Certification audit summary · Web viewEvergreen Care opened on 1 July 2013 providing residential care for up to eighteen residents who will require rest home level care. There are

Union Group Limited

CURRENT STATUS: 25-Sep-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

Evergreen Care opened on 1 July 2013 providing residential care for up to eighteen residents who will require rest home level care. There are currently four residents in this rest home. The service has a service agreement with Waitemata District Health Board. Two experienced managers have been appointed to manage the rest home for and on behalf of the owner/directors Union Group Ltd. There is a staffing and transitional plan in place to ensure there is adequate staff cover to meet the needs of the residents as the number of residents increases. There is a quality and risk programme that is developed but has not yet been fully implemented. Policies and procedures are developed for all aspects of service delivery. Improvements are required for the following: a complaints register is required and there are eight areas for organisational management requiring further development or implementation. There is one area of improvement ensuring a care plan is amended to reflect current interventions required and the infection programme has a surveillance programme to be further implemented for this service.

AUDIT SUMMARY AS AT 25-SEP-13

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short fallsStandards applicable to this service fully attained

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

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

Indicator Description Definition

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights Day of Audit

25-Sep-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.


Organisational Management Day of Audit

25-Sep-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

25-Sep-13

Assessment

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


Safe and Appropriate Environment Day of Audit

25-Sep-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.

Standards applicable to this service fully attained

Restraint Minimisation and Safe Practice Day of Audit

25-Sep-13

Assessment

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

Standards applicable to this service fully attained

Infection Prevention and Control Day of Audit

25-Sep-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 25-SEP-13

Consumer Rights

The Health & Disability Commissioner (HDC) Code of Health & Disability Services Consumers' Rights (the code) information is readily displayed along with avdocacy support and complaint forms. Residents are provided with information on admission including the code and information on how to apply for a subsidy. Residents report that services are provided in a manner that is respectful of their rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Residents and family/whanau interviewed state they are satisfied with the service provided and report that staff are providing care that is appropriate to their needs. There is documented evidence of notification to family members following adverse events and of any significant change in the resident's condition. During interviews, staff demonstrate an understanding of informed consent and informed consent processes.

The service undertakes the complaints process in a manner that complies with Right 10 of the code. The assistant manager confirms there have been no external complaints, issues based audits, coroner`s inquests or police investigations since the service commenced on 1 July 2013. Complaint/compliment forms are accessible in the lounge and reception area. An area of improvement is required to the complaints register.

Organisational Management

The service is managed by a manager and an assistant manager who have worked in the aged care industry for many years. The managers appointed by the owner/directors are fully responsible for the day to day running of the facility and the employment of staff as the number of residents increases. The service has a business plan with an identified philosophy and goals.

A quality and risk management plan is developed for 2013 -2014 but has not been fully implemented.

A registered nurse is employed for twenty hours per week to provide clinical supervision. A casual registered nurse is available to cover as required. There is a system in place for managing the current annual practising certificates for the two registered nurses, the general practitioner and the pharmacist contracted to this service. There are seven staff employed presently who have been fully orientated and one prospective staff member is presently orientating to a caregiver position. An education programme is developed and implemented and records are maintained by the assistant manager. Four staff were interviewed. There are adequate policies and procedures for this service and seven areas of improvement have been identified where policies, processes and procedures have not yet been fully implemented.

Continuum of Service Delivery

Residents receive timely, competent and appropriate service delivery from staff who are qualified and/or trained according to their role. Care plans are developed which involves the Registered nurse (RN), care staff, the resident and their family. A review and evaluation of the care provided is conducted by the care staff daily and the RN. Each stage of service provision is provided within required time frames to meet the needs of the resident. Residents' nutritional needs are overseen by the Manager/Cook. Each residents nutritional needs are catered for with input by the RN staff and dietician as required. All meals and menus have been reveiwed by a registered dietitian. Medicine management systems are implemented to ensure safe and timely management of medicines that meet legislative and medicines guidelines. There is one area of required improvement identified ensuring the tracer resident`s care plan is amended to reflect current interventions required.

Safe and Appropriate Environment

This facility was a rest home previously but the current building owners/managers have totally re-decorated the facility, including new carpets, new vinyl, new furniture and furnishings, new bedding and linen. New equipment for the kitchen and resources are readily available. There are eighteen individual rooms and the rest home has three wings. Toilets and showers are in close proximity to the resident`s rooms. The lounge and dining room is open planned and there is a sunroom at the end of the lounge. The resthome is homely, warm and comfortable with appropriate heating throughout. The front grassed area outside is completely fenced for safety and there is outside garden seating and umbrellas provide shade as required. Emergency and disaster planning has occurred and there are provisions for use in the case of such an emergency. Staff have received training in first aid and basic life support.

The laundry/cleaning is managed by the caregivers presently until the number of residents increases. The laundry is not adequate and does not have enough space for seperating the dirty and clean linen. The service provider is awaiting approval from the Waitakere District Council of plans to make structural changes to the exisiting laundry.

Restraint Minimisation and Safe Practice

The service has a commitment to a 'non restraint' policy and philosophy. There is clearly described restraint minimisation and safe practice policy and processes which comply with the standard. The policies and procedures are documented to guide staff. There are no restraints or enablers in use. Training is provided to staff at orientation and this is ongoing.

Infection Prevention and Control

Infection control management systems are implemented to minimise the risk of infection to patients, service providers and visitors. The infection control programme implemented meets the needs of the organisation and provides information and resources to inform the service providers on infection prevention and control. Documented policies and procedures are in place for the prevention and control of infection and are readily available for staff access. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. There are two areas of required improvement ensuring surveillance methods are implemented for identified multi-resistent organisms and organisms associated with antimicrobial use and the results for surveillance and special recommendations are to be documentd and reported in a timely manner.

Evergreen CareUnion Group

Certification audit - Audit Report

Audit Date: 25-Sep-13

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Union Group t/a Evergreen Care

Premise Name Street Address Suburb City

Evergreen Care 120 Rathgar Road Henderson Auckland

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

Type of Audit Certification audit and (if applicable)

Date(s) of Audit Start Date: 25-Sep-13 End Date: 26-Sep-13

Designated Auditing Agency

HealthShare Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXX

RN, RM (curent APCs), PG Dip HSM, PG Cert Neurosurgical Nursing

16.00 8.00 25-Sept-13 to 26-Sept-13

Auditor 1 XXXXXXX

RN with APC, B. Nursing, RABQSA Lead Auditor

16.00 8.00 25-Sept-13 to 26-Sept-13

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

Peer Review Auditor XXXXXXX

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

4.00

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

20.00 Total Audit Hours 52.00

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

4 of 4 Number of Client Records Reviewed

using Tracer Methodology

1 of 4

Staff Interviewed 4 of 8 Management Interviewed (numeric)

2 of 2 Relatives Interviewed (numeric)

1

Consumers Interviewed 4 of 4 Number of Medication Records Reviewed

4 of 4 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

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

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

Dated this 10 day of October 2013

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

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

Evergreen Care 18 4 0

Executive Summary of Audit

General OverviewEvergreen Care opened on 1 July 2013 providing residential care for up to eighteen residents who will require rest home level care. There are currently four residents in this rest home. The service has a service agreement with Waitemata District Health Board. Two experienced managers have been appointed to manage the rest home for and on behalf of the owner/directors Union Group Ltd. There is a staffing and transitional plan in place to ensure there is adequate staff cover to meet the needs of the residents as the number of residents increases. There is a quality and risk programme that is developed but has not yet been fully implemented. Policies and procedures are developed for all aspects of service delivery. Improvements are required for the following: a complaints register is required and there are eight areas for organisational management requiring further development or implementation. There is one area of improvement ensuring a care plan is amended to reflect current interventions required and the infection programme has a surveillance programme to be further implemented for this service.

