hallway. Wound assessment and wound management plans are in place for one resident with a wound - a skin tear. This wound occurred the evening before the audit and was reviewed by the registered nurse during the audit.The registered nurse interviewed described the referral process and related form for referral to a wound specialist or continence nurse. Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified for day use, night use, and other management. Specialist continence advice is available as needed and this could be described.Continence management in-services and wound management in-service have been provided. Continence management in-services occurred in June 2012.

During the tour of facility it was observed that all staff treated residents with respect and dignity, knocked on doors before entering residents’ rooms and ensured residents’ dignity and privacy was protected when transferring residents to the shower or toilet. Residents interviewed were able to confirm that privacy and dignity was maintained.

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: FAThere is an activities coordinator at Seaview who is responsible for the planning and delivery of the activities programme. Activities are provided in the lounge, dining area and one on one input in resident’s rooms when required. On the day of audit residents were observed being actively involved with a variety of activities. The programme is developed monthly. Residents have an initial assessment completed over the first few weeks after admission obtaining a complete history of past and present interests and life events. The programme includes residents being involved within the community with social clubs, churches and schools. On or soon after admission, a social history is taken and information from this is added into the long term care plan and this is reviewed six monthly as part of the care plan review/evaluation. A record is kept of individual resident’s activities and monthly progress notes completed. The resident/family/EPOA as appropriate is involved in the development of the activity plan. There is a wide range of activities offered that reflect the resident needs. Participation in all activities is voluntary.

Seaview has its own van for transportation. Residents interviewed described attending concerts, school music productions, going shopping, lunches and picnics and visits to the RSA. The activities coordinator has a current first aid certificate.D16.5d Resident files reviewed identified that the individual activity plan is reviewed when at care plan review.

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

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STANDARD 1.3.8 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: FAThere is at least a three monthly review by the medical practitioner. D16.4a Care plans are reviewed and evaluated by the registered nurse six monthly or when changes to care occur as sighted in four of five care plans sampled (the other resident is on respite care). There are short term care plans to focus on acute and short-term issues. All STCPs reviewed evidence evaluation and are signed and dated by the registered nurses when issues have been resolved. One STCP reviewed evidenced transition into the long term care plan. Staff are informed of any changes to resident need at handover between shifts. Examples of STCP's in use included; infections, behaviours and wounds. Caregivers interviewed confirmed that they are updated as to any changes to/or in resident’s care or treatment during handover sessions which occur at the beginning of each shift.ARC D16.3c: All initial nursing assessment/care plans were evaluated by an RN within three weeks of admission.

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.

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

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STANDARD 1.3.9 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 registered nurse described the referral process to other medical and non-medical services. Referral documentation is maintained on resident files. Examples of referrals sighted were to NASC, dietitian and wound care nurse.D16.4c: The service provided examples of where a resident’s condition had changed and the resident was reassessed for a higher level of care.D 20.1; Discussions with the registered nurse identified that the service has access to wound care nurse specialists, incontinence specialists, podiatrist, mental health services, occupational therapist and physiotherapist.

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: FAThere are policies to describe guidelines for death, discharge, transfer, documentation and follow up. There is an associated form for staff to complete. A record is kept and a copy of details is kept on the resident’s file. All relevant information is documented and communicated to the receiving health provider or service. A transfer form accompanies residents to receiving facilities. Follow up occurs to check that the resident is settled, or in the case of death, communication with the family is made and this is documented. Documents evidencing contact/communication with Staff, Pharmacy, GP, NASC, MOH and DHB were sighted re patient transfers to an alternative aged care facility to assist with smooth co-ordination and transfer of residents both on exit and return to the facility once repairs were completed.

