Certification audit summary · Web viewJob descriptions include responsibilities of the position. Staff are aware of and alert to the potential for racial and sexual harassment. Performance

Glendale Retirement Home (2012) Limited

CURRENT STATUS: 14-Aug-13

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

GENERAL OVERVIEW

Glendale retirement home is owned by a private company and managed by a clinical manager (Registered Nurse), with support from the previous owners. Glendale is certified to provide rest home level care for up to 28 residents. On the day of the audit, there were 26 rest home residents. Glendale continues to implement a quality and risk management system and continues to apply the principles of continuous improvement. The clinical manager is supported by a registered nurse with experience in aged care, and from the previous owners who provide administration and quality coordination roles. There is an implemented quality and risk programme that involves the resident on admission to the service. Staff interviewed and documentation reviewed identify that the service continues to implement systems that are appropriate to meet the needs and interests of the resident group. The care services are holistic and promote the residents' individuality and independence. Family and residents interviewed all spoke very positively about the care and support provided.

This audit identified that improvements are required relating to conducting assessments for identified issues for residents and aspects of medication management. The service is commended on achieving one continuous improvement relating to falls prevention programme.

AUDIT SUMMARY AS AT 14-AUG-13

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short fallsStandards applicable to this service fully attained

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

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

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights Day of Audit

14-Aug-13

Assessment

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

Standards applicable to this service fully attained

Organisational Management Day of Audit

14-Aug-13

Assessment

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


Continuum of Service Delivery Day of Audit

14-Aug-13

Assessment

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

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

Safe and Appropriate Environment Day of Audit

14-Aug-13

Assessment

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


Restraint Minimisation and Safe Practice Day of Audit

14-Aug-13

Assessment

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


Infection Prevention and Control Day of Audit

14-Aug-13

Assessment

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


AUDIT RESULTS AS AT 14-AUG-13

Consumer Rights

Glendale retirement home strives to ensure that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. The service functions in a way that complies with the Health and Disability Commissioner's Code of Consumers' Rights (the code). Information about the code of rights and services is easily accessible to residents and families. Policies are implemented to support residents' rights. Information on informed consent is included in the admission agreement and discussed with residents and relatives. Informed consent processes are followed and residents' clinical files reviewed evidence informed consent is obtained. Annual staff training reinforces a sound understanding of residents' rights and their ability to make choices. Care plans accommodate the choices of residents and/or their family/whānau. Complaints and concerns are actively managed and well documented. A complaints register is maintained.

Organisational Management

There is a quality coordinator who, along with the clinical manager, is responsible for the implementation of the quality and risk management programme. The quality and risk management programme includes service philosophy, goals and a quality planner. Quality activities are conducted and this generates improvements in practice and service delivery. Corrective actions are identified, implemented and followed through following audits. Key components of the quality management system link to monthly management meetings and monthly staff meetings. Residents meetings are held monthly and residents and families are surveyed annually. Health and safety policies, systems and processes are implemented to manage risk. Discussions with families identified that they are fully informed of changes in health status. There is a comprehensive orientation programme that provides new staff with relevant information for safe work practice and an in-service education programme that exceeds eight hours annually and covers relevant aspects of care and support. Human resource policies are in place including a documented rationale for determining staffing levels and skill mixes. There is a roster that provides sufficient and appropriate coverage for the effective delivery of care and support. One continuous improvement has been achieved relating to the falls prevention programme.

Continuum of Service Delivery

Glendale retirement home has documented entry criteria, which is communicated to residents, family and referral agencies. Systems are implemented that evidence each stage of service provision has been developed with resident and/or family input and is coordinated to promote continuity of service delivery. Resident and family interviewed confirmed input into care planning, care evaluations and access to a typical range of life experiences and choices. Documentation and observations made of the provision of services and/or interventions demonstrate that consultation and liaison is occurring with other services and residents interviewed confirm that interventions noted in their care plans are consistent with meeting their needs. Evaluations of care plans are within stated timeframes and reviewed more frequently if a resident's condition changes and this is noted on a short term care plan. Planned activities are appropriate to the group setting. Residents and family interviewed confirm satisfaction with the activities programme. An appropriate medicine management system is implemented. Policies and procedures record service provider responsibilities. Staff responsible for medicine management has attended in-service education on medication management and have current medication competencies. There is an improvements required around competencies for the clinical manager and the registered nurse and self-medicating.

A central kitchen and on site staff provide the food service for the home. Kitchen staff have completed food safety training. Residents' individual needs are identified, documented and reviewed on a regular basis.

Safe and Appropriate Environment

There are documented processes for waste management. The service has a policy for investigating, recording and reporting incidents involving infectious material or hazardous substances. Chemicals are stored securely and training is provided to staff. There is a current building warrant of fitness. The residents have access to communal areas for

entertainment, recreation and dining. There are outside paved areas with suitable furniture and natural shading. The service provides adequate space allowing residents to move safely around in their rooms and the facility. Residents are being provided with safe and hygienic cleaning and laundry services, which are appropriate to the setting. The service has implemented policies and procedures for fire, civil defence and other emergencies. There are staff on duty with a current first aid certificate. General living areas and resident rooms are appropriately heated and ventilated. Residents are provided with adequate natural light, safe ventilation, and a safe environment with comfortable temperature.

Restraint Minimisation and Safe Practice

Documentation of policies and procedures and staff training demonstrate residents are experiencing services that are the least restrictive. There were no residents requiring restraint or enabler use at the facility on audit day.

Infection Prevention and Control

Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. These reflect the needs of the service and are readily available for staff access. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and also as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner.

Glendale Retirement HomeGlendale Retirement Home (2012) Limited

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

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Glendale Retirement Home (2012) Limited

Premise Name Street Address Suburb City

Glendale Retirement Home 47 Glenelg Street Bradford Dunedin

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

Type of Audit Certification audit and (if applicable)

Date(s) of Audit Start Date: 14-Aug-13 End Date: 14-Aug-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 XXXXXXXXRCpN,Health auditor, CertQA

8.00 5.00 14-Aug-13

Auditor 1 XXXXXXXXRN, Health auditor

8.00 4.00 14-Aug-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)

11.00 Total Audit Hours 27.00

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

6 of 26 Number of Client Records Reviewed

using Tracer Methodology

1 of 6

Staff Interviewed 10 of 23 Management Interviewed (numeric)

1 of 1 Relatives Interviewed (numeric)

4

Consumers Interviewed 8 of 26 Number of Medication Records Reviewed

12 of 26 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

I, (full name of agent or employee of the company) XXXXXXXX (occupation) Programme Coordinator 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 Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise.

Dated this 27 day of August 2013

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

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

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

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

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

Services and Capacity

Kinds of services certified

Hospital Care Rest Home Care

Residential Disability Care

Premise Name Total Number of Beds

Number of Beds Occupied on Day of Audit

Number of Swing Beds for Aged Residen-tial Care

Glendale Retirement Home

28 26 12

Executive Summary of Audit

General OverviewGlendale retirement home is owned by a private company and managed by a clinical manager (RN), with support from the previous owners (husband and wife team). Glendale is certified to provide rest home and hospital level care for up to 28 residents (16 rest home and 12 hospital). On the day of the audit, there were 26 rest home residents. The service has yet to provide hospital level care. Glendale continues to implement a quality and risk management system and continues to apply the principles of continuous improvement. The clinical manager is supported by a registered nurse with experience in aged care, and from the previous owners who provide administration and quality coordination roles. There is an implemented quality and risk programme that involves the resident on admission to the service. Staff interviewed and documentation reviewed identify that the service continues to implement systems that are appropriate to meet the needs and interests of the resident group. The care services are holistic and promote the residents' individuality and independence. Family and residents interviewed all spoke very positively about the care and support provided. This audit identified that improvements are required relating to conducting assessments for identified issues for residents and aspects of medication management. The service is commended on achieving one continuous improvement relating to falls prevention programme.

1.1 Consumer RightsGlendale retirement home strives to ensure that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. The service functions in a way that complies with the Health and Disability Commissioner’s Code of Consumers’ Rights (the code). Information about the code of rights and services is easily accessible to residents and families. Policies are implemented to support residents’ rights. Information on informed consent is included in the admission agreement and discussed with residents and relatives. Informed consent processes are followed and residents' clinical files reviewed evidence informed consent is obtained. Annual staff training reinforces a sound understanding of residents’ rights and their ability to make choices. Care plans accommodate the choices of residents and/or their family/whānau. Complaints and concerns are actively managed and well documented. A complaints register is maintained.