1.1 Consumer RightsThe Health & Disability Commissioner (HDC) Code of Health & Disability Services Consumers' Rights (the code) information is readily displayed along with avdocacy support and complaint forms. Residents are provided with information on admission including the code and information on how to apply for a subsidy. Residents report that services are provided in a manner that is respectful of their rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Residents and family/whanau interviewed state they are satisfied with the service provided and report that staff are providing care that is appropriate to their needs. There is documented evidence of notification to family members following adverse events and of any significant change in the resident's condition. During interviews, staff demonstrate an understanding of informed consent and informed consent processes.The service undertakes the complaints process in a manner that complies with Right 10 of the code. The assistant manager confirms there have been no external complaints, issues based audits, coroner`s inquests or police investigations since the service commenced on 1 July 2013. Complaint/compliment forms are accessible in the lounge and reception area. An area of improvement is required to the complaints register.

1.2 Organisational ManagementThe service is managed by a manager and an assistant manager who have worked in the aged care industry for many years. The managers appointed by the owner/directors are fully responsible for the day to day running of the facility and the employment of staff as the number of residents increases. The service has a business plan with an identified philosophy and goals. A quality and risk management plan is developed for 2013 -2014 but has not been fully implemented. A registered nurse is employed for twenty hours per week to provide clinical supervision. A casual registered nurse is available to cover as required. There is a system in place for managing the current annual practising certificates for the two registered nurses, the general practitioner and the pharmacist contracted to this service. There are seven staff employed presently who have been fully orientated and one prospective staff member is presently orientating to a caregiver position. An education programme is developed and implemented and records are maintained by the assistant manager. Four staff were interviewed. There are adequate policies and procedures for this service and seven areas of improvement have been identified where policies, processes and procedures have not yet been fully implemented.

1.3 Continuum of Service DeliveryResidents receive timely, competent and appropriate service delivery from staff who are qualified and/or trained according to their role. Care plans are developed which involves the Registered nurse (RN), care staff, the resident and their family. A review and evaluation of the care provided is conducted by the care staff daily and the RN. Each stage of service provision is provided within required time frames to meet the needs of the resident. Residents' nutritional needs are overseen by the Manager/Cook. Each residents nutritional needs are catered for with input by the RN staff and dietician as required. All meals and menus have been reveiwed by a registered dietitian. Medicine management systems are implemented to ensure safe and timely management of medicines that meet legislative and medicines guidelines. There is one area of required improvement identified ensuring one resident`s care plan is amended to reflect current interventions required.

1.4 Safe and Appropriate EnvironmentThis facility was a rest home previously but the current building owners/managers have totally re-decorated the facility, including new carpets, new vinyl, new furniture and furnishings, new bedding and linen. New equipment for the kitchen and resources are readily available. There are eighteen individual rooms and the rest home has three wings. Toilets and showers are in close proximity to the resident`s rooms. The lounge and dining room is open planned and there is a sunroom at the end of the lounge. The resthome is homely, warm and comfortable with appropriate heating throughout. The front grassed area outside is completely fenced for safety and there is outside garden seating and umbrellas provide shade as required. Emergency and disaster planning has occurred and there are provisions for use in the case of such an emergency. Staff have received training in first aid and basic life support. The laundry/cleaning is managed by the caregivers presently until the number of residents increases. The laundry is not adequate and does not have enough space for seperating the dirty and clean linen. The service provider is awaiting approval from the Waitakere District Council of plans to make structural changes to the exisiting laundry.

2 Restraint Minimisation and Safe PracticeThe service has a commitment to a 'non restraint' policy and philosophy. There is clearly described restraint minimisation and safe practice policy and processes which comply with the standard. The policies and procedures are documented to guide staff. There are no restraints or enablers in use. Training is provided to staff at orientation and this is ongoing.

3. Infection Prevention and ControlInfection control management systems are implemented to minimise the risk of infection to patients, service providers and visitors. The infection control programme implemented meets the needs of the organisation and provides information and resources to inform the service providers on infection prevention and control. Documented policies and procedures are in place for the prevention and control of infection and are readily available for staff access. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. There are two areas of required improvement ensuring surveillance methods are implemented for identified multi-resistent organisms and organisms associated with antimicrobial use and the results for surveillance and special recommendations are to be documentd and reported 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 1Standard 1.1.2 Consumer rights during service delivery FA 0 2 0 0 0 4Standard 1.1.3 Independence, personal privacy, dignity and respect FA 0 4 0 0 0 7Standard 1.1.4 Recognition of Māori values and beliefs FA 0 3 0 0 0 7

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

Consumer Rights Standards (of 12): N/A:0 CI:0 FA: 11 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0 PA Crit: 0UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Criteria (of 48): CI:0 FA:22 PA:1 UA:0 NA: 0

1.2 Organisational Management

Attainment CI FA PA UA NA ofStandard 1.2.1 Governance FA 0 2 0 0 0 3Standard 1.2.2 Service Management FA 0 1 0 0 0 2Standard 1.2.3 Quality and Risk Management Systems PA Low 0 1 7 0 0 9Standard 1.2.4 Adverse event reporting PA Low 0 1 1 0 0 4

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

Organisational Management Standards (of 7): N/A:0 CI:0 FA: 5 PA Neg: 0 PA Low: 2 PA Mod: 0 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.3 Continuum of Service Delivery

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

Standard 1.3.12 Medicine management FA 0 4 0 0 0 7Standard 1.3.13 Nutrition, safe food, and fluid management FA 0 3 0 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 11 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.4 Safe and Appropriate Environment

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

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


2 Restraint Minimisation and Safe Practice

Attainment CI FA PA UA NA ofStandard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 0 6Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 0 1

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


3 Infection Prevention and Control

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

Infection Prevention and Control Standards (of 5): N/A: 0 CI:0 FA: 4 PA Neg: 0 PA Low: 1 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: 40 PA Neg: 0 PA Low: 5 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0Total Criteria (of 219) CI: 0 FA: 81 PA: 12 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Union Group t/a Evergreen CareType of Audit: Certification audit

Date(s) of Audit Report: Start Date:25-Sep-13 End Date: 26-Sep-13DAA: HealthShare LimitedLead Auditor: XXXXXXXStd Criteria Rating Evidence Timeframe1.1.13 1.1.13.3 PA

LowFinding:There is no complaints register ready to record complaints should these arise.

Action:To develop a complaints register for this service.

6 months

1.2.3 1.2.3.1 PALow

Finding:The organisation has a documented quality and risk management system. Service providers interviewed do not understand the implemented quality and risk management system.

Action:To ensure the implemented quality and risk management system is understood by staff.

6 months

1.2.3 1.2.3.4 PALow

Finding:A document control system is documented but has not been fully implemented with review dates on the policies and procedures.

Action:To ensure the document control system to manage the policies and procedures is implemented.

6 months

1.2.3 1.2.3.5 PALow

Finding:Key components of service delivery will be linked to the quality management system but this has not been implemented.

Action:To ensure evidence is provided that the key components of service delivery are explicitly linked to the quality management as required.

6 months

1.2.3 1.2.3.6 PALow

Finding:The quality improvement data system is developed. There is no evidence of implementation or staff education on what data is required.

Action:To ensure appropriate quality improvement data is collected, analysed, evaluated effectively and results fed back to staff and where appropriate residents.