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: PA ModerateMedication policies align with accepted guidelines. Medications are stored in a locked trolley in a locked storage cupboard in the hallway. Controlled drugs are stored in a locked safe in the locked storage cupboard in the hallway and two medication competent persons must sign controlled drugs out. The service uses four weekly blister packed medication management system. Medication charts have photo ID’s. There is a signed agreement with the pharmacy. Medications are checked on arrival by the nurse manager and any pharmacy errors recorded and fed back to the supplying pharmacy. Staff sign for the administration of medications on medication signing sheet. The medication folder includes a list of specimen signatures. Competency tests are completed annually and also if there is a medication administration error. Competencies include (but not limited to); medication administration, controlled drugs and insulin and diabetes management. There are currently no residents self-administering medications. Medication profiles are legible, up to date and reviewed at least three monthly by the G.P. Signing sheets correspond to instructions on the medication chart. The controlled drug register is well kept and aligns with legislative requirements. Residents/relatives interviewed stated they are kept informed of any changes to medications. The medication chart has alert stickers for; a) controlled drugs, b) allergies and c) duplicate name.Education on medication management occurred in May 2013. There are improvements required around PRN prescriptions recording indications for use and the administration on non-packaged regular medications. D16.5.e.i.2; Ten medication charts reviewed identified that the GP had reviewed the resident three monthly and the medication chart was signed.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateMedication profiles are legible, up to date and reviewed at least three monthly by the G.P. Signing sheets correspond to instructions on the medication chart. The controlled drug register is well kept and aligns with legislative requirements. Residents/relatives interviewed stated they are kept informed of any changes to medications. The medication chart has alert stickers for; a) controlled drugs, b) allergies and c) duplicate name.D16.5.e.i.2; Ten medication charts reviewed identified that the GP had reviewed the resident three monthly and the medication chart was signed.

Finding Statement(i)Three of ten medication charts sampled have regular non-packaged medications that have not been signed as administered regularly. (ii) Six of ten medication charts have PRN medication prescribed with no documented indication for use.

Corrective Action Required:(i)Ensure that medications are administered as prescribed. (ii) Ensure PRN medications document a reason for use.

Timeframe:1 month - immediately

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 ModerateSeaview employs three cooks and all food is cooked on site. All cooks have attained NZQA food safety standard 167. There is a four weekly rotating winter and summer menu. This was reviewed by a dietitian on 17 April 2013.A food services manual is available that ensures that all stages of food delivery to the resident are documented and comply with standards, legislation and guidelines. All fridges and freezers temperatures are recorded monthly on the recording sheet sighted. Food temperatures are recorded daily. Hand hygiene education occurred as part of infection control education which occurred March 2012. An inspection of the kitchen shows it is clean and tidy with all food stored appropriately and freezers defrosted etc. The oven seal is damaged and the Formica surface under the oven has scalded. This is an area requiring improvement.

The residents have a nutritional profile developed on admission which identifies dietary requirements and likes and dislikes. This is reviewed six monthly as part of the care plan review. Changes to residents’ dietary needs are communicated to the kitchen as reported by the cook. Special diets are noted on the kitchen notice board which is able to be viewed only by kitchen staff. Special diets being catered for include diabetic diet and one resident on a pureed diet. Weights are recorded weekly/monthly as directed by the registered nurse. Residents report satisfaction with food choices, meals are well presented. Lunchtime meal was observed being served and was attractively presented and temperature of food recorded prior to meals being served. Alternative meals are offered as required and individual resident likes and dislikes are noted on notice board in kitchen. There is a cleaning schedule which is signed by member of staff completing cleaning tasks.Previously the cook reports having been unable to adhere to the menu as supplies were not always available to allow for this. However the cook reports that this issue has resolved now that Radius is responsible for purchasing.D19.2 staff have been trained in safe food handling.

Criterion 1.3.13.1 Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.

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

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

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateSeaview employs three cooks and all food is cooked on site. Both cooks have attained NZQA food safety standard 167. There is a four weekly rotating winter and summer menu. This was reviewed by a dietitian on 17 April 2013.A food services manual is available that ensures that all stages of food delivery to the resident are documented and comply with standards, legislation and guidelines. All fridges and freezers temperatures are recorded monthly on the recording sheet sighted. Food temperatures are recorded daily. Hand hygiene education occurred as part of infection control education which occurred March 2012. An inspection of the kitchen shows it is clean and tidy with all food stored appropriately and freezers defrosted etc.