1.2 Organisational ManagementThere is a quality coordinator who, along with the clinical manager, is responsible for the implementation of the quality and risk management programme. The quality and risk management programme includes service philosophy, goals and a quality planner. Quality activities are conducted and this generates improvements in practice and service delivery. Corrective actions are identified, implemented and followed through following audits. Key components of the quality management system link to monthly management meetings and monthly staff meetings. Residents meetings are held monthly and residents and families are surveyed annually. Health and safety policies, systems and processes are implemented to manage risk. Discussions with families identified that they are fully informed of changes in health status. There is a comprehensive orientation programme that provides new staff with relevant information for safe work practice and an in-service education programme that exceeds eight hours annually and covers relevant aspects of care and support. Human resource policies are in place including a documented rationale for determining staffing levels and skill mixes. There is a roster that provides sufficient and appropriate coverage for the effective delivery of care and support. One continuous improvement has been achieved relating to the falls prevention programme.

1.3 Continuum of Service DeliveryGlendale retirement home has documented entry criteria, which is communicated to residents, family and referral agencies. Systems are implemented that evidence each stage of service provision has been developed with resident and/or family input and is coordinated to promote continuity of service delivery. Resident and family interviewed confirmed input into care planning, care evaluations and access to a typical range of life experiences and choices. Documentation and observations made of the provision of services and/or interventions demonstrate that consultation and liaison is occurring with other services and residents interviewed confirm that interventions noted in their care plans are consistent with meeting their needs. Evaluations of care plans are within stated timeframes and reviewed more frequently if a resident’s condition changes and this is noted on a short term care plan. Planned activities are appropriate to the group setting. Residents and family interviewed confirm satisfaction with the activities programme. An appropriate medicine management system is implemented. Policies and procedures record service provider responsibilities. Staff responsible for medicine management have attended in-service education on medication management and have current medication competencies. There is an improvements required around competencies for the clinical manager and the registered nurse and self-medicating. A central kitchen and on site staff provide the food service for the home. Kitchen staff have completed food safety training. Residents' individual needs are identified, documented and reviewed on a regular basis.

1.4 Safe and Appropriate EnvironmentThere are documented processes for waste management. The service has a policy for investigating, recording and reporting incidents involving infectious material or hazardous substances. Chemicals are stored securely and training is provided to staff. There is a current building warrant of fitness. The residents have access to communal areas for entertainment, recreation and dining. There are outside paved areas with suitable furniture and natural shading. The service provides adequate space allowing residents to move safely around in their rooms and the facility. Residents are being provided with safe and hygienic cleaning and laundry services, which are appropriate to the setting. The service has implemented policies and procedures for fire, civil defence and other emergencies. There are staff on duty with a current first aid certificate. General living areas and resident rooms are appropriately heated and ventilated. Residents are provided with adequate natural light, safe ventilation, and a safe environment with comfortable temperature.

2 Restraint Minimisation and Safe PracticeDocumentation of policies and procedures and staff training demonstrate residents are experiencing services that are the least restrictive. There were no residents requiring restraint or enabler use at the facility on audit day.

3. Infection Prevention and ControlInfection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. These reflect the needs of the service and are readily available for staff access. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and also as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner.

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 1

Standard 1.1.2 Consumer rights during service delivery FA 0 2 0 0 0 4

Standard 1.1.3 Independence, personal privacy, dignity and respect FA 0 4 0 0 0 7

Standard 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 2

Standard 1.1.7 Discrimination FA 0 1 0 0 0 5

Standard 1.1.8 Good practice FA 0 1 0 0 0 1

Standard 1.1.9 Communication FA 0 2 0 0 0 4

Standard 1.1.10 Informed consent FA 0 3 0 0 0 9

Standard 1.1.11 Advocacy and support FA 0 1 0 0 0 3

Standard 1.1.12 Links with family/whānau and other community resources FA 0 2 0 0 0 2

Standard 1.1.13 Complaints management FA 0 2 0 0 0 3

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

Criteria (of 48): CI:0 FA:23 PA:0 UA:0 NA: 0

1.2 Organisational Management

Attainment CI FA PA UA NA of

Standard 1.2.1 Governance FA 0 2 0 0 0 3

Standard 1.2.2 Service Management FA 0 1 0 0 0 2

Standard 1.2.3 Quality and Risk Management Systems FA 1 7 0 0 0 9

Standard 1.2.4 Adverse event reporting FA 0 2 0 0 0 4

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

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

Standard 1.2.9 Consumer information management systems FA 0 4 0 0 0 10

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


1.3 Continuum of Service Delivery


Standard 1.3.1 Entry to services FA 0 1 0 0 0 5

Standard 1.3.2 Declining referral/entry to services FA 0 1 0 0 0 2

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

Standard 1.3.4 Assessment PA Low 0 0 1 0 0 5

Standard 1.3.5 Planning FA 0 2 0 0 0 5

Standard 1.3.6 Service delivery / interventions FA 0 1 0 0 0 5

Standard 1.3.7 Planned activities FA 0 1 0 0 0 3

Standard 1.3.8 Evaluation FA 0 2 0 0 0 4

Standard 1.3.9 Referral to other health and disability services (internal and external) FA 0 1 0 0 0 2

Standard 1.3.10 Transition, exit, discharge, or transfer FA 0 1 0 0 0 2

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

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

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 10 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


1.4 Safe and Appropriate Environment


Standard 1.4.1 Management of waste and hazardous substances FA 0 2 0 0 0 6

Standard 1.4.2 Facility specifications FA 0 3 0 0 0 7

Standard 1.4.3 Toilet, shower, and bathing facilities FA 0 1 0 0 0 5

Standard 1.4.4 Personal space/bed areas FA 0 1 0 0 0 2

Standard 1.4.5 Communal areas for entertainment, recreation, and dining FA 0 1 0 0 0 3

Standard 1.4.6 Cleaning and laundry services FA 0 2 0 0 0 3

Standard 1.4.7 Essential, emergency, and security systems FA 0 5 0 0 0 7

Standard 1.4.8 Natural light, ventilation, and heating FA 0 2 0 0 0 3

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


2 Restraint Minimisation and Safe Practice


Standard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6

Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 1 3

Standard 2.2.2 Assessment Not Applicable 0 0 0 0 1 2

Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 3 6

Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 2 3

Standard 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


Standard 3.1 Infection control management FA 0 3 0 0 0 9

Standard 3.2 Implementing the infection control programme FA 0 1 0 0 0 4

Standard 3.3 Policies and procedures FA 0 1 0 0 0 3

Standard 3.4 Education FA 0 2 0 0 0 5

Standard 3.5 Surveillance FA 0 2 0 0 0 8

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


Total Standards (of 50) N/A: 5 CI: 0 FA: 43 PA Neg: 0 PA Low: 1 PA Mod: 1 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 1 FA: 88 PA: 4 UA: 0 N/A: 8

Corrective Action Requests (CAR) Report

Provider Name: Glendale Retirement Home (2012) LimitedType of Audit: Certification audit

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

Std Criteria Rating Evidence Timeframe1.3.4 1.3.4.2 PA

LowFinding:Three of six resident files sampled did not have a pain assessment for pain, although pain was identified in the long term care plan. There is inconsistent monitoring of the effectiveness of pain relief. One resident did not have a continence assessment completed, although an incontinence issue was identified in the long term care plan.

Action:Ensure risk tool assessments are completed for residents identified with pain and continence problems. Ensure the effectiveness of pain relief is monitored.

3 months

1.3.12 1.3.12.1 PALow

Finding:The controlled drug signing administration sheet is signed by one staff member only.

Action:It is recommended that two medication competent persons sign the sheet, one administering the medication and one witnessing the administration of medication as per the MOH medication guidelines 2011

3 months

1.3.12 1.3.12.3 PALow

Finding:The Clinical Manager and RN has not completed medication competencies.

Action:The Clinical Manager and RN is required to completed medication competencies.

3 months

1.3.12 1.3.12.5 PALow

Finding:There is no regular monitoring of the self-medicating residents administration of medications. The self-medicating consent form lacks an assessment process.

Action:There is a requirement to ensure that there is formal monitoring conducted on residents who are assessed to safely self-medicate. Update the consent form to include a more comprehensive assessment of the residents ability to self-medicate.