6 months

1.2.3 1.2.3.7 PALow

Finding:A process to measure achievement against the quality and risk management plan 2013 has not been implemented.

Action:To implement a process to measure achievement against the service quality and risk management plan.

6 months

1.2.3 1.2.3.8 PALow

Finding:A new corrective action plan is developed but has not been signed off for implementation.

Action:To ensure a corrective action plan for areas requiring improvement is signed off and implemented.

6 months

1.2.3 1.2.3.9 PALow

Finding:Neither the hazard register or the Hazardous Substance register has been personalised and implemented for this service.

Action:To ensure the hazard register and the hazardous substance register is personalised for this service and implemented.

6 months

1.2.4 1.2.4.2 PALow

Finding:Staff understands their statutory and/or regulatory obligations in relation to essential notification reporting and correct authority to notify excluding the requirement as per the service agreement to notify the WDHB and HealthCert.

Action:To include in the policy and procedures that notification of essential reporting is required and the WDHB and HealthCert are to be advised.

6 months

1.3.8 1.3.8.3 PALow

Finding:One care plan is not amended to reflect the current care requirements for that resident.

Action:Ensure all care plans are amended as necessary to reflect the residents current care requirement needs.

6 months

3.5 3.5.1 PALow

Finding:EBSL is not documented as part of the surveillance data.

Action:Ensure surveillance methods are implemented for identified multi-resistant organisms and organisms associated with antimicrobial use.

6 months

3.5 3.5.7 PALow

Finding:The infection control report is not tabled at the staff meetings and discussion around infection control is therefore not occurring.

Action:Discuss surveillance data at staff meetings with quality improvement if relevant.

6 months

Continuous Improvement (CI) Report

Provider Name: Union Group t/a Evergreen CareType of Audit: Certification audit

Date(s) of Audit Report: Start Date:25-Sep-13 End Date: 26-Sep-13DAA: HealthShare LimitedLead Auditor: XXXXXXX

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS

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

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

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

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

How is achievement of this standard met or not met? Attainment: FAStaff interviewed (RN, two of two care staff, assistant manager, manager/cook) demonstrate knowledge of the code of Health and Disability Services Consumers' Rights (the code) and how to apply this as part of their everyday practice. Staff interviewed confirm they have received education on the code and this finding is supported by the review of the two day orientation programme and in-service education records sighted. Visual observations during the audit indicate staff are respectful of residents and incorporate the principals of the code in their practice. The requirements of the ARC service agreement are met.

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

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

Finding Statement

Corrective Action Required:

Timeframe:

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

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


How is achievement of this standard met or not met? Attainment: FAInformation on the code of rights and the Nationwide Health and Disability Advocacy Service (NHDAS) are clearly displayed and are included in the residents' information booklet. Interview with the Registered Nurse (RN) confirms that the contents of the information booklet is discussed with the relatives and residents on admission. Signed admission agreements are in four of the four residents' files reviewed. Four of four residents and one family member interviewed confirm that the code, the advocacy service and the complaints process was discussed and explained to them on admission along with the informed consent process. The requirements of the ARC service agreement are met.

Criterion 1.1.2.3 Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service.


Finding Statement


Timeframe:

Criterion 1.1.2.4 Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.


Finding Statement


Timeframe:

STANDARD 1.1.3 Independence, Personal Privacy, Dignity, And RespectConsumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

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


How is achievement of this standard met or not met? Attainment: FAThe service provider policies and procedures were reviewed for spirituality, cultural safety, informed consent, privacy and dignity and abuse and neglect. Staff receive education during orientation (21 and 22 May 2013) and ongoing training on these topics is planned. Staff interviewed confirm they encourage resident independence by asking residents if they want assistance with their cares. All staff interviewed confirm they provide residents with privacy by shutting doors prior to cares being given, knocking on doors before entering residents' rooms, keeping all information regarding the resident in the resident's file and holding discussions in either their bedrooms or a quiet room as evident by observation during the day. Four of four residents interviewed confirm they are receiving services appropriate to their needs, that staff treat them with dignity and respect and are kind, caring and encourage them to be as independent as they are able to be. Residents interviewed confirm their privacy is respected and that they wear their own clothing and have appropriate storage facilities in their rooms. Residents' religious beliefs are documented on the assessment and care plan. Residents and one family member interviewed state that staff assist residents to attend church services either in the community or in the facility if required. The RN and two of two care staff interviewed confirm they respect residents' spiritual and cultural needs. Visual inspection of the facility provides evidence that residents have dedicated areas to keep their personal property and possessions and the rooms are personalised. Communal hygiene facilities display appropriate signage and a safe locking system. The requirements of the ARC service agreement are met.

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


Finding Statement


Timeframe:

Criterion 1.1.3.2 Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

STANDARD 1.1.4 Recognition Of Māori Values And BeliefsConsumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i


How is achievement of this standard met or not met? Attainment: FAThe service provider documentation reviewed includes appropriate Māori protocols and provides guidelines for staff in care provision for Maori residents. The documentation is referenced to the Treaty of Waitangi and includes guidelines on partnership, protection, participation and equality with the inclusion of Te Whare Tapa Wha. There is currently one resident who identifies as Māori. This is reflected in the resident’s assessment and care planning documents. Interview with the resident confirms there are no additional cultural needs requested. Access to Māori support and advocacy services is available if required. Systems are in place to allow for review processes including input from family/whanau as appropriate, for residents who identify as Māori. The RN and two of two care staff interviewed confirm an understanding of cultural safety in relation to care. The education is provided in the orientation programme and annually through the in-service program. Education records are sighted. The requirements of the ARC service agreement are met.

Criterion 1.1.4.2 Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.


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


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


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

Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d


How is achievement of this standard met or not met? Attainment: FAThe service provider documentation provides evidence that appropriate, culturally safe practices are implemented, including respect for residents' cultural and spiritual values and beliefs. The service provider’s cultural policy has guidelines for interacting with residents of differing ethnicity and/or culture. Resident files sampled demonstrate that admission documentation identifies ethnicity, cultural and spiritual requirements and family/whanau contact details. Residents' care plans include interventions that specify how the individual cultural values and beliefs are met e.g. food preferences. The RN and two of two care staff interviewed confirm an understanding of cultural safety in relation to care and that processes are in place to ensure residents have access to appropriate services to ensure their cultural and spiritual values and beliefs are respected. The resident and their family/whanau are involved in the assessment process on admission. This includes assessments of their individual values and beliefs which are then documented in the care plan. Four of four residents and one of one family member interviewed confirm that their values and beliefs are respected by staff. The requirements of the ARC service agreement are met.

Criterion 1.1.6.2 The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs.


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

ARHSS D16.5e


How is achievement of this standard met or not met? Attainment: FAThe service provider policies and procedures in place outline the safeguards to protect residents from abuse, including discrimination, coercion, harassment, and exploitation, along with actions to be taken if there is inappropriate or unlawful conduct. Policies reviewed include complaints policies and procedures. Expected staff practice is outlined in job descriptions. Job descriptions and employment contracts detail responsibilities and boundaries. Four of four residents and one GP interviewed report that staff maintain appropriate professional boundaries. Care staff interviewed demonstrate an awareness of the importance of maintaining boundaries and processes they are required to adhere to.

Criterion 1.1.7.3 Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.


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STANDARD 1.1.8 Good PracticeConsumers receive services of an appropriate standard.

ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c


How is achievement of this standard met or not met? Attainment: FASystems are in place to ensure service providers promote good practice within the facility. The service provider’s policies and procedures reflect good practice and are available for staff (refer to criteria 1.2.3.1 for non-compliance and risk rating). Evidence based guidelines, treatment protocols, reference material and resources are utilised by staff. The manager and assistant manager interviewed confirms that staff are supported in professional development and states the organisation will fund staff to access education through external courses when resident numbers increase. The facility provides staff access to education through orientation and the in-service programme. Staff have access to mentoring and peer supervision and there is evidence of professional networking. The

RN, two of two care staff and the cook confirm that the facility provides a resourceful and supportive environment. Four of four residents and one family member interviewed confirm they are happy and satisfied with the care provided at the facility. The requirements of the ARC service agreement are met.

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


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STANDARD 1.1.9 CommunicationService providers communicate effectively with consumers and provide an environment conducive to effective communication.

ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 ARHSS A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3


How is achievement of this standard met or not met? Attainment: FAThe service provider has an open door policy and relatives and residents can call and discuss issues at any time. One family member interviewed states that visitors are welcome at any time. The incident and accident forms have an area to document if the relatives have been contacted. This was sighted as being completed on the five of five incident and accident forms audited. There is access to interpreter services and advocacy support services if required. Interviews with one family member confirm they are advised immediately if there is a change in their family member's health status and that they have been involved in every aspect of care delivered to their relative. The requirements of the ARC service agreement are met.

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


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


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

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


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

The RN interviewed confirms that information on informed consent is discussed with the relatives and residents on admission and appropriate forms are shown to them at this time. The RN, assistant manager and two of two care staff interviewed demonstrate an understanding of informed consent processes. Four of four residents interviewed confirm they have been made aware of and understand the principles of informed consent and confirm that their choices and decisions are acted on. All four residents' files reviewed demonstrate written and verbal discussions on informed consent have occurred and evidence signed informed consent forms. Four of four residents have an advanced directive in place. These are signed and dated by the resident and GP. The requirements of the ARC service agreement are met.

Criterion 1.1.10.2 Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.


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


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


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STANDARD 1.1.11 Advocacy And SupportService providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f


How is achievement of this standard met or not met? Attainment: FAThe service provider recognises the right of residents to access advocacy or support services of their choice. There are appropriate policies regarding advocacy and/or support services. Advocates can be accessed through the Nationwide Health and Disability Advocacy Service or through the District Health Board if required. Information on how to contact advocacy services is clearly accessible to residents. The Nationwide Health and Disability Advocacy Service brochure is provided to the resident and their famliy on admission. These brochures are also displayed throughout the facility.Training on advocacy and support (code of rights) is provided to staff during orientation and in the ongoing in-service programme. The requirements of the ARC service agreement are met.

Criterion 1.1.11.1 Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.


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

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


How is achievement of this standard met or not met? Attainment: FAThere is a visitors' policy and guidelines available to ensure resident safety and well-being is not compromised by visitors to the service. Access to community support/interest groups is facilitated for residents as appropriate. The manager and assistant manager is available to take residents on community visits and out to appointments.Four of four residents and one family member interviewed confirm they can have access to visitors of their choice, and confirm they/their relative is supported to access services within the community. There are three visitors at the facility during this audit. The requirements of the ARC service agreement are met.

Criterion 1.1.12.1 Consumers have access to visitors of their choice.


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


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

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


How is achievement of this standard met or not met? Attainment: PA LowThe complaints policy and procedure is clearly documented in the quality manual dated 10 Feb 13. The complaints process is fair and complies with Right 10 of the Code. The process for suggestions, complaints and feedback is also documented in the 'Information for living at Evergreen Care Booklet' provided to all residents/family/whanau on admission to this service. The complaints forms are accessible and sighted in the lounge/reception area. The complaints procedure is also documented on the complaints/compliments form sighted. The address and phone number for this service provider is documented on the bottom of the form. Three of four residents interviewed have a good understanding of the procedure and who to talk to if they have any concerns. The fourth resident has mild dementia and was happy when interviewed. Staff interviewed the registered nurse and two caregivers have a good understanding of the complaints procedure. No complaints have been received since the service commenced operation 01 July 13. An improvement is required to the documentation and implementation of the complaints register 1.1.13.3.

Criterion 1.1.13.1 The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.


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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThere is a complaints policy and procedure. No complaints have been received since the service commenced operation. There is no complaints register able to be evidenced.

Finding StatementThere is no complaints register ready to record complaints should these arise.Corrective Action Required:To develop a complaints register for this service.

Timeframe:6 months

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

STANDARD 1.2.1 GovernanceThe governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

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


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

The mission statement has been developed and is clearly documented in the quality manual. The sighted business plan discussed with the assistant manager is also documented in the service information pamphlet and the information booklet 'Information for Living at Evergreen Care'. The mission statement is 'To provide a quality, homely environment in which the elderly may live in an atmosphere of respect and friendliness. To have their physical and psychological needs met regardless of culture, race and creed. To achieve this, the service will provide excellent services for the residents to live in a stress free environment where they can relax and feel comfortable'. The service philosophy is clearly documented in the information booklet and has seven objectives. The manager has worked in the aged care sector for approximately twenty years and has extensive knowledge of the high quality care to be provided. The manager gained experience when acting in management roles, assisting managers and as a quality management consultant and ensuring quality and risk systems are in place for other like services. The manager interviewed has a banking and marketing background which is pivotal in this role as manager of this aged care residential care service. The manager reports directly to the owner directors.The requirements of the ARC service agreement are met.

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


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


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

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


How is achievement of this standard met or not met? Attainment: FAThe assistant manager interviewed is also experienced and has a banking and financial background. The assistant manager`s personal record is available and sighted. The assistant manager has managed three aged care facilities over the last three years owned by one company. Ongoing education in business management (Human Resource and Marketing) has been completed. The assistant manager also has experience in administration.The requirements of the ARC service agreement are met.

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


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STANDARD 1.2.3 Quality And Risk Management SystemsThe organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

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


How is achievement of this standard met or not met? Attainment: PA LowEvergreen Care has a quality and risk system documented with clear objectives for 2013 for this service. This has been developed by Care Association NZ Ltd (CANZ) as a quality assurance package. The quality and risk system documented is inclusive of service management, health and safety and infection prevention and control. The developed policies are aligned and reference good practice and legislative requirements as per 1.1.8 and a schedule has also been developed for reviewing the policies and procedures at the time frames stipulated. It is noted in the policies that any amendment, correction or up-dating of the quality assurance manual contents will need to be signed off appropriately by the quality assurance manager who is the assistant manager for this service. The registered nurse and caregivers interviewed have minimal understanding of the quality and risk management system implemented and require further education for collecting the required data for the quality and risk programme. An area of improvement is required to ensure staff receive education on the quality and risk management system requirements 1.2.3.1. The quality manual has been personalised with the name of the facility on each page of the manual dated 10 Feb 2013 but no review dates on policies are evident 1.2.3.4.There is no evidence of quality meetings including and linking all the key components of service delivery into the quality and risk system 1.2.3.6 and 1.2.3.7. A new corrective action form has been re-developed by the assistant manager but this has not been signed off or implemented. 1.2.3.8. The hazard policies and procedures are documented in the quality and risk management system but the hazard register and hazardous substance registers ae not personalised for this facility and implemented 1.2.3.9.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe service has a documented quality and risk system. The policies and procedures are being implemented. Staff interviewed do not understand the requirements of the quality and risk management system.

Finding StatementThe organisation has a documented quality and risk management system. Service providers interviewed do not understand the implemented quality and risk management system.

Corrective Action Required:To ensure the implemented quality and risk management system is understood by staff.