Finding StatementThe oven seal is damaged and the Formica surface under the oven has scalded. Corrective Action Required:Ensure the oven is safe.

Timeframe:3 months

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: FAThe service has waste management policies and procedures for the safe disposal of waste and hazardous substances. These include (but are not limited to): needles and sharps policy; chemical storage policy; waste disposal policy. There is an incident reporting system that includes investigation of incidents. Chemicals are labelled and there is appropriate protective equipment and clothing for staff. Hazard register identifies hazardous substance and staff indicated a clear understanding of processes and protocols.

Infection control policies state specific tasks and duties for which protective equipment is to be worn. Chemicals were evidenced stored securely in a locked cleaning cupboard inside a locked laundry room.

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: PA LowThe service is over three levels – Seaview, upper Manaia and lower Manaia. On the day of the audit the last two residents in lower Manaia were relocated to Seaview and lower Manaia is now closed. Reactive maintenance occurs. There are no records for preventative maintenance since February 2013. This is an area requiring improvement. Fire equipment is checked by an external provider and was last checked in May 2013. The building holds a current warrant of fitness which expires 17 May 2014. Electrical equipment is checked two yearly and was last checked in November 2011. Medical equipment was last calibrated on 29 August 2013. There is no record of the hoist having been serviced and this is an area requiring improvement. The living areas are carpeted and vinyl surfaces exist in bathrooms/toilets and kitchen areas. Resident rooms have carpet or vinyl. The corridors are carpeted and there are hand rails. There are damaged tubs in two laundries’ and this is an area requiring improvement. Residents were observed moving freely around the areas with mobility aids where required. The external areas are well maintained and gardens area is attractive. The garden/decking area has furniture and umbrellas provide shade. There is wheelchair access to all areas. Water temperatures are checked monthly and are within safe limits.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe service is over three levels – Seaview, upper Manaia and lower Manaia. On the day of the audit the last two residents in lower Manaia were relocated to Seaview and lower Manaia is now closed. Reactive maintenance occurs. Fire equipment is checked by an external provider and was last checked in May 2013. The building holds a current warrant of fitness which expires 17 May 2014. Electrical equipment is checked two yearly and was last checked in November 2011.

Finding Statement(i)There is a tub in the main laundry and another in the upper Manaia laundry that has rust and damaged paint. (ii) There are no records for preventative maintenance since February 2013. (iii) There is no record of the hoist having been serviced.Corrective Action Required:(i)Ensure all surfaces are intact and can be adequately cleaned. (ii) Ensure preventative maintenance is completed. (iii) Ensure the hoist is serviced according to manufacturer’s directions.

Timeframe:6 months

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: FAThe service has mostly single rooms with three double rooms that are not currently being used. There are sufficient communal toilets and showers close to bedrooms to meet the needs of residents. Toilets are located close to dining rooms and lounges for residents' use. A visitor’s toilet is available.

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: FAObservation on day of audit demonstrated walking frames can be manoeuvred around the residents' personal space, this was confirmed at interview with caregivers. Residents were observed manoeuvring walking frames in rooms safely.

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 manoeuvre 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: FAThere is a lounge and dining area on each level and another smaller lounge in Seaview. The lounges and dining rooms are accessible and accommodate the equipment required for the residents. Activities occur throughout the facility but mainly in the large Seaview lounge. Residents are able to move freely and furniture is well arranged to facilitate this. Residents were seen to be moving freely both with and without assistance throughout the audit and residents interviewed report they can move around the facility and staff assist them if required.

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: FAThe laundry and cleaning room is a designated area and is clearly labelled. The clean/dirty areas in the laundry are distinguished by different coloured vinyl. Caregivers complete laundry and there is a dedicated cleaner. Chemicals are stored in a locked room in laundry. All chemicals are labelled with manufacturer’s labels. All laundry is completed on site. Residents and relatives expressed satisfaction with cleaning and laundry services. On a tour of the facility the carpets were noted to be clean and free from stains. All bedrooms, hallways and communal areas were clean and tidy in appearance. Laundry audit occurred in 2013 attaining a score of 100% and a cleaning audit occurred 2013 attaining 100%.