3 months

Continuous Improvement (CI) Report

Provider Name: Glendale Retirement Home (2012) LimitedType of Audit: Certification audit

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

Std Criteria Evidence1.2.3 1.2.3.6 Finding:

A falls prevention programme was initiated in April 2013 - called April Falls. This campaign was developed is in response to the previous year’s falls incidence - in particular the rate of falls for two residents. The programme was extended to all residents with education and training for residents, families and staff. Residents and families were informed of the falls prevention campaign via a letter and a resident meeting.Staff education occurred on 8-Apr-2013. The campaign involved a number of strategies including an increased exercise regime run by the diversional therapist with exercise stations set up around the home. These stations involve strength training and balance exercises. Residents were observed at the exercise stations and eight residents and four care givers interviewed confirmed their involvement in the falls prevention programme. A residents meeting was held to present the falls campaign and explain the significance of the exercises and other falls prevention strategies. Other strategies include a 'tag the walker' system. With the permission of the resident, a colour coded tag is attached to the resident's mobility aid - usually a wheelie walker. A red tag signifies that the resident requires supervision and assistance with walking and if seen to be mobilising unaided, then staff are to intervene or families are to seek assistance from staff for that resident. A yellow tag signifies that some assistance or supervision is required and a green tag signifies that the resident is safe to mobilise independently.The service has instigated a tracking system whereby the time and location of accidents and incidents is logged for analysis. In 2012 from January to July there were 47 falls - 27 falls involving three residents. For the same time period in 2013 there were 44 falls. Of the three residents who were high falls rates in 2012, one resident with 20 falls in 2012 during January - July, same time period in 2013 = three falls; one resident had 10 falls in 2012 and three falls in 2013; one resident had eight falls in 2012 - three in 2013. One resident who was admitted with a wheelie walker, has had physiotherapy input has been reassessed as requiring only a single crutch.

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS

OUTCOME 1.1 CONSUMER RIGHTSConsumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs.STANDARD 1.1.1 Consumer Rights During Service DeliveryConsumers receive services in accordance with consumer rights legislation.

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

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

How is achievement of this standard met or not met? Attainment: FAThe code of health and disability rights is incorporated into everyday care. Discussions with four care givers identified their familiarity with the code of rights. A review of care plans, meeting minutes and discussion with eight residents and four family members confirms that the service functions in a way that complies with the code of rights. Observation during the audit confirmed this in practice. Training was last provided in April 2013.

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: FACode of rights leaflets are available at the front entrance of the facility. Code of rights posters are on the walls in the hallway of the facility. Client right to access advocacy services is identified for residents and advocacy service leaflets are available at the front entrance. If necessary, staff will read and explain information to residents. Information is also given to next of kin or enduring power of attorney (EPOA) to read to and discuss with the resident in private. Residents and families are informed of the scope of services and any liability for payment for items not included in the scope. This is included in the service agreement as evidenced in six of six files reviewed.D6,2 and D16.1b.iii The information pack provided to residents on entry includes how to make a complaint, COR pamphlet, advocacy and H&D Commission.

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 Respect

Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

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


How is achievement of this standard met or not met? Attainment: FAThe service has policies and procedures that are aligned with the requirements of the Privacy Act and Health Information Privacy Code. Residents' support needs are assessed using a holistic approach. The initial and on-going assessment includes gaining details of people’s beliefs and values. Interventions to support these are identified and evaluated. The home's philosophy which states: 'to assist all residents to maintain their independence and involve them in all decision making regarding themselves (with inputs from families too)', is implemented in practice. There is a policy that covers abuse and neglect and staff have completed training in July 2012.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 Six of six resident files reviewed identified that cultural and /or spiritual values, individual preferences are identified.

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: FAThere are current policies and procedures for the provision of culturally safe care for Māori residents. Specialist advice is available and sought when necessary. The service's philosophy results in each person's cultural needs being considered individually. Cultural awareness training occurred as part of the annual in-service education programme in February 2012.A3.2 There is a Maori health plan includes a description of how they will achieve the requirements set out in A3.1 (a) to (e)D20.1i The service has developed links with local iwi. There are currently no Maori residents at Glendale retirement home.

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's philosophy focuses on residents' right to be accepted as an individual and being given the opportunity to enhance the values in their lives thereby enables residents to be individuals. This flows through into each person’s care plan and could be described by four caregivers interviewed. During the admission process, the registered nurse along with the resident and family/whanau complete the documentation. Regular reviews are evident and the involvement of family/whanau is recorded in the resident care plan. Four family members interviewed feel that they are involved in decision making around the care of the resident. Families are actively encouraged to be involved in their relative's care in whatever way they want, and are able to visit at any time of the day.D3.1g The service provides a culturally appropriate service by implementing the Glendale retirement home mission statement which is: "To provide a quality, homely environment in which the elderly may live in an atmosphere of respect and friendliness and have their physical and psychological needs met regardless of culture, race or creed".D4.1c Six of six 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: FAThere are policies and procedures for staff around maintaining professional boundaries and code of conduct. The employment agreement includes a code of conduct. Job descriptions include responsibilities of the position. Staff are aware of and alert to the potential for racial and sexual harassment. Performance appraisals are conducted and staff receive supervision. Discussions with eight residents identify that privacy is ensured. Discussions with four caregivers described how professional boundaries are maintained. Discussions with the clinical manager and a review of complaints identified no complaints of this nature.

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: FA

A2.2 The service has policies and procedures and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards including those standards relating to the Health and Disability Services (Safety) Act 2001. Policies and procedures are provided by an external consultant, who provides regular updates for the service to maintain best practice. A quality monitoring programme is implemented and this monitors contractual and standards compliance and the quality of service delivery. The service monitors its performance through residents meetings, staff appraisals, satisfaction audits, education and competencies, complaints and incident management.There is an internal audit schedule. It includes (but is not limited to): safety, pressure area risk, recreation programme, care/hygiene of resident, infection control, challenging behaviour management, laundry service, resident notes and medication files, cleaning, privacy of information, restraint, medication procedure, building compliance, civil defence kit and care plan audit. Eight residents and four family members interviewed spoke very positively about the care provided. The service utilises a benchmarking service which provides reports and graphs relating to quality indicators including incident forms, infection rates, medication errors, behaviours and hospital admissions. Falls incidence is graphed for visual month by month comparisons. Results are discussed at staff meetings. D1.3 All approved service standards are adhered to.D17.7c. There are implemented competencies for the care givers and registered nurse. 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.


Finding Statement


Timeframe:

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



There is an open disclosure policy, a complaints policy, and an incident reporting policy. Eight residents and four family members stated they were welcomed on entry and were given time and explanation about services and procedures. Resident/relative meetings occur monthly and the clinical manager and registered nurse have 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. The Ministry of Health “Long-term Residential Care in a Rest Home or Hospital – what you need to know” is provided to residents on entryD16.1b.ii The residents and family are informed prior to entry of the scope of services and any items they have to pay that is not covered by the agreement.D16.4b The four family members interviewed stated that they are always informed when their family member's health status changes or of any other issues arising.The service has policies and procedures available for access to interpreter services and residents (and their family/whānau). Management identified that if residents or family/whanau have difficulty with written or spoken English that the interpreter services are made available.D11.3 The information pack is available in large print and advised that this can be read to residents

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

STANDARD 1.1.10 Informed ConsentConsumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

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


How is achievement of this standard met or not met? Attainment: FAPolicies and training support staff in providing care and support so that residents can make choices and be involved in the service. There is an informed consent policy and procedure that directs staff clearly in relation to the gathering of informed consent. Residents' rights training was last provided in Feb-13 and Consent in May-13. Interviews with four care givers identify that consents are sought in the delivery of personal cares and this is confirmed by eight residents. Written consent includes the signed admission agreements, resuscitation status, signed approval of care plans, general consent for the collection and sharing of medical information, photograph identification and display, transport for appointments and outings. The resident also understands they have a right to change or withdraw their consent at any time. All six resident files reviewed has signed consent forms. Resuscitation policy is implemented in all six resident files reviewed and are all signed appropriately. D13.1 There were six admission agreements sighted and six had been signed on the day of admission. D3.1.d Discussion with four family identified that the service actively involves them in decisions that affect their relative’s 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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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: FAClient right to access advocacy services is identified for residents. Leaflets are available at the entrance of the service. The information identifies who the resident can contact to access advocacy services. The information pack provided to residents prior to entry includes advocacy information. Staff are aware of the right for advocacy and how to access and provide advocate information to residents if needed. Advocacy training was provided in November 2012.D4.1d; Discussion with eight residents and four family members identified that the service provides opportunities for the family/EPOA to be involved in decisions and they are aware of their access to advocacy services.D4.1e: Six of six resident files reviewed includes information on residents 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.


Finding Statement


Timeframe:

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: FAD3.1h Discussion with the clinical manager, registered nurse, four caregivers, eight residents and four family members identified that residents are supported and encouraged to remain involved in the community and external groups. Family are encouraged to be involved with the service and care. Relatives interviewed stated they could visit at any time. The service has open visiting hours.D3.1.e Interviews with the diversional therapist described how residents are supported and encouraged to remain involved in the community and external groups. The facility activity programme encourages links with the community. Residents are assisted to meet responsibilities and obligations as citizens e.g. voting / census. Activities programmes include opportunities to attend events outside of the facility including activities of daily living e.g. shopping, attending church services. Entertainers are included in the home's activities programme. The DT and clinical manager described how outings in the facility owned van are tailored to meet the interests of the residents.