Timeframe:6 months

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


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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe 'Control of documents and Records Policy' sighted is developed dated 10 Feb 13. The objective of the quality system is formally identified and documented to guide staff. The document control system is documented but has not been fully implemented. The quality procedure manual has a quality index to guide staff. There are no review dates recorded on the policies or footer of policies and procedures sighted. All policies and procedures are dated 10 Feb 13.

Finding StatementA document control system is documented but has not been fully implemented with review dates on the policies and procedures.Corrective Action Required:To ensure the document control system to manage the policies and procedures is implemented.

Timeframe:6 months

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

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe key components of service delivery inclusive of event reporting, complaints management, infection control, health and safety and restraint minimisation are documented in the quality and risk system. The assistant manager verified that this has not occurred as yet.

Finding StatementKey components of service delivery will be linked to the quality management system but this has not been implemented.

Corrective Action Required:To ensure evidence is provided that the key components of service delivery are explicitly linked to the quality management as required.

Timeframe:6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe manual contains the audit action forms and the audit/survey policy and procedure. The service audit/survey schedule with timeframes eg six weekly, six monthly and annually is documented for 2013. Staff interviewed were unable to provide evidence of what quality data is to be collected. More education is needed for staff to complete the required documentation appropriately for example falls, incidents and infection control data as some forms sighted are completed incorrectly.

Finding StatementThe quality improvement data system is developed. There is no evidence of implementation or staff education on what data is required.

Corrective Action Required:To ensure appropriate quality improvement data is collected, analysed, evaluated effectively and results fed back to staff and where appropriate residents.

Timeframe:6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowA process to measure achievement against the quality and risk management plan is documented in the Quality Assurance Manual dated 10 Feb 13. No meeting minutes sighted or Agenda.

Finding StatementA process to measure achievement against the quality and risk management plan 2013 has not been implemented.

Corrective Action Required:To implement a process to measure achievement against the service quality and risk management plan.

Timeframe:6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowExamples of forms are documented in the quality assurance manual sighted. The assistant manager interviewed provided a form developed for this purpose of addressing areas requiring improvement in order to meet the specified standard and/or requirements but this has not been signed off for implementation.

Finding StatementA new corrective action plan is developed but has not been signed off for implementation.Corrective Action Required:To ensure a corrective action plan for areas requiring improvement is signed off and implemented.

Timeframe:6 months

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

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

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowA policy has been developed to ensure all existing and potential hazards/risks are identified. The procedure is to guide staff. The hazard management process is available as well on a flow chart sighted which clearly outlines the process. Hazard identification forms are developed for all areas of the service eg care services, external, cleaning/laundry and kitchen. Hazard identification forms are available for staff to complete should a hazard be identified to include the type of hazard, description of the hazard, immediate action and if the hazard is eliminated, isolated or minimised.

Finding StatementNeither the hazard register or the Hazardous Substance register has been personalised and implemented for this service.

Corrective Action Required:To ensure the hazard register and the hazardous substance register is personalised for this service and implemented.

Timeframe:6 months

STANDARD 1.2.4 Adverse Event ReportingAll adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner.

ARC D19.3a.vi.; D19.3b; D19.3c ARHSS D19.3a.vi.; D19.3b; D19.3c


How is achievement of this standard met or not met? Attainment: PA LowThe assistant manager and the registered nurse interviewed understand the statutory and/or regulatory obligations to essential reporting. The form sighted 'For Notice of Uncontrollable Event' covers for example infection outbreak, pandemic, loss of power/water/essential services, extra ordinary action, other events eg sentinel event, coroner`s case. The contact details for health and safety obligations eg notification of serious harm accidents in the workplace to Ministry of Business, Innovation and Employment (MBIE) is documented and a flow chart is available to guide staff. Infection control notifiable diseases are to be reported to the medical officer of health. An improvement is required to reporting to the DHB and HealthCert as per the ARC contract.

Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe staff interviewed understood their statutory and/or obligations in relation to essential notification reporting excluding the requirement as per the service agreement to notify the WDHB and HealthCert.

Finding StatementStaff understands their statutory and/or regulatory obligations in relation to essential notification reporting and correct authority to notify excluding the requirement as per the service agreement to notify the WDHB and HealthCert.

Corrective Action Required:To include in the policy and procedures that notification of essential reporting is required and the WDHB and HealthCert are to be advised.

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6 months

Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.


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STANDARD 1.2.7 Human Resource ManagementHuman resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

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


How is achievement of this standard met or not met? Attainment: FAThe manager and the assistant manager are responsible for the employment of staff for this service. The assistant manager interviewed explained the staff roster. Job descriptions are available for each staff position. One additional staff member has been a volunteer but is commencing orientation in readiness for when the number of residents increases and will work as a caregiver/activities person. (refer to 1.3.7.1) A two day orientation was provided 21 and 22 May 2013 and seven newly appointed staff completed this orientation before the service commenced operation. The relief cook has been orientated to this role and was interviewed during the audit. The orientation programme covered health and safety, infection control, facility, staff competencies, fire evacuation training, restraint, complaints, house rules, cultural awareness, safety and advocacy. A full checklist is signed off by the registered nurse or the manager when fully completed. Seven of eight staff files sighted verified that orientation had been completed prior to the service commencing. A staff training register is available and a record of each staff members education is recorded. The manager has records of each training session, staff who attended and the date and name of facilitator is recorded. Comments and feedback are encouraged.

The education programme May to December is documented clearly and evidences in-services for example 13 July 13 medication management, 23 July 13 communication, reporting and documentation, 12 Aug 13 dementia, delirium, depression and 16 Sept 13 head to toe & code of rights. All staff have completed first aid training and certificates were sighted.Professional qualifications are valid and sighted for the two registered nurses employed. One is employed twenty hours a week (on leave presently) and one registered nurse is casual and is covering the facility presently. Seven of eight staff records are available and reviewed. Records are well presented. Currently the staff consists of the manager/cook, assistant manager, two registered nurses (one permanent RN and one casual RN), one relief cook (two days a week) four caregivers one of whom resigned as from last week and one volunteer who is orientating and will take on the caregiver role and activities. The staff are providing activities for the four residents presently until the numbers increase.The requirements of the ARC service agreement are met.

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


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


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


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Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.


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STANDARD 1.2.8 Service Provider AvailabilityConsumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

ARC D17.1; D17.3a; D17.3 b; D17.3c; D17.3e; D17.3f; D17.3g; D17.4a; D17.4c; D17.4d; E4.5 a; E4.5 b; E4.5c ARHSS D17.1; D17.3; D17.4; D17.6; D17.8


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

Currently there are four residents. The registered nurse covers twenty hours per week but is currently on leave. The casual registered nurse is covering these hours for the duration of the fulltime RNs leave (previously arranged prior to the service opening). The staff roster was sighted and explained by the assistant manager interviewed. There is a documented rationale 'staffing and transitional plan' available for staffing and staff mix which will change as the number of residents increases. When ten residents are admitted to the rest home, a second caregiver will be added and a cleaner/laundry person will be employed. The caregivers perform the cleaning and laundry duties on their respective shifts. The caregivers complete twelve hour shifts. The staff available for interview include the registered nurse, the relief cook, the manager/cook and two caregivers. The staff reported that there is adequate cover at all times. The RN is on call at all times. The staff provide activities for the four residents during the day and the residents interviewed enjoyed this. The one care giver who resigned will be replaced immediately. Cover is available until replaced.The requirements of the ARC service agreement are met.

Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.