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

An approved evacuation scheme was signed off by the New Zealand Fire Service on 26 March 2001.The last trial evacuation that there is documented evidence for occurred in December 2012. There is a trial fire evacuation with an external consultant schedules for 17 October 2013 (email confirmation sighted). Staff interviews and review of files provides evidence of current training in relevant areas. There is a staff member on duty at all times who has a current first aid certificates as confirmed in staff interviews and in staff files sampled. Emergency and security situation education is provided to service providers during their orientation phase and at appropriate intervals. This includes fire safety training and emergency security situations. Staff records sampled evidences current training regarding fire, emergency and security education. Processes are in place to meet the requirements for the 'Major Incident and Health Emergency Plan' in the Service Agreement. There is information in relation to emergency and security situations is readily available/displayed for service providers and residents; emergency equipment is accessible, stored correctly, not expired, and stocked to a level appropriate to the service setting; there is emergency lighting, torches, extra food supplies, blankets, and cell phones. There is a portable gas cooker should the mains gas supply fail. There is sufficient stored water in tanks for three litres per person per day for three days.There is a call bell system that is easily used by the resident or staff to summon assistance if required. Call bells are accessible / within easy reach, and are available in resident areas, e.g. bedrooms, ablution areas, ensuite toilet/showers, the lounge and dining room. However, the call system does not interconnect throughout the facility. The second and third floor call bell systems are able to alert staff members located on the upper floor but a call bell rung on floor one (Seaview) cannot be received on the second or the third floors. Should the staff member located on the upper floor during the night period be required to provide assistance to the residents located on the second floor, a call bell rung by any resident on the upper floor to summons a staff member’s assistance cannot be heard on the second floor. This is an area requiring improvement. The Radius general manager reports that Radius and a call bell supplier currently used by Radius have a conference call booked for the day following the audit to discuss ways to rectify the call bell issue. This may include using pagers for staff.D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowTraining includes fire safety training and emergency security situations. Staff records sampled evidences current training regarding fire, emergency and security education.

Finding StatementThe last trial evacuation that there is documented evidence for occurred in December 2012.Corrective Action Required:Ensure trial evacuations occur six monthly.

Timeframe:3 months

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

Finding Statement

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

Finding Statement

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

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateThere is a call bell system that is easily used by the resident or staff to summon assistance if required. Call bells are accessible / within easy reach, and are available in resident areas, e.g. bedrooms, ablution areas, ensuite toilet/showers, the lounge and dining room.

Finding StatementThe call system does not interconnect throughout the facility. The second and third floor call bell systems are able to alert staff members located on the upper floor but a call bell rung on floor one (Seaview) cannot be received on the second or the third floors. Should the staff member located on the upper floor during the night period be required to provide assistance to the residents located on the second floor, a call bell rung by any resident on the upper floor to summons a staff member’s assistance cannot be heard on the second floor.Corrective Action Required:Ensure there is a call bell system that is interconnected throughout the facility.

Timeframe:3 months

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

Finding Statement

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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: FAThe facility has oil heaters in hallway and communal areas and individual oil heaters are available in resident’s rooms. The temperature can be adjusted to suit individual resident temperature preference. Rooms are well ventilated and windows provide natural light. Facility temperatures are monitored. Eight residents interviewed stated the temperature of the facility was comfortable.

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

Finding Statement

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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 MINIMISATIONSTANDARD 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: FAThere are four residents voluntarily using aids to help themselves to get in and out of bed and turn over in bed (sighted). These aids do not limit the normal freedom of movement of the residents and do not meet the definition of an enabler as defined in the standard. These aids are being treated as enablers currently and each resident had a record of the aid recorded in their clinical records (sighted). No residents require restraint (confirmed in discussions with the nurse manager). Policies record that residents will voluntarily agree to the use of an enabler to promote their independence and safety, if enablers are required. Staff are aware of the enabler and restraint policy (confirmed in discussions with three of three HCAs, one enrolled nurse and the nurse manager). Staff receive training on restraint minimisation and providing care to residents who may

exhibit behaviours that challenge (last training occurred on 22 August 2013 attended by 19 staff). There have been no reported episodes of restraint under this management team. Policies and procedures are in place if restraint was ever required. These have been developed to meet the requirements of the standard.

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.

Finding Statement

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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: PA LowThe service and the environment minimise the risk of infection to residents, staff and visitors. The infection prevention and control programme is well known by staff as described by three caregivers and the assistant manager. There are documented processes implemented. There has been no annual review of the infection control programme and this is an area requiring improvement.There are infection control policies that meet the Infection Control Standard SNZ HB 8134.3.1.2008 with policies reviewed in 2012.The infection control programme includes clear lines of accountability and is appropriate for the size, complexity, and degree of risk associated with the service.

The registered nurse/manager (infection control coordinator) could describe how the service would manage an outbreak. Staff and visitors suffering from infectious diseases are advised not come to the facility. Residents suffering from infections will be isolated. An outbreak management policy is documented.Staff are aware not come to work when suffering from infections (confirmed at interviews with three health care assistants, one enrolled nurse and the registered nurse interviewed). There is a staff policy around what should happen if staff are sick.

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.

Finding Statement

Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowInfections are collated and reported on monthly.

Finding StatementThere has been no annual review of the infection control programme.Corrective Action Required:Ensure there is an annual review of the infection control programme.

Timeframe:6 months

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.

Finding Statement

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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 facility has adequate human, physical and information resources to implement the infection prevention and control programme. Administrative resources are available. The registered nurse/infection control coordinator is able to describe access to the DHB and the GP if advice and support is needed. Infection prevention and control policies and procedures guide the infection control personnel in implementing the infection prevention and control programme.

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.

Finding Statement

Timeframe:

STANDARD 3.3 Policies and proceduresDocumented 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: FAInfection control and prevention policies and procedures are documented and implemented. The infection prevention and control policies and procedures contained in the infection prevention and control manual are directly linked to the overarching infection prevention and control programme and the quality and risk management programme through monthly staff meetings.D 19.2a: Infection control policies include hand washing policy and technique, standard precautions policy, isolation, disinfection, outbreak procedure, cleaning, disinfection and sterilisation guidelines, single use equipment, and policy and guidelines for antimicrobial usage and renovation and construction etc. Infection prevention and control policies and procedures are documented in a user friendly format and accessible to all staff. Policies and procedures relate to health and disability sector infection control standards and relevant reference material.

Criterion 3.3.1 There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.

Finding Statement

Timeframe:

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: PA LowAll staff receive infection prevention and control education at orientation and as part of the on-going education programme. Resident education is expected to occur as part of providing daily cares. Support plans can include ways to assist staff in ensuring this occurs. Visitors are advised of any outbreaks of infection and are advised not to attend until the outbreak has been resolved. A sign is pre template to be displayed if there is a need to alert visitors. The infection control coordinator i.e. registered nurse is responsible for coordinating education and training to staff. The three of three HCAs, one enrolled nurse and one registered nurse interviewed said that education was included in training throughout the year. Infection control education was last delivered by the DHB infection control resource person in March 2012 and included hand hygiene and standard precautions. This is an area requiring improvement.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe DHB infection control nurse provides staff training and this last occurred in March 2012.

Finding StatementThere has been no staff training in infection control since March 2012.

Corrective Action Required:Ensure infection control training is provided to staff at least annually.

Timeframe:6 months

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.

Finding Statement

Timeframe:

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

Criterion 3.5.1 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.

Finding Statement

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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.

Finding Statement

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Certification audit summary · Web view14-Oct-13 The following summary has been accepted by the...

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