Criterion 1.1.12.1 Consumers have access to visitors of their choice.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

STANDARD 1.1.13 Complaints ManagementThe right of the consumer to make a complaint is understood, respected, and upheld.

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


How is achievement of this standard met or not met? Attainment: FAThe service has a complaints policy in place and residents and their family/whanau are provided with information on the complaints process on admission through the information pack. Complaint forms are available at the entrance of the service. Staff are aware of the complaints process and to whom they should direct complaints. The complaints process is in a format that is readily understood and accessible to residents/family/whanau. A complaints/compliments folder is maintained with all documentation. No complaints have been received for 2013 and three complaints for 2012. A review of the communication folder evidences that these concerns from residents have been documented and managed. Both verbal and written complaints are actively managed. There is a complaints register and this has been utilised for documenting complaints or concerns. Eight residents and four family members advised that they are aware of the complaints procedure and how to access forms.D13.3h. a complaints procedure 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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

OUTCOME 1.2 ORGANISATIONAL MANAGEMENTConsumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. STANDARD 1.2.1 GovernanceThe governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

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


How is achievement of this standard met or not met? Attainment: FAGlendale Retirement Home 2012 Ltd is a privately owned company who provide governance and business support to the clinical manager of the home. The clinical manager (RN) has been in the role since October 2012 and is supported by the previous owners/managers who now work in the roles of administrator and quality coordinator respectively. The previous owners/managers were in the roles for six years. The clinical manager has experience in acute and

emergency care. The clinical manager reports to the owner/s on a fortnightly basis. The clinical manager is supported by an experienced part time registered nurse who has worked in aged care for more than 10 years. The home provides care for up to 28 residents - certified for 12 hospital and 16 rest home level residents. On the day of audit there were 26 rest home residents. The service has yet to utilise the hospital level swing beds. Glendale has a current strategic/business plan and a quality plan for 2013. The quality programme is managed by a quality coordinator (previous owner/manager) who is a qualified auditor, with assistance from the clinical manager. The service has an annual planner/schedule which includes audits, meetings, education and policy review time table. Quality improvement activities are identified from audits, meetings, staff and resident feedback and incidents/accidents. The quality committee incorporates the management team of the clinical manager, registered nurse, quality coordinator and administration person. The committee meets monthly to assess, monitor and evaluate quality care at Glendale retirement home. There are clearly defined and measurable goals developed for the strategic plan and quality plan. The mission statement sets out the vision and values of the service: "To provide a quality, homely environment in which the elderly may live in an atmosphere of respect and friendliness and have their physical and psychological needs met regardless of culture, race or creed". The service philosophy includes aspects of care and service relating to: assisting residents to maintain their independence, involvement in making decisions, resident and family involvement in care planning, promoting wellness, maintaining outside contacts, encouraging residents to mix with other residents and join in activities within the home, and to maintain links with cultural or spiritual home and ensure our staff are knowledgeable and sensitive to the values and beliefs which are important to the resident. The clinical manager has worked with staff and residents to develop a set of values for the service. Glendale values include: caring, choice, professionalism, respect and teamwork.D15.3d: The clinical manager has maintained at least eight hours of professional development activities related to managing a rest home since commencing in the role in October 2012.

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


Finding Statement


Timeframe:

Criterion 1.2.1.3 The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.


Finding Statement


Timeframe:

STANDARD 1.2.2 Service ManagementThe organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers.

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


How is achievement of this standard met or not met? Attainment: FADuring a temporary absence of the clinical manager, the facility is managed by the registered nurse or the quality coordinator. The registered nurse is experienced in aged care and management. The service has well developed policies and procedures at a service level and a strategic plan and quality improvement plan that are structured to provide appropriate safe quality care to people who use the service including residents that require rest home and hospital level care.D19.1a; a review of the documentation, policies and procedures and from discussion with staff identified that the service operational management strategies, QI programme which includes culturally appropriate care, to minimise risk of unwanted events and enhance quality.

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


Finding Statement


Timeframe:

STANDARD 1.2.3 Quality And Risk Management Systems

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

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


How is achievement of this standard met or not met? Attainment: FAThe quality management manual includes the business quality risk and management plan and service philosophy. The quality programme is reviewed annually (last conducted 5-Feb-2013). The quality and risk management plan has 10 documented aims with implemented activities for each aim. Aims for the service include: a consumer focus, provision of effective programmes, certification and contractual requirements, risk management, continuous improvement, service management and staffing, education, medication management, food and fluids, and hospital level rooms. There is an internal audit schedule and internal audits are completed. Progress with the quality plan is monitored through monthly management/quality meetings, followed by a monthly staff meeting. The management meeting agenda and the staff meeting agenda includes (but is not limited to): complaints/concerns, audits, training, risks and hazards, health and safety, infection control, incidents/accidents, restraint, quality activities, policies and procedures. Minutes are maintained and easily available to staff. Management meeting minutes sighted for 5-Aug-2013 and staff meeting minutes for 5-Aug-2013. Minutes include actions to achieve compliance where relevant. Quality goals developed by the clinical manager for 2013 include review of RN orientation, infection control policies, and staff recruitment processes; falls prevention; and advertising. Discussions with the registered nurse and four care givers confirm their involvement in the quality programme. Resident/relative meetings take place monthly. Audits are conducted and include: safety, pressure area risk, recreation programme, care/hygiene of resident, infection control, challenging behaviour management, laundry service, resident notes and medication files, cleaning, privacy of information, restraint, medication procedure, building compliance, civil defence kit and care plan audit. Audits for 2012 and 2013 have been completed and there is documented management around non-compliance issues identified. Finding statements and corrective actions have been documented. A resident and family survey conducted in May 2013 evidences that families are over all very satisfied with the service. A survey evaluation has been conducted for follow up and corrective actions required. The service collects information on resident incidents and accidents as well as staff incidents/accidents. A falls prevention initiative was commenced in April 2013 (April Falls) with implemented activities evidencing a reduction in falls and improved outcomes for residents. The service is commended for this quality improvement initiative. Benchmarking is conducted around the following quality indicators: incident forms, infection rates, medication errors, behaviours, and hospital admissions. The external benchmarking service provides monthly reports based on the data provided. Staff are informed of the outcomes of the benchmarking and this information is utilised in corrective actions and improvements for resident care. The service has a health and safety management system and this includes the identification of a health and safety officer. Security and safety policies and procedures are in place to ensure a safe environment is provided. Emergency plans ensure appropriate response in an emergency.There is an infection control manual, infection control programme and corresponding policies. There is a restraint use policy and health and safety policies and procedures.There is an annual staff training programme that is implemented that is based around policies and procedures. Records of staff attendance are maintained. There is a document control policy that outlines the system implemented whereby all policies and procedures are reviewed regularly. Documents no longer relevant to the service are removed and archived.D5.4 The service has the following policies/ procedures to support service delivery; Policies and procedures align with the client care plans. Policies are provided by an external provider who provides the service with regular updates. The owner/manager is responsible for policy review.D17.10e: There are procedures to guide staff in managing clinical and non-clinical emergencies.

D19.3 there are implemented risk management, and health and safety policies and procedures in place including accident and hazard managementD19.2g Falls prevention strategies such as an implemented falls prevention programme in April 2013 - actions include exercise programme, education for staff, residents and families, tagging resident walkers with a risk warning for staff and family, falls risk assessment, walking aids, physiotherapy assessment, use of appropriate footwear, correct seating, increased supervision and monitoring and sensor mats if required.

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.


Finding Statement


Timeframe:

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

Audit Evidence Attainment: CI Risk level for PA/UA: Audits for 2012 and 2013 have been completed and there is documented management around non-compliance issues identified. Finding statements and corrective actions have been documented. A resident and family survey conducted in May 2013 evidences that families are over all very satisfied with the service. A survey evaluation has been conducted for follow up and corrective actions required. The service collects information on resident incidents and accidents as well as staff incidents/accidents. A falls prevention initiative was commenced in April 2013 (April Falls) with implemented activities evidencing a reduction in falls and improved outcomes for residents. Benchmarking

is conducted around the following quality indicators: incident forms, infection rates, medication errors, behaviours, and hospital admissions. The external benchmarking service provides monthly reports based on the data provided. Staff are informed of the outcomes of the benchmarking and this information is utilised in corrective actions and improvements for resident care.