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STANDARD 1.2.9 Consumer Information Management SystemsConsumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

ARC A15.1; D7.1; D8.1; D22; E5.1 ARHSS A15.1; D7.1; D8.1; D22


How is achievement of this standard met or not met? Attainment: FAReview of the four of four residents` records demonstrates that all had been assessed by the Needs Assessment Service Co-ordinators at Waitemata District Health Board prior to admission. The detail is adequate and records information important for ongoing care and support being provided to the individual residents.

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

Criterion 1.2.9.1 Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.


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


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


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


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

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

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


How is achievement of this standard met or not met? Attainment: FADocumented processes are implemented to ensure residents' entry into the service has been facilitated in a competent, equitable, timely and respectful manner. There are currently four residents admitted to the facility. Four of four residents' files reviewed and staff interviewed confirms all residents have been referred by NASC. An information booklet and brochure is developed for residents and their family/whanau that explains the entry criteria and assessment process. The admission agreement defines the scope of service and includes all of the contractual requirements. Four of four residents and one family member interviewed confirm that during admission, staff explain the information and allow time for discussion. The service provider is actively promoting the facility to increase resident numbers. The needs assessors at the District Health Board are informed of the levels of service available at this facility and relevant community agencies are also informed. The requirements of the ARC service agreement are met.

Criterion 1.3.1.4 Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.


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STANDARD 1.3.2 Declining Referral/Entry To ServicesWhere referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate.

ARHSS D4.2


How is achievement of this standard met or not met? Attainment: FAA process to decline resident entry to the service is documented which states that the referral source, resident, their family/whanau and their GP will be informed of the reason for this. The RN, manager and assistant manager interviewed state residents' will be declined entry if a bed is not available at the time or if the level of care required exceeds that of rest home level care. One example is sighted where the process is implemented and support is provided to a resident and their family/whanau to access more suitable options for placement.

Criterion 1.3.2.2 When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services.


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STANDARD 1.3.3 Service Provision RequirementsConsumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

ARC D3.1c; D9.1; D9.2; D16.3a; D16.3e; D16.3l; D16.5b; D16.5ci; D16.5c.ii; D16.5e ARHSS D3.1c; D9.1; D9.2; D16.3a; D16.3d; D16.5b; D16.5d; D16.5e; D16.5i


How is achievement of this standard met or not met? Attainment: FAThe facility operates 24/7. Service delivery is overseen by the RN. Staff interview and review of resident files identified that an assessment and initial care plan is completed on admission by the RN. Desired outcomes and goals are recorded in the care plan. A GP medical review is within two days of admission and evident as monthly thereafter. Identified need and appropriate intervention as a result of the medical consultation is recorded in the care plan. A full care plan is completed within three weeks of admission by the RN.

Four of four residents' files reviewed provide evidence that assessment, planning, provision and evaluation occurs. Four of four residents and one family member interviewed confirm their input into service delivery planning and assessments. Family/whanau communication is recorded, progress notes are recorded and the authors are identified. The requirements of the ARC service agreement are met.

Tracer Methodology. XXXXXX This information has been deleted as it is specific to the health care of a resident.

Criterion 1.3.3.1 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.


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Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.


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


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

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


How is achievement of this standard met or not met? Attainment: FAAll staff interviewed confirm that the RN admits new residents on the day of admission, and confirms access and entry processes are followed. Residents' files reviewed demonstrate full nursing and medical assessments for the level and type of care required. Residents' needs, desired outcomes and goals are identified and recorded. As documented in residents care plans, the care staff monitor the resident daily to identify additional support requirements and these are reported to the RN. Appropriate resources and equipment are available. Staff and residents' interviewed state that assessments are conducted in safe, private and appropriate settings that includes the resident's room.The requirements of the ARC service agreement are met.

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


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STANDARD 1.3.5 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: FAThe residents' care plans reflect input by the RN, GP and care staff. Staff interviewed state that input by hospital and allied health services occurs as required and may include podiatrist, physiotherapists, occupational therapists, dietitican, specialists and district health nurses. The RN works closely with the GP regarding the residents' medical issues and concerns. The GP interviewed confirmed that prescribed treatments are followed by staff. Clinical handover between shifts occurs. The verbal handover includes a physical round of residents. There is documented evidence that residents' and their family/whanau have input into the development and review of care plans. Goals are identified by the resident and family and service providers. Four of four residents' and one family member interviewed state they have input into care planning and that they are satisfied with the care provided. Risk assessments are completed on admission and there is evidence of reassessment as required. Four of four residents' care plans reviewed are client focused, integrated and promote continuity of care.The requirements of the ARC service agreement are met.

Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.


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Criterion 1.3.5.3 Service delivery plans demonstrate service integration.


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

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


How is achievement of this standard met or not met? Attainment: FAThe service provider has documented and implemented policies and procedures that guide staff with service delivery and care interventions. Four of four resident files reviewed show evidence of interventions relating to the residents' assessed needs and desired outcomes. Care interventions are holistic and are provided by the multidisplinary team (RN, care staff, GP and cook). All patient information can be accessed by the multidisciplinary team members. Care staff interviewed confirm they use the resident's care plan, are directed by the RN and report any change or concern identified and that this is recorded. Progress notes are documented and handover occurs each shift. There is a process to identify and respond to variances/trends e.g. accident / incident reporting system. In all four resident files reviewed there is evidence sighted of links to other services. The requirements of the ARC service agreement are met.

Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.


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STANDARD 1.3.7 Planned ActivitiesWhere specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service.

ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h


How is achievement of this standard met or not met? Attainment: FAResidents have an activities assessment and social history completed on admission by the RN or care staff member. A care plan is developed and reflects the client’s preferences and capability to participate. There is evidence of monthly evaluations of activities care plans by the RN. Staff interviewed state that activities currently include social interaction, games, music/dance and individual resident coffee outings. Three of four residents interviewed state that they enjoy the activities being offered. Staff interviewed confirm that activities are provided on a daily basis as time permits. Residents were observed playing card games with a staff member on the first day of audit. On the second day of audit, residents were observed watching television with staff. The service provider intends to employ a delegated activities coordinator to implement a planned activities programme when resident numbers increase to ten.

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

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

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STANDARD 1.3.8 EvaluationConsumers' service delivery plans are evaluated in a comprehensive and timely manner.

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


How is achievement of this standard met or not met? Attainment: PA LowResidents' files reviewed provide evidence that some evaluation of care plans has occurred. The evaluation is completed by the RN. One family member interviewed states they are notified of any changes in their relatives' condition. Communication with family/whanau is documented in residents' files reviewed. Resident interviews confirm their participation in care plan evaluations. There is one area for improvement in this standard. On one occasion where progress is different from expected, the care plan is not amended to reflect the current intervention required for that resident (refer to criteria 1.3.8.7).

Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.


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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe RN completed a falls risk assessment and pain assessment on one resident who suffered a fall. Required intervention as a result of the assessments was noted in the progress notes and reported at handover. Medical intervention included the initiation of PRN pain relief.

Finding StatementOne care plan is not amended to reflect the current care requirements for that resident.Corrective Action Required:Ensure all care plans are amended as necessary to reflect the residents current care requirement needs.

Timeframe:6 months

STANDARD 1.3.9 Referral To Other Health And Disability Services (Internal And External)Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4


How is achievement of this standard met or not met? Attainment: FAThe service provider has policies and procedures that provide staff guidelines for referral to other health and disability services. The RN with the GP facillitates the referral process. The RN and GP interviewed confirmed residents are advised of their options to access other health and disability services. Three of four residents have been referred to supporting health services. External referrals evident in the residents' files reviewed include the physiotherapist and podiatrist. Assistance to transport is available for residents to attend hospital, medical and specialist appointments. The requirements of the ARC service agreement are met.

Criterion 1.3.9.1 Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.


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

ARC D21 ARHSS D21


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

Criterion 1.3.10.2 Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives.


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Std Criteria Rating Evidence Timeframe

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

ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d


How is achievement of this standard met or not met? Attainment: FAAppropriate systems are in place for safe medication management. Service provider policies and procedures cover all aspects of safe medicine practice relevant to the service level. The RN is responsible for the overall management of medication. Care staff administer all medicines and are deemed competent to do so. Training records are sighted.Medicines are securely stored in the medicine trolley in the locked medications room. Staff interviewed understand the requirements relating to the safe management of controlled drugs. A controlled drugs register is available. There were no controlled drugs in use on the day of audit. The service provider uses a blister pack system of medicine management. Medicines documentation is complete. Appropriate storage is sighted. The received medicines are checked by the RN for accuracy when the packs or medicines are delivered. Each resident has an individual medicines profile and medicine prescription form, an individually dispensed blister pack for their medicines and a medicine signing sheet. One signing sheet is used for non-packed items, PRN medicines and short course medicines. Four of four resident’s medicine charts are reviewed. Medicines are prescribed and individually signed by the GP. Signing charts are correctly documented by staff after each administration. Allergies and sensitivities are clearly identified. Photo identification is sighted in all medication files. All care givers administering medication have been assessed as competent to do so by the RN. A formal review of medicine management competencies is scheduled for staff annually. There is a system implemented that ensures the safe, self-administration of medicines for residents. Two residents are assessed as being competent to self medicate (Inhaler, creams). Reassessment for safety is ongoing by the RN and is also reviewed at the residents three monthly medical review. Unused or expired medicines are returned to the pharmacy.The facility opened 01 July 2013. The process of three monthly medication reviews by the GP is not yet evident.

Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.


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


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


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Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.


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STANDARD 1.3.13 Nutrition, Safe Food, And Fluid ManagementA consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c


How is achievement of this standard met or not met? Attainment: FAFood, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines appropriate to the resident group. An individual dietary assessment is performed on each individual resident on admission to identify any special needs and preferences. Residents who have additional or modified nutritional requirements have these met by the service. There is a dietary profile available in the kitchen for each resident which identifies all dietary requirements (sighted). The cook maintains a record of people's likes and dislikes and endeavours to give alternative food if possible. Four of four residents interviewed express satisfaction with the meals and drinks available. Weight charts observed in four of four residents' files identify that residents' weights are monitored. There is a three weekly rotating menu approved by a dietitian (June 2013) in line with the nutritional guidelines for the older persons in long term care environment. Meals are provided according to individual likes and dislikes of the residents. Additional snacks are available. Two cooks are employed to provide food services. The manager, also the cook works five days per week as cook. The assistant cook works two days per week. Both have been trained (basic food hygiene) and orientated. There is a cleaning schedule sighted. Visual inspection of food storage and food preparation areas indicate food is stored in the fridges, freezers or pantry available. Food is covered and dated and stock is rotated. Fridge and freezer temperature monitoring records are maintained by the kitchen staff. The requirements of the ARC service agreement are met.

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


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


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


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OUTCOME 1.4 SAFE AND APPROPRIATE ENVIRONMENTServices are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.

These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3.STANDARD 1.4.1 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: FAPolicies and procedures are documented and implemented for health and safety inclusive of management of waste and hazardous substances dated 10 Feb 13. Minimal supplies are available presently and storage is minimal. A locked cupboard is available for additional supplies in the medication room. The service has an arrangement with the contracted pharmacy of choice for sharpes collected in the yellow sealed container is to be collected by the pharmacy and they will be responsible for the disposal due to the size and nature of this service. The yellow bag system will be utilised if and when required for hazardous waste. The service recycles rubbish and the Waitakere City Council has a specific day for collection (Thursday every fortnight). The green bin system is contracted to a private company for collection weekly. Personal protective equipment (PPE) is readily available such as gloves, goggles, aprons, hats for the kitchen, masks and isolation gowns if required. One resident has ESBL and signage and standard precautions is practiced by staff. The registered nurse is the designated health and safety officer for this service. Staff are performing the cleaning and laundry duties presently on their respective shifts until the resident numbers increase. Education has been provided to all caregivers. The National Poison Centre contact details are documented for urgent information and non-urgent information should this be needed.The requirements of the ARC service agreement are met.

Criterion 1.4.1.1 Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.


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Criterion 1.4.1.6 Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.


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STANDARD 1.4.2 Facility SpecificationsConsumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a; D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4


How is achievement of this standard met or not met? Attainment: FAThe building warrant of fitness expires 28 September 2013. The fire equipment has been checked by Chubb initially and First Fire is now contracted. The fire evacuation approval letter is dated the 30 May 13. The health and safety policy is clearly documented 10 Feb 13. All electrical equipment checks have been completed prior to the service commencing 1 July 13. All legislative requirements have been met. Equipment is tagged and the hot water is monitored by the manager and the records indicate safe ranges. The facility has eighteen individual resident`s rooms with four rooms currently occupied. The rooms are adequate in size for those residents requiring the use of walking frames or wheelchairs (nil presently). There are handrails in the hallways in the three wings. There is a front grassed area with a garden and pergola available. Table and chairs and an umbrella setting is available, appropriate and practical for the elderly to sit outside in the warmer weather. Two budgies are in a cage in the entranceway. There is a fence around the rest home. An enclosed area at the end of the lounge is visible and residents can observe two streets as located on a corner site. Residents interviewed are pleased with the facility and the environment being so comfortable, clean and tidy.

The requirements of the ARC service agreement are met.

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


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Criterion 1.4.2.4 The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.


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


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STANDARD 1.4.3 Toilet, Shower, And Bathing FacilitiesConsumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

ARC E3.3d ARHSS D15.3c


How is achievement of this standard met or not met? Attainment: FAThere are three toilets, one staff/visitors toilet and two showers. All are in close proximity of the residents rooms and meet the requirements and needs of the residents. Privacy is maintained. Signage is visible on all toilets and bathrooms. The facility has been renovated prior to 1 July 13 with new flooring and all surfaces can be easily cleaned. The residents interviewed report satisfaction with the facilities available.The requirements of the ARC service agreement are met.

Criterion 1.4.3.1 There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.


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STANDARD 1.4.4 Personal Space/Bed AreasConsumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii


How is achievement of this standard met or not met? Attainment: FAThere are three wings. One wing has six smaller sized rooms, one wing has two large rooms and two medium size rooms and the remaining wing has eight larger rooms. There is adequate space for residents who require the use of walking aides and/or wheelchair access. The four residents interviewed enjoy their rooms but spend most of the day in the lounge/dining area.The requirements of the ARC service agreement are met.

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


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

ARC E3.4b ARHSS D15.3d


How is achievement of this standard met or not met? Attainment: FAThere is adequate access provided to a large lounge with a television and an open plan dining room. The lounge has comfortable chairs for the elderly and one bed chair arrangement on a trial basis presently. There are adequate dining room tables and chairs available. There is also a sunroom lounge which is a separate area at the end of the lounge. A quiet area with comfortable seating arrangements. Paintings, cushions and ornaments provides a homely environment. The lounge is appropriate for entertainment and is very warm with heating provided by a heat pump and wall heaters in the hallways of each wing. Residents interviewed feel safe and all areas are accessible.

The requirements of the ARC service agreement are met.