Finding StatementA falls prevention programme was initiated in April 2013 - called April Falls. This campaign was developed is in response to the previous year’s falls incidence - in particular the rate of falls for two residents. The programme was extended to all residents with education and training for residents, families and staff. Residents and families were informed of the falls prevention campaign via a letter and a resident meeting. Staff education occurred on 8-Apr-2013. The campaign involved a number of strategies including an increased exercise regime run by the diversional therapist with exercise stations set up around the home. These stations involve strength training and balance exercises. Residents were observed at the exercise stations and eight residents and four care givers interviewed confirmed their involvement in the falls prevention programme. A residents meeting was held to present the falls campaign and explain the significance of the exercises and other falls prevention strategies. Other strategies include a 'tag the walker' system. With the permission of the resident, a colour coded tag is attached to the resident's mobility aid - usually a wheelie walker. A red tag signifies that the resident requires supervision and assistance with walking and if seen to be mobilising unaided, then staff are to intervene or families are to seek assistance from staff for that resident. A yellow tag signifies that some assistance or supervision is required and a green tag signifies that the resident is safe to mobilise independently. The service has instigated a tracking system whereby the time and location of accidents and incidents is logged for analysis. In 2012 from January to July there were 47 falls - 27 falls involving three residents. For the same time period in 2013 there were 44 falls. Of the three residents who were high falls rates in 2012, one resident with 20 falls in 2012 during January - July, same time period in 2013 = three falls; one resident had 10 falls in 2012 and three falls in 2013; one resident had eight falls in 2012 - three in 2013. One resident who was admitted with a wheelie walker, has had physiotherapy input has been reassessed as requiring only a single crutch.Corrective Action Required:

Timeframe:

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


Finding Statement


Timeframe:

Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.


Finding Statement


Timeframe:

Criterion 1.2.3.9 Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include:

(a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk;

(b) A process that addresses/treats the risks associated with service provision is developed and implemented.


Finding Statement


Timeframe:

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 is an accidents and incidents reporting policy. Accidents and near misses are investigated and analysis of incidents trends occurs. There is a discussion of incidents/accidents at monthly quality and monthly staff meetings including actions to minimise recurrence. There is an incident/accident policy.

Incident/accident forms are completed and given to the registered nurse who completes the follow up. All incident/accident forms are seen by the clinical manager who completes any additional follow up. The quality coordinator collates and analyses data to identify trends. Benchmarking with an external agency occurs with monthly reports and graphs provided. Discussions with the service confirms that there is an awareness of the requirement to notify relevant authorities in relation to essential notifications. There is an open disclosure policy and four family members interviewed stated they are informed of changes in health status and incidents/accidents. Incident reports for July 2013 were reviewed and included three falls, two behaviour incidents and one skin tear. All reports were completed and family notified as appropriate. Monthly incident/accident analysis occurs with subsequent annual summary and analysis.D19.3b; there is an incident reporting policy that 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.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

STANDARD 1.2.7 Human Resource Management

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

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


How is achievement of this standard met or not met? Attainment: FAThere are human resource management policies in place which includes recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications, experience and veracity. A copy of practising certificates including the clinical manager, registered nurse and general practitioners is kept. The human resources policies also include orientation, staff training and development. Six staff files were reviewed (one clinical manager, one registered nurse, two care givers, one diversional therapist, and one cleaner. Advised that reference checks are completed before employment is offered as evidenced in three recently employed staff files reviewed. The service has in place a comprehensive orientation programme that provides new staff with relevant information for safe work practice. Four caregivers were able to describe the orientation process and stated that they believed new staff were adequately orientated to the service. Orientation checklists evident in six of six staff files reviewed.Discussion with the quality coordinator, clinical manager, registered nurse and four caregivers confirm that a comprehensive in-service training programme is in place that covers relevant aspects of care and support and meets requirements. There is an in-service calendar for 2013. The annual training programme exceeds eight hours annually. Four caregivers interviewed have either completed the national certificate in care of the elderly or have either completed or commenced the aged care education programme. The clinical manager and registered nurse attend external training including conferences, seminars and sessions provided by the local DHB. Education provided in 2013 includes: fire safety, residents rights, infection control, handling of medical and general waste, advanced directives, recording observations, care plans, falls prevention, informed consent, emergency management, safe manual handling, confidentiality and privacy, pain management, restraint minimisation, and catheter care. In 2012 the programme included (but not limited to): infection control and hand hygiene, advocacy, medication administration, complaints and incident reporting, diabetes, continence management, abuse and neglect, independence, civil defence, challenging behaviours and de-escalation techniques, cultural awareness, and first aid training. Fire evacuation drill last conducted 17-June-2013. On review of six staff files, performance appraisals for three of six staff have been conducted (three staff whose files were reviewed, have been employed within the past 12 months).

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

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: FAGood employer policy includes staff rationale and skill mix. Sufficient staff are rostered on to manage the care requirements of the rest home residents. At least one staff rostered on at any one time with one staff on-call. Registered nurse or clinical manager provide first on call and share this week about. Advised that extra staff can be called on for increased resident requirements. Roster includes: two care givers work 7 -3.15pm daily, one care giver works 7-1pm; one care giver works 3-11pm, one care giver works 3.30 - 10pm, one care giver works 4.45 - 7.15pm as care giver/ kitchen hand/cleaner. One care giver works overnight from 10.45pm-7.15am. A cleaner is employed Monday to Friday 9.30 -1.30pm./g cook works 8.30-1.30pm Monday to Friday. Food is prepared for the weekend by the cook -with kitchen assistants employed to reheat, cook and serve meals 9-1pm weekends. The clinical manager works 40 hours per week, and the registered nurse works 30 hours per week. The quality coordinator and administrator work 20 hours per week each. Interviews with four caregivers, eight residents and four family members identify that staffing is adequate to meet the needs of residents.

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.


Finding Statement


Timeframe:

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



The resident files are appropriate to the service type. Residents entering the service have all relevant initial information recorded within 24 hours of entry into the resident’s individual record. An initial care plan is also developed in this time. Residents' files are protected from unauthorised access by being locked away in the nurses’ station. Informed consent to display photographs is obtained from residents/family/whanau on admission. Information containing sensitive resident information is not displayed in a way that can be viewed by other residents or members of the public.D7.1 entries are legible, dates and signed by the relevant care giver or RN including designationIndividual resident files demonstrate service integration. This includes medical care interventions and records of the activities coordinator. Medication charts are in a separate folder.

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.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

OUTCOME 1.3 CONTINUUM OF SERVICE DELIVERYConsumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.

STANDARD 1.3.1 Entry To ServicesConsumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.

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


How is achievement of this standard met or not met? Attainment: FAThere is a policy for resident admissions that includes responsibilities, assessment processes and time frames. Needs assessments are required for entry to the rest home service. The service communicates with needs assessors and other appropriate agencies prior to the resident’s admission regarding the level of care requirements. A suitable and timely admission day is arranged in consultation with the referring provider, registered nurse and family. There is an

information pack provided to all residents and their families on the service provided. The pack includes all relevant aspects of service delivery and residents and or family/whānau are provided with associated information such as the H&D Code of Rights,' complaints information, advocacy, and admission agreement. Four family members and eight residents interviewed stated that they had received the information pack and had received sufficient information prior to and on entry to the service. Signed service agreements are contained in the eight resident files sampled. The resident/family sign a form to acknowledge they have received a copy of the resident information booklet and Code of Rights. D13.3 The admission agreement reviewed aligns with a) -k) of the ARC contractD14.1 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.


Finding Statement


Timeframe:

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: FAThere is a declining entry section in the admission procedure. The service records the reason for declining service entry to residents should this occur and communicates this to residents/family/whānau. The reason for declining would be if the client did not meet the level of care provided at the facility or there are no beds available.

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.


Finding Statement


Timeframe:

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: FAThere is a policy and process that describe resident’s admission and assessment procedures. A registered nurse (RN) undertakes the assessments on admission, with the initial nursing assessment and care plan completed within 24 hours of admission. Within three weeks the Resident comprehensive care plan is developed in the six rest home files viewed. In all resident files sampled the initial admission assessment and resident comprehensive long term care plans were completed and signed off by a registered nurse. Six monthly reviews or earlier if resident health changes are completed by the RN with input from the care staff, the diversional therapist and any other relevant person. Initial activity assessments and the activities care plans have been completed by the Diversional Therapist (DT). Care plans are used by nursing and care staff to ensure care delivery is in line with the residents assessed needs. Handover occurs at the end of each duty that maintains a continuity of service delivery. There is a communication folder which staff read that includes reviewed policies There is an RN on-call after hours and weekends Medical assessments are completed within 48 hours of admission by the GP as evidenced in the medical notes of six resident files sampled. The house GP for residents at Glendale rest home stated on interview he conducts weekly visits to attend to three monthly resident reviews and attend to any RN resident concerns. He is available for resident visits in between routine visits if required. The RN contacts him by phone, fax or text. The GP has a partner or a locum at the Mornington Health Centre that covers for his leave. There are up to 20 GP's at the practice and they are looking at a shared model of care. The GP states the staff are caring and his patients receive very good care. He receives positive feedback on the care from his patients and their families. There is a range of assessment tools completed on admission and reviewed six monthly if applicable including (but not limited to); a) dietary profile b) Norton pressure area risk assessment, c) continence assessment d) coombes falls risk assessment e) Abbey pain assessment f) oral assessment and g) challenging behaviour assessment. All six files identified integration of allied health including DHB Nurse Practitioner for Mental Health, Older Peoples Health, Diabetes nurse specialist, palliative care nurse, City podiatry.