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


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STANDARD 1.4.6 Cleaning And Laundry ServicesConsumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e


How is achievement of this standard met or not met? Attainment: FAThe laundry and cleaning policies are available to guide staff. The caregivers are currently responsible for the laundry and cleaning of the rest home on their respective shifts presently until the number of residents increases. Chemicals are stored appropriately. The products from the cleaning trolley are locked up when not in use as there is no designated room for the actual trolley until the laundry is renovated. A sluice has been installed in the laundry. The Jasco system is utilised and a wall pump system is situated in the locked medication room. Safety data sheets are available with product information and first aid measures and sighted in the laundry and the kitchen. The manager monitors the cleaning and laundry processes for effectiveness on a daily basis.The requirements of the ARC service agreement are met.

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


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


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

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


How is achievement of this standard met or not met? Attainment: FACivil defence resources are available in the case of an emergency. Water containers are checked regularly, extra blankets, torches, batteries are available. Additional food is stored for this purpose. A mini gas barbecue and gas bottle is readily available. All staff have received training during the two days orientation prior to the rest home commencing this service on 1 July 13. Training and orientation was held 21 and 22 May 13 which covered all emergencies and fire evacuation procedures.

The fire register is maintained and is kept at reception. The fire warden vest is available at the nurses’ station. There are three fire cells. A fire drill was held with the fire service 22 May 2013 and another is due in November 13. The fire evacuation approval letter from the fire service was sighted dated the 30 May 13. A record is maintained of when the drills occur by the assistant manager. The contracted service provider checks the building and resources such as the smoke detectors, sprinkers, extinguishers on a monthly basis. The sprinklers and fire alarm are directly connected to the fire service. The smoke detectors are connected to the contracted service provider. Fire exit signage was sighted and the assembly point documented. Staff interviewed one registered nurse, two caregivers and the relief cook are well informed of emergency procedures and their responsibilities in an emergency situation.There is a nurse call sytem which is working effectively. The room number is displayed in the nurses’ station until the bell is responded to and turned off by a staff member outside the residents room.The staff on duty are responsible for checking the building windows and doors to ensure the resthome is secure especially on the afternoon/night shift. The two caregivers interviewed know to contact the manager if concerned or the New Zealand police if required.The requirements of the ARC service agreement are met.

Criterion 1.4.7.1 Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.


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


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


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


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


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STANDARD 1.4.8 Natural Light, Ventilation, And HeatingConsumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

ARC D15.2f ARHSS D15.2g


How is achievement of this standard met or not met? Attainment: FAEach resident’s room has an external window for light and ventilation. There is a heat pump in the main lounge and three wall heaters one on each of the three wings. There is a heater in each resident`s individual rooms. The facility is smokefree. The rest home is safe, warm with an even temperature throughout is maintained. A resident interviewed found his room warm and comfortable.The requirements of the ARC service agreement are met.

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


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


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

OUTCOME 2.1 RESTRAINT MINIMISATION

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

ARC E4.4a ARHSS D16.6


How is achievement of this standard met or not met? Attainment: FAA policy on restraint minimisation and the use of enablers is documented dated 13 Feb 13. Definitions are clearly documented to ensure they are consistent with the definitions contained within the standard NZS 8134.2. There is no evidence of restraint or enablers being used at this facility. Training for staff was provided at the orientation two days 21 and 22 May 13 prior to the service commencing on 1 July 13. Challenging behaviour and person centred care is the topic for the next training day 22 October 13. Staff interviewed one registered nurse and one caregiver have a good understanding of what an enabler is and that it is voluntary to meet the needs of an individual resident if required.The requirements of the ARC service agreement are met.

Criterion 2.1.1.4 The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.


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

STANDARD 3.1 Infection control managementThere is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service.

ARC D5.4e ARHSS D5.4e


How is achievement of this standard met or not met? Attainment: FAThe infection control (IC) programme implemented provides information and resources to inform staff on infection prevention and control and is appropriate to the size and scope of the service. The RN is responsible for infection control matters throughout the facility. This is documented in the RN job description sighted. A comprehensive two day orientation programme was attended by all staff prior to the opening of the facility on 01 July 2013. This included infection control training. There are scheduled internal audits about to commence. Care staff interviewed confirm there are infection control policies and procedures available to provide them with adequate guidance. Visual inspection provides evidence staff provide infection management precautions.The requirements of the ARC service agreement for Infection control are met.

Criterion 3.1.1 The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.


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


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Criterion 3.1.9 Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.


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



How is achievement of this standard met or not met? Attainment: FAThe infection control programme meets the needs of the facility and provides information and resources to inform and guide staff. The IC coordinator is the RN with the relevant skills and resources necessary to achieve the requirements of this standard. The job description for the IC coordinator is sighted. The IC committee comprises of the RN and facility Manager. The RN, management and staff have access to relevant and current information, which is appropriate to the size and complexity of the organization. Care staff and residents interviewed confirm RN availability for management of infection control issues or advice as required.

Criterion 3.2.1 The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.


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STANDARD 3.3 Policies and 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: FAIC policies, procedures and guidelines reviewed are practical and safe and are available to staff. Staff interviewed confirm there are infection control policies and procedures available to provide them with adequate guidance. The facilities IC policies and procedures include handwashing, standard precautions, transmission based precautions, outbreak management, staff issues, cleaning and disinfection and sterilisation, linen and waste management and surveillance.

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


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



How is achievement of this standard met or not met? Attainment: FAAll staff attended IC training during a two day orientation programme held prior to the facility opening on 01 July 2013. The training was provided by the RN. The training addressed the implementation of the facilities IC policies and procedures including handwashing, standard precautions, transmission based precautions, outbreak management, staff issues, cleaning and disinfection and sterilisation, linen and waste management and surveillance. Reading of referenced policies are required tasks for completion of the orientation programme and ongoing training for staff. The Manager interviewed states staff will have the opportunity to attend external IC education when resident numbers increase. The IC coordinator last attended education on Infection control and wound care August 2013. Two residents were identified as having extended spectrum beta lactamase (ESBL). The RN provided education to staff on ESBL and what precautionary measures are to be taken. The residents care plan reflected ESBL status and documented guidelines for management. Resident and family/whanau interview confirms education on IC and prevention is provided by the RN.

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


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Criterion 3.4.5 Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept.


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


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

The surveillance programme implemented is relevant to the level of service provided. The RN is responsible for promoting surveillance activities and ongoing monitoring. All staff are responsible for reporting infections. Surveillance activities are monitored and reported by the RN as part of the internal quality system to the owners. Improvements are required to documentation of EBSL in surveillance data and to infection control surveillance discussed at staff meetings.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe IC manual includes the requirement for monthly collation and reporting of infections and antibiotic use. Antibiotic use is documented in the residents' records and the monthly infection control reports (evidence is seen in the IC folder). Surveillance activities include monitoring of multi-resistant organisms and antibiotic use excluding EBSL.

Finding StatementEBSL is not documented as part of the surveillance data.

Corrective Action Required:Ensure surveillance methods are implemented for identified multi-resistant organisms and organisms associated with antimicrobial use.

Timeframe:6 months

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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowMonthly data collections of infections is conducted and reported on individual infection control reports. The RN completes a monthly infection control report which includes infection by type and number. Monthly summaries of infections, actions and outcomes are included in the reporting process.

Finding StatementThe infection control report is not tabled at the staff meetings and discussion around infection control is therefore not occurring.

Corrective Action Required:Discuss surveillance data at staff meetings with quality improvement if relevant.

Timeframe:6 months

Documents

Certification audit summary · Web viewEvergreen Care opened on 1 July 2013 providing residential care for up to eighteen residents who will require rest home level care. There are