D16.2, 3, 4: The six resident files reviewed identified that in all six files a nursing assessment was completed within 24 hours and six of six files identify that the resident comprehensive long term care plan was completed within three weeks. There is documented evidence that the care plans were reviewed by an RN and amended when current health changes. Five of six resident files sampled evidenced written evaluations are completed at least six monthly. One resident had been in the facility less than six months.D16.5e: Six resident files reviewed identified that the GP had seen the resident within two working days. It was noted in resident files reviewed that the GP has assessed the resident as stable and is to be seen 3 monthly.Six rest home resident files sampled. Tracer Methodology: Resident.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.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

STANDARD 1.3.4 AssessmentConsumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

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


How is achievement of this standard met or not met? Attainment: PA LowA initial nursing assessment is completed within 24 hours of admission and the resident comprehensive long term care plan is completed within three weeks. Personal needs outcomes and goals of residents are identified. There is a range of assessment tools completed on admission and reviewed six monthly if applicable including (but not limited to); a) dietary profile b) Norton pressure area risk assessment, c) continence assessment d) coombes falls risk assessment e) Abbey pain assessment f) oral assessment and g) challenging behaviour assessment. Three of six resident files sampled did not have a pain assessment for pain identified in the long term care plan. There is inconsistent monitoring of the effectiveness of pain relief. One resident did not have a continence assessment completed for an identified continence problem in the long term care plan. Assessments are conducted in an appropriate and private manner. All residents interviewed are satisfied with the support provided. Assessment process and the outcomes are communicated to staff at shift handovers, via communication books, progress notes, initial assessment and care plans. Eight resident interviews and four family members stated they were informed and involved in the assessment process.

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

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

There is a range of assessment tools completed on admission and reviewed six monthly if applicable including (but not limited to); a) dietary profile b) Norton pressure area risk assessment, c) continence assessment d) coombes falls risk assessment e) Abbey pain assessment f) oral assessment and g) challenging behaviour assessment. However, three of six resident files sampled did not have a pain assessment for pain identified in the long term care plan and there is inconsistent monitoring of the effectiveness of pain relief. One resident did not have a continence assessment completed for an identified continence problem in the long term care plan.

Finding StatementThree of six resident files sampled did not have a pain assessment for pain, although pain was identified in the long term care plan. There is inconsistent monitoring of the effectiveness of pain relief. One resident did not have a continence assessment completed, although an incontinence issue was identified in the long term care plan.

Corrective Action Required:Ensure risk tool assessments are completed for residents identified with pain and continence problems. Ensure the effectiveness of pain relief is monitored.

Timeframe:3 months

STANDARD 1.3.5 PlanningConsumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

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


How is achievement of this standard met or not met? Attainment: FAResidents' files include; initial nursing assessment, initial care plan, daily progress notes, BP, pulse, oxygen saturation and weight recordings, short term care plans, resident comprehensive long term care plans, risk assessments/nutrition, regular evaluations, GP initial assessment and visits, lab results, allied health reports, activities, consents, advance directives, letters, discharge summaries, NASC assessment and admission agreements.The initial care plan is developed from the RN initial assessment and identifies the areas of concern or risk. Resident comprehensive long term care plans are individually developed with the resident and family/whānau who sign to acknowledge their approval of the care plan. Six residents and four family members interviewed stated they are involved in the care planning process. Six resident comprehensive long term care plans reviewed were evidenced to be up to date. Nursing diagnosis, goals and outcomes are identified and agreed and how care is to be delivered is explained. The resident comprehensive long term care plan covers all areas of need identified as follows: current medical /surgical history, dressing and hygiene needs, skin integrity, mobility, nutrition, sleep patterns, continence, pain, orientation and perception, behaviour, identity (social, spiritual, cultural) and additional information. Additional specific care plans for behavioural problems, congestive heart disease, chronic obstructive respiratory and catheter care. Service delivery plans demonstrate service integration. There is evidence that residents are seen by their GP at least three monthly. The GP signs a declaration label on the medical notes page stating the resident is stable and for three monthly visit. Notes are well maintained. D16.3k, Short term care plans are in use for changes in health status and infections. Examples sighted are chest infection and UTI. D16.3f; Six resident files reviewed identified that family were involved.

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.


Finding Statement


Timeframe:

Criterion 1.3.5.3 Service delivery plans demonstrate service integration.


Finding Statement


Timeframe:

STANDARD 1.3.6 Service Delivery/InterventionsConsumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

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


How is achievement of this standard met or not met? Attainment: FAThe service provides services for residents requiring rest home level care. Individualised care plans are completed. When a resident's condition alters, the registered nurses initiate a GP review or nurse specialist referral. The four care givers and RN interviewed stated that they have all the equipment referred to in long and short term care plans necessary to provide care, including sling hoist, wheelchairs, walking frames, chair scales, transferring equipment, pressure relieving equipment. D18.3 and 4 Dressing supplies are available and the medication room holds adequate supplies of wound care products, blood glucose monitoring equipment and other medical equipment.

There are currently no wounds or skin tears. Wound care is based on up-to-date information and wound care advice is readily accessible. Eight residents and four family members interviewed confirm their current care and treatments they and their family members are receiving meet their needs. Family communication sheets record family communications, sighted in all six residents' files sampled.Continence products are available and continence products are identified for day use, night use, and other management. Specialist continence advice is available as needed. Staff were provided with catheter care and continence management education in August 2013 and the RN attended wound management education in 2012.All falls are reported on the resident accident/incident form and reported to the RN. Coombes falls risk are done on admission and reviewed at least six monthly or earlier should there be an increased falls risk. A physiotherapist referral through Dunedin Physio Med can be initiated as required. Staff attended in-service on falls prevention April 2013 as part of the 'April Falls' falls prevention programme in place at Glendale.Palliative care is delivered with support from the Hospice nurses and specialists as required. The Nurse Practitioners from the Mental Health services are readily available on request for input and advice on behavioural problems. The nurse practitioner provided Challenging behaviour/restraint in April 2012.

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.


Finding Statement


Timeframe:

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: FAThe Diversional therapist (DT) joined the service five weeks ago and works from 10am - 3.30pm. She qualified as a DT three years ago and has worked as a care giver previously. The DT is a member of the NZ DT Society and attends DT monthly meetings and two workshops a year. There is good communication between the teams and she is aware if there have been resident changes to mobility or health status. The DT attends handovers and staff meetings. The DT

meets with a new resident/family within the first two weeks of admission and completes an initial activities interest form that includes the residents life history, hobbies, interests, family, pets and achievements. The activity care plan is then developed in consultation with resident/family to identify goals. The DT and RN have developed an action plan to co-ordinate the review of the residents long term care plan and activity care plan at the same time. Residents forward suggestions and ideas for outings, entertainments and activities at the monthly resident meeting. The programme is planned a month ahead and displayed on the dining room board and residents have a copy in their room. The DT explained there are two younger persons and their interests and taste in music is acknowledged. They attend outings and entertainment that they specifically enjoy such as café outings and shopping. There is a daily focus group that is well attended where residents take part in discussions, quizzes, newspaper reading, exercises (Otago ACC exercise programme at exercise stations around the home) and walking. There are visiting “mystery persons”, men's outings and activities, ladies craft and dance group, Happy Hour and one on one activities. A husband and wife volunteer to assist with bowls, housie and outings. Music and entertainment s scheduled weekly as are outings. The DT transports residents for outings in the 12 seater van. There are no residents who are wheelchair bound therefore all residents have the opportunity to enjoy the outings. The DT has a current first aid certificate. Weekend activities are co-ordinated by the care staff and include regular weekend drives, DVD evenings and manicures. Residents are encouraged to maintain social and community links and there are inter-home competitions, community concerts, Age Concern concerts, attendance at Probus, Senior Citizens and RSA. There is an inter-denominational church service monthly, visiting ministers and some residents attend their own church. Eight residents interviewed confirm they are involved in their activity plan and enjoy the activities, entertainment and outings offered. D16.5d Resident files reviewed identified that there are some timeframes outside of the six monthly review. There is a plan in place (sighted) to align the activity care plan review and long term care plan review at the same time.

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.


Finding Statement


Timeframe:

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: FAAll initial care plans were developed by an RN within 24 hours of admission and resident comprehensive long term care plans developed within three weeks of admission. Long term care plans are evaluated at least six monthly or if there is a change in health status. There was documented evidence that care plan evaluations were up to date in five of six resident files sampled. One residents care plan is not due for an evaluation. Overall changes in health status are documented and followed up. Care plan reviews are signed as completed by an RN. There is a three monthly review by the GP. GP's review residents medication at least three monthly or when requested if issues arise or health status changes. Short term care plans are evaluated, resolved or added to the long term care plan if the problem is on-going. D16.4a Care plans are evaluated six monthly more frequently when clinically indicatedD16.3c: All initial care plans were evaluated by the 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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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: FAThe service facilitates access to other medical and non-medical services. The GP interviewed confirms RNs inform him of any referrals made directly to other nursing services or the needs assessment team. Referrals to specialists are made by the GP. Referral forms and documentation are maintained on resident files as sighted: Otago community hospice, eye clinic, older peoples health, nurse practitioner, ophthalmologist, dental, optometrist, Psychiatrist, urology, diabetes nurse specialist. Relatives (four) and residents (eight) interviewed state they are informed of referrals required to other services and are provided with options and choice of service provider. The GP had discussed referrals options with a relative on the day of audit. D16.4c: The service currently have no residents awaiting a NASC reassessment. D 20.1 discussions with Clinical Manager and registered nurse identified that the service has access to wound care, diabetes, continence, hospice and mental health nurse specialists, physio, podiatry and dietitian services as required.

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.


Finding Statement


Timeframe:

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 is a policy that describes guidelines for death, discharge, transfer, documentation and follow up. A record is kept and a copy of which is kept on the resident’s file as sighted for two residents recently transferred to ED. There is evidence in the progress notes that there has been communication with the family regarding transfers and discharges as sighted in two of six residents records sampled. Follow up occurs to check that the resident is settled, or in the case of death, communication with the family is made

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.


Finding Statement Corrective Action Required:

Timeframe:

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. The medication trolley and pharmaceutical supplies are kept in the locked nurses’ station. The medication trolley holds the medico blister packs and prn medications. The RN checks, signs and dates the medico pack when deliveries are made. All medications received are recorded into the pharmacy delivery book. The supplying pharmacy also collect returns and carry out six monthly pharmacy audits. There are no eye drops in use. The medication fridge is monitored weekly and has a visual external thermometer. Approved containers are used for the safe disposal of sharps. The trolley is kept locked when not in use. Controlled drugs are stored in a locked safe in the nurse’s office and two medication competent staff sign out controlled drugs. The controlled drugs are checked weekly. The controlled drug signing administration sheet was signed by one staff member only. It is recommended that two medication competent persons sign the sheet, one administering the medication and one witnessing the administration of medication as per the MOH medication guidelines 2011.Caregivers have completed medication competencies for oral medications, insulin, eye drops and controlled drugs. The Clinical Manager and RN have not completed medication competencies. Annual education is provided and there is an upcoming education session scheduled. The medication folder contains medication information on the 5 R's of administration, medico pack administration, warfarin information, problems and interactions. End of life medications can

be administered orally or subcutaneously as per GP prescription. Residents requiring syringe driver pain management and palliative care are transferred to hospital level of care. Standing orders meet the required medication guidelines and a list is kept in the medication folder. Residents self-medicating are identified on the medication chart, sign consents witnessed by the RN and GP, and keep their medication safe within their room. There is no formal record of the self-medicating residents administration of medications. There is an improvement identified around the consent form to include a more comprehensive assessment of the residents ability to self-medicate. There is a requirement to ensure there is formal monitoring of the self-medicating resident as per the self-medication policy. 12 resident medication charts are sampled. All medication charts have photo identification and allergies are noted. The medication charts are reviewed three monthly by the GP. The prescribing of regular medications meet legislative requirements. The prescribing of PRN medications require an indication for use. D16.5.e.i.2; 12 medication charts reviewed identified that the GP had seen the reviewed the resident 3 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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowControlled drugs are stored in a locked safe in the nurse’s office and two medication competent staff sign out controlled drugs. The controlled drugs are checked weekly. On review of the administration records for residents with controlled drugs, it was noted that only one staff member signs the administration sheet.

Finding StatementThe controlled drug signing administration sheet is signed by one staff member only.Corrective Action Required:It is recommended that two medication competent persons sign the sheet, one administering the medication and one witnessing the administration of medication as per the MOH medication guidelines 2011

Timeframe:3 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowCaregivers have completed medication competencies for oral medications, insulin, eye drops and controlled drugs. Annual education is provided and there is an upcoming education session scheduled. The Clinical manager and the registered nurse have not completed medication competencies.

Finding StatementThe Clinical Manager and RN has not completed medication competencies.

Corrective Action Required:The Clinical Manager and RN is required to completed medication competencies.

Timeframe:3 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowResidents self-medicating are identified on the medication chart, sign consents witnessed by the RN and GP, and keep their medication safe within their room. There is no formal record of the self-medicating resident’s administration of medications. There is an improvement identified around the

Finding StatementThere is no regular monitoring of the self-medicating residents administration of medications. The self-medicating consent form lacks an assessment process. Corrective Action Required:There is a requirement to ensure that there is formal monitoring conducted on residents who are assessed to safely self-medicate. Update the consent form to include a more comprehensive assessment of the resident’s ability to self-medicate.

Timeframe:3 months

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.


Finding Statement


Timeframe:

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: FAThere is a Food Services manual with policies and procedures that align with current best practice and food safety and hygiene standards. The service employs a qualified cook Monday to Friday 8.30pm - 1.30pm. The care staff serve breakfast and a kitchen person serves the tea. The cook has completed

food safety and hygiene NZQA units and other staff who work in the kitchen have completed the ACE Education Food and nutrition module. There is a five weekly seasonal menu that has been reviewed (Nov-12) by the dietitian based at the Mornington Health Centre. Corrective actions have been addressed. The RN completes a dietary profile on admission which identifies the type and texture of the resident’s food, special crockery or utensils required and any likes or dislikes. The kitchen has a copy of the profile and is informed of any dietary changes. Alternative foods are offered as required. There are weekly fridge and freezer temperature monitoring recordings and visual temperature readings on the equipment. Hot and cold foods are monitored daily and temperatures recorded weekly. There is a smaller fridge, tea making facilities and juice and water readily available in the dining room area for the residents. All perishable foods are date labelled. The kitchen is well equipped with two ovens, a top stove, microwave and dishwasher that have all been checked and maintained. Staff working in the kitchen are observed wearing protective clothing such as hats, aprons and gloves. Food is ordered fortnightly and the pantry goods are rotated on delivery. There is a second storage area and the service holds enough food for at least three days. ACE foods have a contract to supply foods in the event of an emergency and the unavailability of a cook due to sickness. Chemicals are stored in a pad locked kitchen cupboard. Pestgone are contracted to carry out regular treatments maintaining a pest/vermin free food services environment. The food service audit Oct-13 achieved 94% compliance. Corrective actions are implemented. Eight residents and four family members report satisfaction with meal choices, meals are well presented (observed) and alternative meals are offered as required.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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

OUTCOME 1.4 SAFE AND APPROPRIATE ENVIRONMENTServices are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3.STANDARD 1.4.1 Management Of Waste And Hazardous SubstancesConsumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

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


How is achievement of this standard met or not met? Attainment: FAThere are policies in place in for waste management, waste disposal for general waste and medical waste management. Refuse is collected from the property by an external contractor. There an approved sharps container for the safe disposal of sharps. All chemicals are labelled with manufacturer labels. There are designated areas locked areas for storage of cleaning/laundry chemicals. Product use charts are available. Hazard register identifies hazardous substance. Chemicals are stored in a locked garage until required. There are padlocked chemical cupboards in the bathrooms areas for staff to access if required. Gloves, aprons, and goggles are available for staff. Interviews with four care givers and one cleaner could describe management of waste and chemicals, infection control policies and specific tasks/duties for which protective equipment is to be worn (as observed). Staff received education on medical and general waste March-13 and there is chemical safety training scheduled for Dec-13.

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.


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

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: FAThe service displays a current building warrant of fitness which expires 20-Dec-2013. The Fire evacuation scheme letter of approval is dated 13-Jul-2011 following previous refurbishment. Fire testing of equipment is current. The quality co-ordinator is responsible for the day to day maintenance and requests are

written into the maintenance book. There are planned maintenance schedules. Maintenance policies and procedures are in place. The chair scales are calibrated. Electrical testing is due and the hoist overdue for its annual functional and safety check. Equipment is booked for checks and the email sighted. The interior is well maintained with a home-like décor and furnishings. There are communal lounges (TV, upstairs and activity lounge), dining area, hairdressing area, library area, communal bathroom and toilet facilities. There are small seating nooks available for residents and visitors. The bedrooms are divided into wings: Gallery, Rosendale, Garden view and the Loft which is five rooms upstairs. There is a chair lift and call bell readily accessible for residents should they require assistance to access the chair lift. Resident’s rooms are carpeted and all areas have fitted carpet in living areas. The corridors are wide with handrails in place. There is an internal covered area and external designated smoking areas. There is easy access to the outdoors. Outdoor ramps have handrails. The exterior is well maintained with safe paving, outdoor shaded seating, large lawn and gardens. Interviews with four care givers confirmed there was adequate equipment to carry out the cares according to the resident needs as identified in the care plans. D15.3; : The following equipment is available, pressure relieving resources, shower chairs, sling hoists, transferring aids, chair scales, wheelchairs, walking frames, shower stools, two electric beds.

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


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

Criterion 1.4.2.6 Consumers are provided with safe and accessible external areas that meet their needs.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: FAAll bedrooms have hand basins. There are four bedrooms with shared ensuites. There are adequate numbers of communal toilets and showers with appropriately placed handrails. The toilet/shower rooms have engaged/vacant signage. Shower rooms have privacy curtains. Eight residents interviewed state their privacy and dignity is maintained while attending to their personal cares and hygiene.

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.


Finding Statement


Timeframe:

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



The rooms are spacious enough to meet the assessed resident needs. Residents are able to manoeuvred mobility aids around the bed and personal space. Two residents have electric beds. All other ordinary beds are of an appropriate height for the residents. Four care givers interviewed report that rooms have sufficient room to allow cares to take place. The bedrooms are personalised.

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


Finding Statement


Timeframe:

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 are separate lounges(communal, TV, activities) and seating nooks where group or individual activity can occur. The dining room is spacious and located directly off the kitchen/servery area. All areas are easily accessible for the residents. The furnishings and seating are appropriate for the consumer group. D15.3d seating and space is arranged to allow both individual and group activities to occur. Residents were seen to be moving freely both with and without assistance throughout the audit and eight 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.


Finding Statement


Timeframe:

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: FAGlendale has documented systems for monitoring the effectiveness and compliance with the service policies and procedures. There is a separate laundry area where all linen and personal clothing is laundered by the care staff. Staff attend infection control education and there is appropriate protective clothing available and worn (observed). Internal laundry services audit in March-13 achieved 100% compliance and satisfaction with the service. There are designated cleaners employed four hours a day to cover the seven day week. The cleaner interviewed stated her duties include vacuuming, cleaning of toilets, bathrooms, hand basins. The spring cleaning of rooms are rotated with a room each week. Unoccupied rooms are kept clean, fresh and ready to occupy. Wet vaxing is also done as required. The cleaning trolley is stored in a locked cupboard when not in use. A chemical product chart is available. The cleaner is observed wearing protective clothing. Internal cleaning services audit in March-13 achieved 98% compliance and satisfaction with the service Residents and family interviewed report satisfaction with the laundry service and cleanliness of the room/facility

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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: FAThe service has a fire and emergency procedures manual. There is currently a trained person with a first aid certificate on each shift. Glendale retirement home has a NZFS approved fire evacuation scheme, dated 17-Nov-2006 and updated on 13-Jul-2011 following refurbishment. A call bell light alerts staff to the area in which residents require assistance. The home is small and advised that most visitors are known to staff and/or management. Fire drill last conducted 18-June-2013. A civil defence kit is stocked and checked six monthly. Water is stored - sufficient for at least three days. Alternative heating and cooking facilities are available. Emergency lighting is installed. Advised that a generator can be hired if required. Call bell system evident and in use in the resident areas. Staff conduct checks of the building in the evenings to ensure the facility is safe and secure.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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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: FAAll communal and resident bedrooms have external windows with plenty of natural sunlight. General living areas and resident rooms are appropriately heated and ventilated. There is under floor heating for rooms on the ground floor. The heat can be controlled with thermostats in rooms. Other rooms have panel heating. Eight residents interviewed state the environment is warm and comfortable.

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


Finding Statement


Timeframe:

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.


Finding Statement


Timeframe:

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

OUTCOME 2.1 RESTRAINT MINIMISATION

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

ARC E4.4a ARHSS D16.6


How is achievement of this standard met or not met? Attainment: FADocumented systems are in place to ensure the use of restraint is actively minimized. The facility was not utilising restraint or enabler use on audit day. Staff interviews and staff records evidence guidance has been given on RMSP, enabler usage and prevention and/or de-escalation techniques. Policies and procedures include definition of restraint and enabler that are congruent with the definition in NZS 8134.0. Restraint minimisation policies reviewed 29-Oct-2012.

Staff education on RMSP /Enabler was conducted in June 2013. Challenging behaviour management and de-escalation techniques training was provided in July 2012 and April 2012. Use of restraint audit was conducted in June 2012 and indicated no restraint use at that time. The restraint approval group meets six monthly to review use of restraint or enablers (last held 22-May-2013).

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


Timeframe:

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: FAGlendale retirement home has an established infection control programme. The infection control programme, its content and detail, is appropriate for the size, complexity and degree of risk associated with the service. It is linked into the incident reporting system. The registered nurse is the designated infection control nurse with support from the clinical manager and quality coordinator. There is a monthly quality management meeting which incorporates infection control and health and safety and includes discussion and reporting of infection control matters and consequent review of the programme. Minutes are available for staff. Regular audits take place that include hand hygiene, infection control practices, laundry and cleaning. Annual education is provided for all staff. The clinical manager has developed a quality improvement plan for infection prevention at Glendale and incorporates hand hygiene practices, wound care, preparation for isolation, policy review and sharps disposal. The infection control programme has been reviewed by the clinical manager, an infection control expert, the local laboratory and the quality coordinator. A documented review has been signed by all parties and is dated May 2013.

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.


Finding Statement


Timeframe:

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


Timeframe:

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 registered nurse at Glendale is the infection control nurse. There are adequate resources to implement the infection control programme for the size and complexity of the organisation. The infection control (IC) nurse and the clinical manager maintain their practice by attending annual infection control updates (last attended a training session on outbreak management and new infection definition in May 2013). The IC nurse and IC team (comprising the management team and care staff) has good external support from the local laboratory infection control team and IC nurse consultant. The infection control team is representative of the facility. As part of a quality improvement initiative of the clinical manager, there has been an increase in alcohol hand gel available for staff and residents, education provided on the five moments of hand hygiene, improvements to wound care and management of dressings to reduce risk of cross infection, availability of isolation packs, improved availability of sharps containers and review of the infection control policies.

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: FAThere is are infection control policy and procedures appropriate to for the size and complexity of the service.D 19.2a: The infection control section of the nursing manual outlines a comprehensive range of policies, standards and guidelines and includes defining roles, responsibilities and oversight, the infection control team and training and education of staff. The policies are developed by an external provider and reviewed and updated annually. The clinical manager has also conducted a review of all the infection control policies completed in August 2013. The infection control policies include (but not limited to): hand hygiene; standard/transmission based precautions; prevention and management of staff infection; surveillance, antibiotic and antimicrobial agents; infectious outbreaks management; environmental infection control (cleaning, disinfecting and sterilising); single use items; construction/renovation risk assessment, personal protective equipment, medical waste and sharps and spills management.

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: FAThe infection control policy states that the facility is committed to the on-going education of staff and residents. This is facilitated by the infection control nurse and the clinical manager with support from external providers who provide the service with current and best practice information. All infection control training is documented and a record of attendance is maintained. The IC nurse and clinical manager attends training annually - last session in May 2013. Visitors are advised of any outbreaks of infection and are advised not to attend until the outbreak has been resolved. Information is provided to residents and visitors that is appropriate to their needs and this is documented in medical records. Education on hand hygiene and infection control provided for staff in February 2013, December 2012, and September 2012.

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


Finding Statement


Timeframe:

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: FAInfection surveillance is an integral part of the infection control programme and is described in Glendale's infection control manual. Monthly infection data is collected for all infections based on signs and symptoms of infection. An individual resident infection form is completed which includes signs and symptoms of infection, treatment, follow up, review and resolution. Surveillance of all infections are entered on to a monthly infection summary. This data is monitored and evaluated monthly and annually. Outcomes and actions are discussed at the monthly management meetings, and monthly staff meetings. If there is an emergent issue, it is acted upon in a timely manner. Reports are easily accessible to the owner/manager.

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


Timeframe:

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


Timeframe: