Example report · Web viewRN,MBA NZQA 8086 6.00 Total Audit Hours on site 15.50 Total Audit Hours off site (system generated) 16.00 Total Audit Hours 31.50 Staff Records Reviewed

Hilary Isabel Bird

CURRENT STATUS: 03-Apr-13

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

GENERAL OVERVIEW

Tui Glen Rest Home is a six bed facility and provides aged residential care at a resthome level. At the day of audit there were six residents present.

This audit is undertaken as the present owner is completing the process of selling the facility with the proposed change of ownership date of 10 May 2013. The prospective owner has been a senior carer at the facility for two years and plans to continue with the present organisational structure, policies and procedures and staffing, with the exception of the registered nurse (RN) coverage, as she is looking to employ RNs rather than continuing an agency contact.

There are eight areas identified as a result of this audit that require improvement. These relate to having copies of enduring power of attorney, the activities programme, medication management, the recruitment process, training for staff who undertake food services and maintenance of equipment. The employment of the new RNs will need to be completed prior to the cessation of the support provided by the Nelson Nursing Service.

Tui Glen Rest Home Hilary Isabel Bird

Provisional audit - Audit Report

Audit Date: 03-Apr-13

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Hilary Isabel Bird

Premise Name Street Address Suburb City

Tui Glen Rest Home 23 Tui Glen Road Atawhai 7010 Nelson

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

Proposed new owner/manager

Type of Audit Provisional audit and (if applicable) Provisional audit

Date(s) of Audit Start Date: 03-Apr-13 End Date: 04-Apr-13

Designated Auditing Agency

The DAA Group Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXX

RN (with APC) MA Applied (nursing), ADN, NZQA8086

15.50 10.00 03-Apr-13 to 04-Apr-13

Auditor 1

Auditor 2

Auditor 3

Auditor 4

Auditor 5

Auditor 6

Clinical Expert

Technical Expert

Consumer Auditor

Peer Review Auditor XXXXXX RN,MBA

NZQA 8086

6.00

Total Audit Hours on site 15.50 Total Audit Hours off site (system generated)

16.00 Total Audit Hours 31.50

Staff Records Reviewed 5 of 5 Client Records Reviewed 4 of 6 Number of Client 1 of 4

(numeric) Records Reviewed using Tracer Methodology

Staff Interviewed 3 of 5 Management Interviewed (numeric)

2 of 2 Relatives Interviewed (numeric)

2

Consumers Interviewed 2 of 6 Number of Medication Records Reviewed

6 of 6 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

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

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

Dated this 18 day of April 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

Tui Glen Rest Home 6 6 0

Executive Summary of Audit

General Overview

Tui Glen Rest Home is a six bed facility and provides aged residential care at a resthome level. At the day of audit there were six residents present.

This audit is undertaken as the present owner is completing the process of selling the facility with the proposed change of ownership date of 10 May 2013. The prospective owner has been a senior carer at the facility for two years and plans to continue with the present organisational structure, policies and procedures and staffing, with the exception of the registered nurse (RN) coverage, as she is looking to employ RNs rather than continuing an agency contact.

There are eight areas identified as a result of this audit that require improvement. These relate to having copies of enduring power of attorney, the activities programme, medication management, the recruitment process, training for staff who undertake food services and maintenance of equipment. The employment of the new RNs will need to be completed prior to the cessation of the support provided by the Nelson Nursing Service.

1.1 Consumer Rights

Prospective residents and their families receive a copy of the Health and Disability Commissioner's Health Code of Health and Disability Services Consumers' Rights (the Code) and the Nationwide Health and Disability Advocacy Service. The service agreement, signed by family/whanau and/or residents, contains information on the Code and consent to care. The new manager has had training in the Code. There is a poster of the Code in English and te reo Maori on the wall within the facility as well as the complaints process, complaint form and a suggestion envelope. The organisation has policies and procedures related to the Code, including open disclosure, and these are known to staff.

There is a complaints policy and process, known to staff. There has been one complaint lodged in 2005.

There is a Maori health plan, but the service has never had a resident who identifies as Maori. Interpreter services have not been used but access to these is through the local DHB.

1.2 Organisational Management

The owners have had the business for 13 years and the prospective provider will continue with the present organisational structure with support from her family. The new manager will move into the manager's house which is attached to the rest home and continue to be 'hands on' in a caregiver role. It is proposed that clinical management will be provided by the prospective provider's sister who is a RN with care of the elderly experience. The new manager has a diploma in social work, a certificate in mental health from Nelson Marlborough Institute of Technology (NMIT), has completed Careerforce care of the elderly courses to dementia level. She has worked as a caregiver at other rest homes. The lead in time for the prospective provider is six months with intensive oversight by the manager then six months oversight from a distance. There is no legislative compliance issues affecting this service and the prospective provider is aware of reporting responsibilities.

The prospective provider is part of the review and development of the business and quality plan, risk management process for 2012/13 and these will have a review annually. The audit schedule is underway with the prospective provider. Staff meetings occur four times a year, a template agenda is used and include results of audit, complaints, incidents and accidents, health and safety, resident review and general business. The minutes show good attendance by staff.

The present policies and procedures and document control process will continue. There is an adverse event policy and process, known to staff. There Adverse event forms are available and come to the manager for investigation and review. Sixteen accidents/incidents are recorded for 2012

There is policy and process for the recruitment and retention of staff. All five staff files are reviewed and there is evidence of education, however there is no evidence of interviews, reference checking or police checking of new staff and this is an area requiring improvement. All new staff will be employed by the prospective provider. Orientation occurs and meets the needs of the organisation and good practice. A limited amount of ongoing education occurred in the last year, however, the majority of the staff have undertaking orientation in this period. The manager and prospective provider provided evidence of the training proposed for the current year with input from external providers and which meets the requirements of the Standards and the resident group.

The six week staff roster has a caregiver on morning and afternoon and the activities person 2.5 hours Monday to Friday. From 7 pm to 7.30 am the manager provides the caregiver role. There is a letter dated 2005 from the NMDHB stating that this is acceptable. The two residents and two family members interviewed have no concerns about this practice and speak highly of the staff availability. Incidents reviewed did not show an increase in numbers at night. The prospective provider will continue with the present roster process. Nursing care is provided under contract with the NNS who provide two hours a week onsite and a 24 hour on call service. The prospective provider is working with two senior RNs to in order to employ them to take over this role. This needs to be in place prior to the contract with NNS being terminated, and is identified as an area requiring an improvement. One of the new RNs will step into manage the facility when the manager is away.

The residents' files are kept in a locked cupboard and staff complete their shift report in the lounge/office area but are aware of the need to keep the documents private. Entries into the file are twice daily, and only at night, if there is a need. The entries are seen as timely. The activities assessment and plan for each resident is kept in a separate folder and this is an area that requires improvement. Residents' files, including discharged/deceased residents' files, are held safely.

An area for improvement is copies of enduring power of attorney being avialble on residents files.

1.3 Continuum of Service Delivery

The entry criteria is documented as well as reasons for decline. Information on the service is available on the Eldernet website. Service assessment, planning and review is completed by a RN from the NNS and meets the requirements of the provider's contract with the NMDHB, as seen in the four residents' files reviewed. The documentation includes a nursing assessment and there is a number of assessment tools in use including, falls, skin integrity, pain, wound and continence assessments. There is a lifestyle care plan with individual goals, and a short term care plan used when required

for any short term clinical issues. Progress is documented by the caregiver morning and afternoon and separately by the RN weekly. There is a RN review of the care plan six monthly, this includes use of the assessment tools. The GP reviews each resident three monthly along with medications.

Each resident has a resident's profile identifying their past and present interests, however there is no evidence of the profiles being updated on a regular basis or input from the family or the resident. The range of activities are limited and there is limited interactions with the wider community. This is an area that requires improvement.

There is evidence of referral to other services, such as allied health and specialists. The GP spoken with stated that these are timely and appropriately managed.

Policies procedures and education is available for caregivers on medication management. Medication is blister packed and received and signed off by agency registered nursing staff. All medication is kept in a locked cupboard, with the exception of insulin that is kept in two fridges. Six medication files are reviewed and show medication being prescribed and administered as per the prescription. There are areas of medication management documentation that require improvement.

A four week rotational menu is provided and has not changed since it was reviewed by a registered dietitian in 2011. The purchase of food is by the manager weekly or more often if required. The caregiver on duty prepares, cooks and serves the food. There is guidance on residents' special needs and preferences. Presently there is a resident who has type one diabetes and his meals are planned, including snacks. The meals are sighted and residents state they are happy with the food provided.

1.4 Safe and Appropriate Environment

The facility is a house that the present managers have added onto and is seen to be in good order. Each resident has their own room with a hand basin and an external opening window. The residents can bring in their own furnishings and fittings if they desire. The rooms are of a good size for use of mobility aids and there are no residents that require a hoist. The corridors are wide enough for residents with aids, such as a walker and a carer. In an emergency an ambulance trolley is able to enter all rooms.

There is a lounge room, and off this a separate dining area and a number of accessible external areas are available. There are two toilets and one shower and a further toilet for staff and visitors. Heating is by a heat pump and thermometers are sighted around the facility to monitor the temperature. Call bells are available in all residents' rooms and toilets and showers.

There is a current building warrant of fitness and fire service approved evacuation plan. Not all electrical equipment have current electrical test labels and clinical equipment has not been calibrated; this is an area that requires improvement.

The cleaning and laundry is onsite and carried out by caregivers. There are policies and procedures to be followed by staff and a twice yearly audit to check compliance with these. Chemicals are stored in the laundry and the area is kept locked when not in use. Residents and their families spoken with report the facility is clean and tidy. Family members report that their family member is always presented well.

Emergency policy and procedures are available and known to staff, and fire fighting equipment is available in all areas. Emergency planning includes torches for lighting, food stores, extra blankets for heating and extra water supplies. A first aid box and infection control box are available to staff. Staff files reviewed show all but one have current first aid certificates. This staff member is booked in to complete the training at the next available time; the managers are aware of this and will not roster this person on duty unless they are also on site.

2 Restraint Minimisation and Safe Practice

There are restraint minimisation policies and procedures with forms available to use in the event of the need for restraint use. The manager and prospective provider both stated that restraint is not used and staff spoken with confirm this. This is also confirmed by the GP spoken with. There is no evidence of restraint use seen during audit. The prospective provider is able to define an enabler. There are no enablers in use at the time of audit.

3. Infection Prevention and Control

Policies and procedures are in place for infection prevention and control and are known to staff. There is a register of residents who have had infections and the treatment, if any, prescribed. The oversight of infection management is by the NNS registered nurse who visits weekly, and this is seen in the residents' notes reviewed. The NNS registered nurse also provides education within their scope of practice, including vaccine administration and hand hygiene. There is evidence of staff attending external infection control education last year and education is planned for this year.

Summary of Attainment

1.1 Consumer Rights

Attainment CI FA PA UA NA ofStandard 1.1.1 Consumer rights during service delivery FA 0 1 0 0 0 1

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

Standard 1.1.3 Independence, personal privacy, dignity and respect FA 0 4 0 0 0 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 PA Low 0 2 1 0 0 9Standard 1.1.11 Advocacy and support FA 0 1 0 0 0 3Standard 1.1.12 Links with family/whānau and other community resources FA 0 2 0 0 0 2Standard 1.1.13 Complaints management FA 0 1 0 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:21 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 3

Standard 1.2.2 Service Management FA 0 1 0 0 0 2

Standard 1.2.3 Quality and Risk Management Systems FA 0 8 0 0 0 9

Standard 1.2.4 Adverse event reporting FA 0 1 0 0 0 4

Standard 1.2.7 Human resource management PA Low 0 3 1 0 0 5

Standard 1.2.8 Service provider availability PA Moderate 0 0 1 0 0 1

Standard 1.2.9 Consumer information management systems PA Low 0 3 1 0 0 10

Organisational Management Standards (of 7): N/A:0 CI:0 FA: 4 PA Neg: 0 PA Low: 2 PA Mod: 1 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.3 Continuum of Service Delivery

Attainment CI FA PA UA NA ofStandard 1.3.1 Entry to services FA 0 1 0 0 0 5

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

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

Standard 1.3.4 Assessment FA 0 1 0 0 0 5

Standard 1.3.5 Planning FA 0 2 0 0 0 5

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

Standard 1.3.7 Planned activities PA Low 0 0 1 0 0 3

Standard 1.3.8 Evaluation FA 0 2 0 0 0 4

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

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

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

Standard 1.3.13 Nutrition, safe food, and fluid management PA Low 0 2 1 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 9 PA Neg: 0 PA Low: 3 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 6

Standard 1.4.2 Facility specifications PA Low 0 2 1 0 0 7

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

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

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

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

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

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

Safe and Appropriate Environment Standards (of 8): N/A:0 CI:0 FA: 7 PA Neg: 0 PA Low: 1 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 6

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

Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2

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

Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3

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

Restraint Minimisation and Safe Practice Standards (of 6): N/A: 5 CI:0 FA: 1 PA Neg: 0 PA Low: 0 PA Mod: 0PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0UA 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 9

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

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

Standard 3.4 Education FA 0 2 0 0 0 5

Standard 3.5 Surveillance FA 0 2 0 0 0 8

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


Total Standards (of 50) N/A: 5 CI: 0 FA: 37 PA Neg: 0 PA Low: 7 PA Mod: 1 PA High: 0 PA Crit: 0UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 0 FA: 83 PA: 8 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Hilary Isabel Bird Type of Audit: Provisional audit

Provisional audit

Date(s) of Audit Report: Start Date:03-Apr-13 End Date: 04-Apr-13DAA: The DAA Group LimitedLead Auditor: XXXXXX

Std Criteria Rating Evidence Timeframe1.1.10 1.1.10.7 PA

LowFinding:There are a number of residents who have a relative or public trust with an enduring power of attorney, however copies of these are not available in the facility and this is an area requiring improvement. This is confirmed by the manager.

Action:Copies of enduring power of attorney are kept by the organisation.

Six months.

1.2.7 1.2.7.3 PALow

Finding: In five staff files reviewed there is no interview documentation, reference checking or police checking. This was confirmed by the present manager.

Action:Employment of new staff include appropriate pre-employment checking to ensure safety of the residents.

Six months.

1.2.8 1.2.8.1 PAModerate

Finding:The prospective provider is in discussions with two relatives who are RNs to take on the current RN role provided by NNS.

Action:Ensure that the proposed changed to registered nursing cover meet the requirements of the ARRC, are finalised and implemented, prior to the prospective provider/manager taking over the service.

Prior to the change of management.

1.2.9 1.2.9.10 PALow

Finding:The details of residents' activities is kept in a separate folder and there is not integration of these into the care planning.

Action:The activities profile and details of activities be integrated into the one resident's file.

Six months.

1.3.7 1.3.7.1 PALow

Finding:There is no evidence of the individual resident's profiles being updated on a regular basis or input from the family of the resident. The range of activities are seen as limited, with outings and reading of the newspaper. The afternoon activities are very 'fluid' and dependant on the caregivers interaction with the residents and no guidance is given to them from the resident's profile of interests. There is limited interactions with the wider community except for trips to the beach or café.

Action:The resident's profile is updated on a regular basis with the resident and their family and forms the basis of the individual activities plan for the resident and the weekly activities programme. The weekly programme include activities of interest, community involvement and special events, such as Easter.

Six months.

1.3.12 1.3.12.1 PALow

Finding:The back page of the medication chart, where 'as required' and short term medications are prescribed has an area to document the identification details of the resident; this is not completed in all files reviewed and is an area for improvement. It is seen in four out of six charts 'as required medication' and short term medication dated early last year, have been discontinued but not signed and dated as discontinued by the GP. The prescribing of non regular medications does not identify under what circumstances the medication should be given.

Action:Each section of the medication record have the resident's details documented. The 'as required' medications have detailed under what circumstances the medication is to be administered. The 'as required' and short term medications are reviewed as part of the three monthly medication review, and discontinuation be documented.

Six months.

1.3.13 1.3.13.5 PALow

Finding:The staff decant dry goods into sealed containers, however they do not indicate on the container the expiry date of the item from the manufacturers packaging. There is six monthly recording of the temperature of the fridge and freezer.

Action:Dry goods out of manufacturers containers are dated to ensure use within manufacturers expiry time. Fridges and freezers have their temperature monitored daily.

Six months.

1.4.2 1.4.2.1 PALow

Finding:The thermometer and sphygmomanometer have not been calibrated. There is an electric bed, televisions and other electrical equipment that have not been tested for electrical safety and labelled accordingly. Those pieces of equipment that are labelled have dates for rechecking that are expired.

Action:Equipment is calibrated on a regular basis as per the manufacturer's requirements. All electrical equipment has maintenance checking labels as required.

Six months.

Continuous Improvement (CI) Report

Provider Name: Hilary Isabel Bird Type of Audit: Provisional audit

Provisional audit

Date(s) of Audit Report: Start Date:03-Apr-13 End Date: 04-Apr-13DAA: The DAA Group LimitedLead Auditor: XXXXXX

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 Delivery

Consumers 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: FA

Document review - sighted the Resident Code of Rights. This covers, all areas of the Health and Disability Commissioner's, Code of Health and Disability Services Consumers' Rights (the Code) and the requirement of staff to uphold residents' rights and access to the Health and Disability Commissioner. Sighted on the notice board in the rest home the Code in English and te reo Maori. The manager provided a copy of the Code and advocacy service information she gives to all potential residents. The Code is included in the service agreement signed by all residents/family members on admission. Two staff members interviewed are able to state where the Code is on the wall of the rest home and an awareness of its contents. Two residents and two family members spoken with stated a knowledge of the Code and that the rights of residents are met.The requirements of ARC 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 Delivery

Consumers are informed of their rights.

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



At document review the Residents Code of Rights document sighted, states “Your Rights” poster, in English and te reo Maori, issued by the Health and Disability Commissioner is displayed for all residents to read with ease. This is observed in the rest home. Two residents, two family members and three staff spoken with are able to state the existence of the Code in the rest home and have a knowledge of its content. The manager provided a copy of the Code and the Nationwide Health and Disability Advocacy Service brochures which she gives to all potential residents. The Code is included in the service agreement signed by all residents/family members on admission. Residents interviewed (two) stated their rights are upheld and that they have opportunity to discuss this with the manager and staff.

The prospective provider has a diploma in social work and as part of this she has become aware of the Code. She is able to express the requirements of the Code related to the residents in the rest home.

The requirements of ARC 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 Respect

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

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


How is achievement of this standard met or not met? Attainment: FAAt document review the following was sighted:1. The Residents Code of Rights document which states resident’s privacy, dignity and respect will be maintained. Facilities are made available for private conversation, access to residents' files will be facilitated. 2. The Privacy and Dignity Policy, states the manager is the privacy officer. Covers privacy of documents, property and private conversations, residents' rights to dignity in personal clothing and preferred name. Complaints regarding breach of privacy can be made to the Privacy Officer and failing a satisfactory outcome, to the Privacy Commissioner or Health and Disability Commissioner. Advocacy services will be sought to facilitate this process if required. Staff will be trained in privacy and dignity.3. Prevention detection and removal of abuse or neglect policy. Defines abuse and neglect outlines the signs which might indicate abuse and neglect. The “Elder Abuse and Neglect” handbook and awareness prevention kit produced by Age Concern will be available for reference for all staff and used as the facilities guideline to promote the rights and well being of the Residents at Tui Glen Rest Home.4. Sexual harassment, coercion, exploitation and discrimination policy. Gives examples of harassment, coercion or intimidation. All suspected incidents of harassment, coercion, exploitation and discrimination will be dealt with through the complaints process.

The initial assessment and life style plan allows for the documentation of any values or beliefs the resident wishes staff to be aware off.

The prospective provider stated residents' notes are not left open where people can read them. This was confirmed by a caregive when asked about the process around writing notes in residents' files. The employment contract signed by all staff contain a section on confidentiality of information.

Two residents spoken with stated that their privacy is maintained and they are treated with respect and their dignity is maintained. They state they have no values or beliefs that staff need to be aware of. This is confirmed by two family members spoken with.

Residents are observed moving freely around the facility and external areas. One resident interviewed goes off on his bike to town, family members state they are free to visit any time and take their family member out with them.


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 Beliefs

Consumers 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



At document review the Maori Health Plan 2012/13 is sighted. This recognises the Ministry Maori Health Plan 2001 and contains general Maori words with the English equivalent. It identifies an educator, from whom advice can be obtained and recognises the input of whanau in admission and ongoing. Tui Glen Rest Home has an arrangement in place to contact Ngati Koata Social Services to assist with advice and guidance, which includes providing contacts for different iwi and hapu. Identifies translation services and the National Advocacy Service. As part of the self auditing process, a specific satisfaction survey will be sent to whanau within three months of a Maori resident’s arrival and annually from then on. Tui Glen recognises the need to provide clients with a choice of culturally sensitive caregivers. Where possible, Maori staff will be engaged to balance any resident perceived deficit. Eleven goals are set out in the Maori Health Plan. Sighted the Maori Death Policy, the objective of which is to ensure staff are aware of and sensitive to cultural issues surrounding the death of Maori residents.

The prospective provider stated that the service has never had a Maori residents at the rest home. She has access to a teacher of Maori protocols at NMIT and this person is available as a contact person if a Maori person wishes to be admitted. The person is available to provide support to the resident, family/whanau and staff.


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


Finding Statement


Timeframe:

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


Finding Statement


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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: FAAt document review the Cultural Safety Policy is sighted. This states staff are trained on cultural support, respect, values and beliefs every two years. Admission documentation will identify individual residents' cultural needs. Management will ensure that residents have access to interpreters and independent advocates when required to ascertain their needs and requests.The nursing assessment care plan has an area to document cultural and spiritual values and beliefs. Two residents and two family members interviewed stated they have no cultural or spiritual values or beliefs that staff need to be aware of. The requirements of ARC 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 Discrimination

Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e



Sighted at document review the sexual harassment, coercion, exploitation and discrimination policy. This gives examples of harassment, coercion or intimidation. All suspected incidents of harassment, coercion, exploitation and discrimination will be dealt with through the complaints process.The two staff interviewed are aware of the policy and stated how they would report any incident they might see related to discrimination or harassment. It was observed during the two days that staff interactions with the residents is respectful, and this is confirmed by two residents and two family members spoken with.

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 Practice

Consumers receive services of an appropriate standard.

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


How is achievement of this standard met or not met? Attainment: FAThe organisation has a range of polices that are up to date, meet good practice and the requirements of the ARC contract. Examples are:1. Death and Dying Policy, provides staff with guidance on dealing with residents whose death is expected and those who are unexpected.

2. Personal Grooming and Hygiene Policy. States hygiene and grooming reassessments will be carried out at least 6 monthly or sooner if needs and requirements change. Dignity and privacy is to be maintained while hygiene cares are managed. Hair, hearing aids, glasses and make up for female residents is to be maintained. The prospective provider stated she keeps current by reading and keeping up to date using relevant website such as the Ministry website. The manager attends the monthly Nelson rest home mangers' meetings and the organisation is a member of the New Zealand Aged Care Providers Association. Staff spoken with (three care givers and one caregiver/activities person) stated that they are given the opportunity for education and are supervised when orientated to meet the policies of the organisation.The requirements of ARC 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 Communication

Service 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



The organisation has an Open Disclosure Policy. This details the management and reporting of incidents and accidents. The manager an RN and/or GP has the responsibility to discuss any event and issues relating to harm or potential harm with residents and their family. The incident register is reviewed with the manager. The incident form has an area for documenting when a family member is informed of an incident. Sighted this area ticked in one out of four incident forms reviewed. The manager stated that the resident is always part of the incident and the family are informed if the resident requests this or if the family wish to be informed of incidents. She stated this would be asked on admission and on an ongoing basis Two family members spoken with stated that they are informed when their family member has had an incident and this has been discussed with them. There is an Interpreter Policy, this states, language requirements are documented as part of the resident’s care plan and this is reviewed at least six monthly. If family/whanau are unable to interpret, Tui Glen Rest Home will endeavour to provide information in: dictated form; sign language, Braille; te reo Maori and/or another language through an interpreter.The manager stated they have never needed to use interpreter services, however they would contact the DHB for this service, if this were required. The requirements of the ARC 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 Consent

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

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


How is achievement of this standard met or not met? Attainment: PA LowAt document review the Informed Consent policy is sighted. The policy states informed consent is paramount to any care options provided and is a component of quality of life and care and do not support the idea of “general consent” for all treatments. Written consent forms are available for invasive procedures and will be kept in the residents' notes. This is confirmed in resident files with nformed consent forms seen for the administration of 'flu' vaccination last year. The prospective provider stated that these are being circulated for this yearThe policy identifies the process for residents with impaired cognitive capacity. Written advanced directives, activated when cognitive competency becomes impaired, must be in accordance with common law. The right to withdraw consent is acknowledged. Each resident/family member signs an admission agreement to consent to care given. Two residents spoken with stated that staff discuss care given to them prior to this occurring. One remembers being involved in care planning the other cannot remember this occurring. The two family members when asked about involvement in care planning, stated that the manager discusses this with them on a regular basis and if their relative's status changes.The prospective provider spoke of advanced directives and how each resident has a documented advanced directive in their file completed with their doctor. This is seen in all files reviewed. There are a number of residents who have relatives or public trust with an enduring power of attorney, however, copies of these are not available in the facility and this is an area requiring improvement. The requirements of the ARC 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.

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

The prospective provider spoke of advanced directives and how each resident has a documented advanced directive in their file completed with their doctor. This is seen in all files reviewed. There are a number of residents who have a relative or public trust, with an enduring power of attorney, however copies of these are not available in the facility and this is an area requiring improvement. This is confirmed by the manager.

Finding Statement

There are a number of residents who have a relative or public trust with an enduring power of attorney, however copies of these are not available in the facility and this is an area requiring improvement. This is confirmed by the manager.

Corrective Action Required:Copies of enduring power of attorney are kept by the organisation.

Timeframe:Six months.

STANDARD 1.1.11 Advocacy And Support

Service 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 manager stated that she provides a copy of the Nationwide Advocacy Service to all prospective resident and their family. The prospective provider stated that family members and other supports are welcomed. Examples of supports from external services mentioned include, the Public Trust and the diabetes nurse specialist. The manager stated that staff also see themselves as advocates for the residents. Two family members stated that they are made to feel welcome when they visit and visit frequently.

The requirements of the ARC 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 Resources

Consumers 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: FAThe manager stated that the rest home has an open visiting policy. This is confirmed by the two family members spoken with, who visit regularly and frequently. One spoke of taking her mother on outings. One resident spoken with goes out on a daily basis and visits town and his lock up facility. He has not been a member of any community group and had no wish to do so. The activities person spoke of taking residents on outings to cafes and to the beach in groups and individually. (Refer also CAR 1.3.7)

The requirement of the ARC 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 Management

The 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: FADocuments reviewed:

1.The Complaints Policy. This covers written and verbal complaints. The complaints process is facilitated by the management or Nelson Nursing Service to ensure anonymity. The timeframes meet the requirement of the standard. Residents have access to support to make a complaint. Complaint forms are kept in on the notice board by the front door.

2. The Complaints Procedure states how a complaint will be handled. Timeframes meet the requirement of the standard. States complaint can also be made to the Ministry or Ombudsman. If the matter is not resolved satisfactorily with Tui Glen Rest Home management or Advocacy Service, complainants are entitled to take the matter to the office of the Health and Disability CommissionerSighted with the manager the complaints register. There is one complaint in the register, dated 2005. The manager reports that if any resident raises a concern this would be written in the daily notes and communication book and dealt with when it occurred. She identified the suggestion envelope available in the main hall way for residents and visitors to use. There has been nothing in this envelope for some time. Residents' meetings were held some time ago but are no longer seen as required. A copy of the complaints policy is on the hallway wall of the rest home as well as a complaint form. Beside this, is an envelope for suggestions.

The two residents and two family members spoken with confirm knowledge of the complaints process and suggestions envelope. None wished to raise any issue of concern. The residents did not see the need for residents' meetings and would discuss issues with staff or the manager. The manager is seen as being available for discussions. The residents interviewed also stated that they had no concerns about the new manager taking over the rest home.


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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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 Governance

The 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: FAAt document review the Business Plan 2012/13 is sighted. This states there are plans for refurbishment/upgrade of nine areas over a period of three years, this is dependent on full occupancy. The plan is discussed with the prospective provider. She has been part of the planning of these documents and will continue with the audit process and annual review. The manager/owner has been in the position for 13 years, prior to this she has worked within the intellectual disability service in Auckland. She is also working with NZ Care with over sight of four community houses. The prospective provider has a diploma in social work, a certificate in mental health from NMIT and has undertaken Careerforce training core and dementia levels. She has managed a business with her ex partner, has been a caregiver at other rest homes, and has been a caregiver at Tui Glen for two years. In taking over as the manager she has no plans to change the management structure, vision, mission or scope of services provided. The transition to the new manager has begun and involves six month intensive oversight from the present manager then a six months distance oversight by telephone or as required. The transfer is set down for the 10 May 2013. The manager's job description, seen at document review identifies the responsibilities and key tasks of the role. Two residents and two family members spoken with stated that they are aware of the proposed change of management/ownership and were comfortable with it as they now the new owner as a senior care giver at the resthome.The requirements of the ARC 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 Management

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

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


How is achievement of this standard met or not met? Attainment: FAThe manager stated that during her temporary absence the senior caregiver who is to be the manager stands in. The prospective provider stated that she is looking at employing her sister who is a RN and is working in another rest home, who will stand in during her temporary absence, or a senior caregiver. This was confirmed by the sister/RN when spoken with. The requirement of the ARC is 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 Systems

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

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


How is achievement of this standard met or not met? Attainment: FAAt document review the following is sighted:

1.The Quality Plan 2013 which covers quality philosophy, vision statement, mission statement and philosophy. There are eleven quality objectives and the plan states how these are measured. The document covers the quality plan strategy, health and safety, hazards and risk management, the audit process, infection control, satisfaction surveys, family meetings, assessment and care. Sighted the review of the aspects of the quality plan by the present manager for 2012.2. The Risk Policy states a hazard register is in place. This prioritises risks, likelihood and consequence scores, potential harm, management controls and training requirements, as appropriate. Staff are to identify hazards via a hazard identification form.3. The Risk process document defines the components of risk, identifies five external risks and twenty seven internal risks. States there is a Health and Safety (H&S) Committee, identifies the functions and objectives of the committee. Contains the Emergency Plan, this has contact details for the manager, identifies an emergency kit, fire wardens and assembly point. Covers earthquake, bomb threat, theft/burglary/intruder, power failure, chemicals, hazardous substance and waste, flooding/tidal wave and missing person.

The manager provided the risk/hazard register; this commenced some years ago and is added to as other risks/hazards are identified. The register then documents the risk/hazard, its likelihood/consequence scored, any risk factors identified, potential harm, the eliminated, isolated or minimised strategy and the management/controls put in place. This includes any staff training requirements. Forty one risks/hazards are listed in the register, plus an older register from 2003 is available. The prospective provider stated this will continue to be kept up to date and reviewed annually. The three documents above are discussed with the prospective provider. She has been part of the planning of these documents and will continue with the audit process and annual review. Sighted the 2012 review of the aspects of the quality plan by the present manager, including the audits undertaken six monthly; infection control and restraint process. Corrective actions are taken and the present manager is able to identify these related to incidents and this is sighted on the incident form. Examples given are; the alarming of all external doors at night following an incident when a resident left the premises and was found wandering in the grounds. A second example is the change of room for a resident who was unsteady on the stairs from a room on the first floor to a room on the ground floor.

The Documentation Policy covers the organisation's responsibility for the safe storage of residents' information. Resident’s records are to be kept up to date and securely locked away including old records. Requests for residents or family to view records are managed by the manager. It also covers the development and review of the organisation's policies and procedures. These are to be signed off by the manager and reviewed every two years. There are sign off sheets in the various manuals (sighted). This process is to be continued by the new manager. There is a process to ensure that if a document is copied and put on the wall that it is identifiable by the manager. There are a number of policy manuals that meet legislative requirements and good practice, for example recruitment policies, health and safety policy. The prospective provider stated that the RN would review relevant policies with her on an ongoing basis.

The prospective provider provided the list of sixteen audits undertaken six monthly. She has completed these for March 2013, and they cover, water temperature activities, food/fridge/freezer temperatures, room alarm check, clinical documentation, security, shaver cleaner, maintenance, hygiene and

grooming, linen transporting, hand washing, waste management, laundry procedure, laundry cleaning, presentation of personal clothing and linen and cleaning. Sampling is undertaken for each of the audits and there is general comments on the compliance of each audit; this is seen as high.

Staff meetings, set down for five times in 2013, acts as the umbrella group for infection control; Occupational Health and Safety (OSH) and risk; care and assessment; and quality. The minutes of the staff meeting, January 2013, October, September, July, March 2012 are seen. There is a template agenda used and this covers, infection control, training, residents, OSH, risk management, complaints, care plan, clinical documentation, quality audits, restraint, improvements and 'general'. Staff spoken with (three) stated that they attend staff meetings and are informed of incidents, complaints and results of audits at these meetings.


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


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


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


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Criterion 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system.

This shall include, but is not limited to:

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.


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


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


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


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

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

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


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STANDARD 1.2.4 Adverse Event Reporting

All 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: FAThe incident/accident policy is seen and meets the requirements of legislation for open disclosure. The folder containing all the incident forms is sighted and shows analysis of the incidents for 2012. There are 16 in total (eight incidents and eight accidents), analysis is by type and staff/resident/visitor. The largest number of accidents relate to falls and there were two emergency events. The forms detail the manager's investigation and identify any steps required to prevent a reoccurrence. There is evidence in one incident related to medication management where the RN from NNS was contacted for advice on how they should manage the resident. There are no legislative compliance issues sighted and both mangers are able to state their statutory and contract reporting requirements.

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


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STANDARD 1.2.7 Human Resource Management

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

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


How is achievement of this standard met or not met? Attainment: PA LowThe organisation has policies on:1. Staff Orientation Policy. This policy states that all new staff receive orientation. The check list is to be completed by the new staff member, signed and dated. 2. Staff Education Policy. This policy states all staff are required to undertake 8 hours training (annually) in the field of caring for the elderly as well as specific training.3. Job descriptions for the activities co-ordinator, the manager, RN and caregiver. These describe the responsibilities and key tasks for the role.

The manager spoke of the employment process and provided evidence of employment forms available for use. In five staff files reviewed there is no interview documentation, reference checking or police checking. This was confirmed by the present manager. This is an area that requires improvement. All new staff will be employed by the prospective provider. Presently the nursing staff are employed by NNS who are responsible for the annual practising certification checking of their staff as noted in the memorandum of understanding with the provider. This is confirmed by telephone with the manager of NNS. The prospective provider is intending to employ two RNs, both are interviewed and their current annual practising certificates sighted. The state that employment details are yet to be finalised with the prospective provider. One is the brother of the new manager and has his own business related to health and safety in employment and also first aid certification. The other is the sister of the new manager who will take on the clinical oversight of the

residents on a weekly basis. Currently she is employed full time at another local rest home, but will reduce duties to work at Tui Glen. She has had a look at the present care planning process and has some ideas for changes. (See 1.2.8.1)The activities co-ordinator has trained as a nanny then worked as an activities co-ordinator prior to employment at Tui Glen. She has no formal training in this area and presently she has no formal supervision for this role. The manager stated that there is an activities co-ordinators group in the area and the activities co-ordinator is looking at joining this group ongoing, this is seen as a recommendation. She stated that she has undertaken Careerforce training, three papers but has no documentation on this. She has also undertaken Care of the elderly certificate from Eldernet and this is seen on her staff file. There is an orientation process that includes working with the manager/senior caregiver for at least three duties and the manager explained the 'buddy time' is extended until the new caregiver is seen as competent. An orientation check list is completed and covers areas of care and policies and procedures. Competency check lists are available for aspects of care, including medication management, infection control, restraint and emergency management. Orientation is seen as being completed in the five files reviewed and evidence of training undertaken. Two staff spoken with about orientation confirm the process. The managers and prospective provider spoke of education being undertaken to meet the needs of the residents. The manager stated the use of external providers for education and this is seen in staff files reviewed. There is evidence of education on challenging behaviour and diabetes which is pertinent to two present residents. The prospective provider spoke of the use of the DHB and is hoping to use some of the training provided by other rest home providers for the staff. Sighted the education calendar for 2013 this includes the Code, infection control, diabetes, chemical handling, and first aid. All but one staff member has a current first aid certificate, and the staff member has been booked to undertake this training next month. The prospective provider is aware that this staff member cannot be on duty on her own until this is completed.

It is seen that the prospective provider has undertaken Careerforce training on care of the older person core and dementia level. Another caregiver is a RN who does not have a current annual practicing certificate and has considerable experience in care of the older person. Two staff who have commenced in the last month are to commence their Careerforce training within the next few months. The activities person has completed the four papers and has not been able to source the certificate. This is being followed up by the managers.


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.

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe manager spoke of the employment process and provided evidence of employment forms available for use. In five staff files reviewed there is no interview documentation, reference checking or police checking. This was confirmed by the manager. This is an area that requires improvement. All new staff will be employed by the prospective manager.

Finding Statement

In five staff files reviewed there is no interview documentation, reference checking or police checking. This was confirmed by the present manager.

Corrective Action Required:Employment of new staff include appropriate pre-employment checking to ensure safety of the residents.


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 Availability

Consumers 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: PA ModerateAt document review the following documents are sighted:

1. The Staff Cover Procedure Description of Staff Cover Over 24 Hour Period. The manager will cover most shifts as principal caregiver. Staff are rotated on a duty roster on a 6 weekly basis. There is a sleep over person who will check on patients at least two hourly or more frequently if required by RN or GP.

The roster is sighted. There is a caregiver on duty 7.30 am till 1.30 pm, then 1.30 till 7 pm, and on a Wednesday till 9.30pm. The activities person works five days a week, she stated she works 2.5 hours on activities and then some days she does caregiving. The prospective provider stated that she will continue this roster but may look at employing an additional caregiver at some future time. The manager and her husband are on duty from 7 pm till 7.30 am and check on the residents two hourly. The prospective provider and her family, that include the activities person, will be living on site and will take on the night duty and a rotation with one week end off. The prospective provider's sister who is a RN will be on site at weekends to cover the weekend when the manager is off duty. Sighted a letter from the NMDHB, dated 2005, this states that the overnight coverage as set up is allowable as long at the residents are checked two hourly and have access to a call bell.

2. The Staffing Levels and Skill Mix Policy. This states all residents are encourage where possible to maintain the service of their own GP. All residents have a support/needs assessment level. Tui Glen Rest Home is contracted to provide 24 hour care and supervision of residents with CNL scores 4, Care Support and Respite care. There is always at least one senior caregiver immediately available to respond to all care and assistance needs. If the manager or RN felt that the skill mix of staff was not adequate to cater for the prospective resident with special care needs, the roster will change to reflect the care needs (ie, extra staff with appropriate training for the care needs will be rostered on).

The RN coverage is discussed with the manager, she provides a copy of the contract they have with NNS. This covers the initial assessment of new residents and the development of the lifesytle plan in accordance with the ARC contract. Weekly a RN provides assessment and oversight of residents for two hours a week as well as providing a 24 hour and seven day a week on call service (24/7). This is confirmed with the manager from NNS by telephone. The prospective provider stated that she is looking at employing her sister and brother who are RNs to take over the role presently preformed by the NNS. These RNs are spoken with and confirm that the prospective provider has discussed options with them and they are very supportive of her in her new role. One who is likely to be the main RN has seen a job description but has not received any formal offer of employment. The other is still in discussions about his role. Discussions have been related to him acting as a 'backup role' for advice; no formal offer of employment has been agreed. It is recommended that the services of NNS are continued until formal arrangements have been made to take over this role, the new manager is in agreement with this.


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.

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateThe RN coverage is discussed with the manager, she provides a copy of the contract they have with NNS. This covers the initial assessment of new residents and the development of the lifesytle plan in accordance with the ARC contract. Weekly a RN provides assessment and oversight of residents for two hours a week as well as providing a 24/7 on call service. This is confirmed with the manager from NNS by telephone. The prospective provider stated that she is looking at employing her sister and brother who are RNs to take over the role presently preformed by the NNS. These RNs are spoken with and confirm that the prospective provider has discussed options with them and they are very supportive of her in her new role. One who is likely to be the main RN has seen a job description but has not received any formal offer of employment. The other is still in discussions about his role. Discussions have been on a backup role for advice; no formal offer of employment has been agreed. It is recommended that the services of NNS are continued until formal arrangements have been made to take over this role, the prospective provider is in agreement with this.

Finding Statement

The prospective provider is in discussions with two relatives who are RNs to take on the current RN role provided by NNS.

Corrective Action Required:Ensure that the proposed changed to registered nursing cover meet the requirements of the ARRC, are finalised and implemented, prior to the prospective provider/manager taking over the service.

Timeframe:Prior to the change of management.

STANDARD 1.2.9 Consumer Information Management Systems

Consumer 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: PA LowThere is a Documentation Policy, this covers the organisation's responsibility for the safe storage of residents' information. Residents' records are to be kept up to date and securely locked away, including old records. Requests for residents or family to view records are managed by the manager. It also covers the development and review of the organisation's policies and procedures. The policies and procedures are signed off by the manager and reviewed every two years. This is recorded on sign off sheets in the various manuals. Sighted the check off sheet in the manuals, these identify when a policy and procedure requires review.

It is observed that resident's current records are kept in a locked cupboard and only staff have access to them. Documentation in the resident's file is morning and afternoon and is seen as accurate to care needs and timely. Staff use initials to state who has made the entry. A list is kept of the initials used by the caregivers and a change has been made recently and current documentation requires caregiver to enter their designation as well as initials. The manager stated that care plans are written by the RNs from NNS on admission and reviewed six monthly or if changes are needed. Sighted short term care plan activated, (e.g. for wounds), as required. An area requiring improvement relates to the activities documentation being kept in a separate folder and not integrated into the residents' records. Residents' files that are not current are kept in a lockable cupboard in the upstairs manager's lounge/office. Archived records are kept in the basement in boxes.


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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe activities co-ordinator provided a folder containing the residents' profile and activities plan. These are kept in the locked cupboard beside the other residents' files, however, there is no integration of the activities and the care planning.

Finding Statement

The details of residents' activities is kept in a separate folder and there is not integration of these into the care planning.

Corrective Action Required:The activities profile and details of activities be integrated into the one resident's file.

Timeframe:

Six months.

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 Services

Consumers' 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: FASighted at document review:- 1. The Access and Entry Criteria document. This states all residents will be assessed by an appropriate agency and be of the care levels, 1 or 2, Carer Support or Respite Care and lists four criteria for decline of entry. - 2. The Private Residents Contract Agreement, this covers aspects of the Code, informed consent, payment for extra services and outings. The present manager stated information about the facility is available on the Eldernet website - this is seen. She provided the Nelson Needs Assessment and Service Coordination (NASC), assessment for two residents.


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


Finding Statement


Timeframe:

STANDARD 1.3.2 Declining Referral/Entry To Services

Where 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: FASighted at document review the Access and Entry Criteria document. This states all residents will be assessed by an appropriate agency and be of the care levels, 1 or 2, Carer Support or Respite Care and lists four criteria for decline of entry. The manager stated that declines would be notified to the NASC agency and the family/resident. She stated this has not happened, but she has had residents re-assessed for other facilities and has discharged a resident, the reasons were put in writing.

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


Finding Statement


Timeframe:

STANDARD 1.3.3 Service Provision Requirements

Consumers 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: FATracer : Resident XXXXXX This information has been deleted as it is specific to the health care of a resident.

The three other files reviewed have evidence of services being consistent with the assessed needs of the resident. Three caregivers spoken with stated they use the care plan and other documents to guide the services they give each resident as well as discussions with the resident. They state they are flexible in the delivery of care if the resident does not wish to shower at the stated time. Sighted pain score being undertaken frequently for a resident who has had back problems, referrals to an orthopaedic surgeon, occupational therapist and social worker in a timely manner. Another resident has a continence assessment checklist completed on an annual basis. The resident who has Type 1 diabetes has an emergency plan from the diabetic specialist on actions to be taken by staff in the event he becomes unconscious. Staff interviewed are aware of this plan. In four residents' files reviewed there is an initial assessment undertaken within two days and a lifestyle plan is completed within six weeks. Re-assessment occurs on a six monthly basis. These are undertaken by the RNs from NNS. Sighted in the four files reviewed the RN from NNS weekly monitoring of resident is documented. The prospective provider states this process is likely to be undertaken by a RN she is to employ, in the future. The prospective RN is spoken with, she is aware of the responsibilities related to care planning. Two caregivers spoken with state they write in the residents' files in the morning and afternoon. This is seen in the four files reviewed and relate to the care given and any changes to the resident's condition. The manager stated that she would right in the resident's file is anything occurred over night. The GP spoken with states he reviews residents three monthly and this is confirmed in the four residents' files seen. The GP stated he has confidence in the ability of the staff to refer any problems to him in a timely way and referral to other services, such as, specialist services is also timely. The referral to physiotherapy, dental services, mental health services and orthopaedic specialist is seen in the files reviewed.


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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

STANDARD 1.3.4 Assessment

Consumers' 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: FASighted in the four residents' files the nursing assessment care plan completed on admission to the service by the RN from NNS. The assessment covers appropriate areas for this service including, cultural/spiritual, circulation, diet/fluids, social interaction, falls, elimination, sleep, personal cares, skin integrity, communication and mobility. Sighted in the four files the use of the Braden scale, Combs assessment, pain scale and continence assessment tools. Blood pressure, weight, pulse and temperature are recorded. The manager stated a wound management chart is available. Blood glucose is being monitored for one resident who has Type 1 diabetes and staff monitor the reading. There is a weight chart in each file. The recordings on these is variable in 2012 and the prospective provider stated this will be done monthly from now on. The four charts reviewed showed that the weight has been recorded on a one to three monthly basis and the present weight of the residents show a stability or gain, no loss is seen. Re-assessment is seen in the Lifestyle plan which has residents' goals for 15 areas documented. This is carried out six monthly in the files reviewed, with the majority completed within this timeframe. There is evidence of more frequent re-assessment occurring when a change is seen in the resident's condition. The requirement of the ARC 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.


Finding Statement


Timeframe:

STANDARD 1.3.5 Planning

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

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


How is achievement of this standard met or not met? Attainment: FASighted at document review the Nursing Care Plan policy. This states that each resident has an individualised care plan developed within two days of admission by the RN. The resident and family/whanau of choice will be involved with the development. Assessment tools used are pain, continence, wound care, skin (pressure area), falls risk, mobility assessment, infection risk are completed for every new resident on admission, as a sound benchmark for the future. A short term care plan will be completed, only if a short term problem arises which is likely to be resolved in a short time (e.g. urinary tract infection). The four residents' care plans reviewed show that appropriate assessment is undertaken and developed into an individualised care plan within the timeframes of the ARC. This includes individualised goals.

A number of documents sighted are devolved from the care plan, this includes an individual resident's care notes. This page summaries the cares of the resident. A daily shower list states when each resident likes to have their shower and the assistance each resident requires, this ranges from independent to two person. Three caregivers spoken with stated they use the care plan and other documents to guide the services they give each resident as well as discussions with the resident and the use of a communication book. They state they are flexible in the delivery of care if the resident does not wish to shower at the stated time they can choose. Two residents and two family members spoken with stated they could not remember being involved in the planning of care however they stated that they have ongoing communication on the care they and their relative receive and may have forgotten this occurring.


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


Finding Statement


Timeframe:

Criterion 1.3.5.3 Service delivery plans demonstrate service integration.


Finding Statement


Timeframe:

STANDARD 1.3.6 Service Delivery/Interventions

Consumers 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: FAThere is evidence in the four residents files reviewed of service delivery being consistent with the needs of the residents, with goals being developed and reviewed six monthly. The RN from NNS documents her assessment for the weekly visits in the RN documentation and where residents need change the service delivery also changes.

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


Finding Statement


Timeframe:

STANDARD 1.3.7 Planned Activities

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

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


How is achievement of this standard met or not met? Attainment: PA LowAt document review the activities co-ordinator's job description is seen. The activities coordinator is responsible to provide a positive, caring and friendly environment with a family atmosphere where residents receive quality care and stimulation designed to maintain a healthy and safe life style. The key tasks are listed for this position. There is an activities folder which is kept in a separate folder from the resident's care plan (See CAR 1.2.9.10). It contains a Resident Profile form for each resident. This is completed on admission of the resident by the activities co-ordinator; none of the profiles have been completed by the present co-ordinator. The document has no place to write a date or signature of who has completed the document. Some of the profiles have changes made to them, however the why, who and when cannot be verified. The profile covers areas of history of the resident and family, friends and significant others, interests, including values and beliefs, dislikes and a space for life history. The present co-ordinator completes a monthly Activities Evaluation template, which is an update on each resident's activities in the form of a tick box and space to write an evaluation. The information sighted as written here includes the resident's participation and mood. This goes to the manager. A weekly recreation programme is put on the notice board. This lists the Monday to Sunday activities organised in the morning and a list of activities that are to be encouraged in the afternoon. The activities co-ordinator spoken with stated that she has spoken with each resident and ascertained their likes and dislikes. She stated that there is not a lot of activities that all the residents wish to participate in, some like art and others do not. She takes them for regular drives either as a group or individuals. The list of activities seen for the week are limited and when asked about the activities around Easter she stated that the residents do not like art or making things. She has looked into getting groups to come to the rest home but because of the size this is limited. The manager is spoken with regarding the activities and stated the list of activities go up on a weekly basis and caregivers in the afternoon are encouraged to do activities from the afternoon list. She confirmed that the activities co-ordinator takes the residents out to cafes and the beach.Of the two residents spoken with, one stated that he prefers to keep to himself and the other stated that she does some activities, and has her ipad. The family members spoke of taking their relatives out for trips and could not remember being involved in the Resident Profile development.

This is seen as an area requiring improvement. The requirement of ARC D16 5 c iii) and D 16.5 d are not met.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowDocumentation on activities planning is sighted and includes a Resident Profile form for each resident. This is completed on admission of the resident by the activities co-ordinator; none of the (six) profiles have been completed by the present co-ordinator. The document has no place to write a date or signature of who has completed the document. Some of the profiles have changes made to them and the why, who and when cannot be verified. The profile covers areas of history of the resident and family, friends and significant others, interests including values and beliefs, dislikes and a space for life history.

The co-ordinator completes a monthly Activities Evaluation template, which is a record of each resident's activities that month in the form of a tick box and space to write an evaluation. The information sighted as written here includes the resident's participation and mood. This is given to the manager.

A weekly recreation programme is put on the notice board. This lists the Monday to Sunday activities organised in the morning and a list of activities that are to be encouraged in the afternoon.

The activities co-ordinator spoken with stated that she has spoken with each resident and ascertained their likes and dislikes. She stated that there is not a lot of activities that all the residents wish to participate in, some like art and others do not. She takes them for regular drives either as a group or individuals. The list of activities seen for the week are limited and when asked about the activities around Easter she stated that the residents do not like art or making things. She has looked into getting groups to come to the rest home but because of the size this is limited.

The two family members spoken with could not remember being involved with the writing of the resident's activity profile, they did state that they come and take their family member on outings.

Finding Statement

There is no evidence of the individual resident's profiles being updated on a regular basis or input from the family of the resident. The range of activities are seen as limited, with outings and reading of the newspaper. The afternoon activities are very 'fluid' and dependant on the caregivers interaction with the residents and no guidance is given to them from the resident's profile of interests. There is limited interactions with the wider community except for trips to the beach or café.

Corrective Action Required:The resident's profile is updated on a regular basis with the resident and their family and forms the basis of the individual activities plan for the resident and the weekly activities programme. The weekly programme include activities of interest, community involvement and special events, such as Easter.


STANDARD 1.3.8 Evaluation

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

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


How is achievement of this standard met or not met? Attainment: FAThere is evidence in the four residents' files reviewed of monitoring of the residents by the RN from NNS on a weekly basis and evaluation of the residents' lifestyle care plans on a maximum of six monthly basis. The lifestyle plan has individualised goals recorded and evaluation of these is seen. When the resident has a change in condition the plan is reviewed or a short term care plan commenced and documented in the file. Assessment tools, in use are pain, weight chart, falls and skin integrity. An example is the increase in the monitoring of a resident’s pain score with a back problem and use of a short term care plan when she has a respiratory infection. The two residents and two family members spoken with do not remember being involved in the six monthly review but stated they may have been as they have regular discussions with the staff and manager. It is recommended that the family and resident be encouraged to be part of these reviews and this involvement is documented.


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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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

Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

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


How is achievement of this standard met or not met? Attainment: FAThere is evidence in the four residents' files reviewed of referral to other health and disability services as appropriate. These include, physiotherapy, occupational therapy, dentist, diabetic clinic and diabetic nurse specialist, orthopaedic out-patients and massage and reflexologist. The GP spoken with stated Tui Glen staff refer to him appropriately and in a timely manner and that referral to other services is also timely. The resident with Type 1 diabetes stated that he attends the diabetic clinic on a regular basis.


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


Finding Statement


Timeframe:

STANDARD 1.3.10 Transition, Exit, Discharge, Or Transfer

Consumers 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: FAThe manager stated that there is a short term care-plan for use when a patient is transferred to another rest home. Medication records are copied and sent with the resident with the current blister packs. Sighted a copy of such a document used to transfer a patient on the manager's computer. The requirement of ARC D21 is 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.


Finding Statement


Timeframe:

STANDARD 1.3.12 Medicine Management

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: PA LowAt document review the Medications Policy is sighted. This states all medication will be prescribed by a GP, self administration will be assessed by the RN and assessed three monthly. For identity purposes a photograph of each resident will be kept in front of their medication order sheet. All outdated or obsolete medication will be returned to the Collingwood Pharmacy in a timely fashion. Caregivers who have been trained by the Rn or manager are permitted to administer medication, this occurs on an annual basis. The on duty caregiver must check and sign for the medication administration. Medication is blister packed and liquid medicines are to be stored in a locked cupboard. All allergies or sensitivities are recorded on the medication chart and any incident related to the administration of medication is to be reported to the manager. Family/whanau/next of kin or Enduring Power of Attorney are to be notified of administration errors by the manager, or general practitioner as soon as possible.All six resident medication charts are reviewed. The medication chart has a picture of the resident that is current. Prescribing is seen by the resident's GP and review of medications on a three monthly basis. The administration of medications is signed by the caregiver. The back page where 'as required' and short term medications are prescribed has an area to document the identification details of the resident, this is not completed in all files reviewed. In four out of six charts there are 'as required medication' and short term medication dated early last year, that are discontinued but not signed and dated by the GP. The prescribing of non regular medications does not identify under what circumstances the medication should be given. These areas are discussed with the GP and are seen are areas that require improvement. Allergies are noted on all resident's medication charts.Sighted in the staff files evidence of education on medication management. There is one resident with Type 1 diabetes and there is evidence of his insulin being given as prescribed by the diabetes specialist and the monitoring of the blood glucose three times a day. The caregiver spoken with regarding medication stated she has been given education on medication and she is able to state the insulin management process.

Medication is delivered monthly from a local pharmacy in blister packs and the sign off sheet is seen as signed by the RN from NNS, the manager stated that medication other than blister packs are checked by her against the patients prescription. The blister packs, and as required medications, are stored in a locked cupboard. Medication that has expired or no longer required is returned to the pharmacy and a box of expired medication is sighted awaiting return by the manager.The manager stated that there is a policy on self administration of medication, however this is not encouraged. Where residents wish to self administer inhalers, this will be facilitated, following assessment of the person. No resident is self administering medications at the time of audit. The requirements of the ARC are met.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowAll six resident medication charts are reviewed. The administration records have a photo of the resident and are initialled for the administration of the medication by the caregiver. Each record has a list of sample signature list for caregivers and there is a sample GP signature register available. The back page where 'as required' and short term medications are prescribed has an area to document the identification details of the resident; this is not completed in all files reviewed and is an area for improvement.

There is evidence of the prescribing and review of medications on a six monthly basis by the resident's GP. This is confirmed by the GP spoken with. It is seen in four out of six charts 'as required medication' and short term medication dated early last year, examples are topical medications and antibiotics have been discontinued but not signed and dated as discontinued by the GP. The prescribing of non regular medications does not identify under what circumstances the medication should be given. These areas are discussed with the GP and are seen are areas that require improvement.

Finding Statement

The back page of the medication chart, where 'as required' and short term medications are prescribed has an area to document the identification details of the resident; this is not completed in all files reviewed and is an area for improvement. It is seen in four out of six charts 'as required medication' and short term medication dated early last year, have been discontinued but not signed and dated as discontinued by the GP. The prescribing of non regular medications does not identify under what circumstances the medication should be given.

Corrective Action Required:Each section of the medication record have the resident's details documented. The 'as required' medications have detailed under what circumstances the medication is to be administered. The 'as required' and short term medications are reviewed as part of the three monthly medication review, and discontinuation be documented.


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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

STANDARD 1.3.13 Nutrition, Safe Food, And Fluid Management

A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

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


How is achievement of this standard met or not met? Attainment: PA LowAt document review the Kitchen and Food Handling Policy and Principles are sighted. This states staff will follow good food handling practices and residents likes and dislikes will be taken into consideration at all times. Food temperature and satisfaction surveys are included in quality audit activity. The four weekly menu will be followed as this provides an interesting, wholesome and varied diet. Input into special menus and diets from a Registered Dietician is provided where appropriate. Fridge and freezer temperatures will be monitored regularly, as per audit activity, to ensure they are appropriate for safe food storage. The Waste Master will be used as much as possible to dispose of food scraps as to deter pests. The manager purchases food on a weekly basis or more frequently if required. The kitchen is a good sized domestic kitchen with a pantry for dry goods. The staff decant dry goods into sealed containers, however they do not indicate on the container the expiry date of the item from the manufacturers packaging and this is seen as an area for improvement. The staff member spoken with described stock rotation. There is a fridge and freezer in the kitchen and a further two in a store room at the back of the building and a further fridge in the manager's lounge/office. Two fridges are used to store insulin, the recording of the temperatures of these is six monthly and this is seen as an area that requires improvement. Food preparation and cooking is done by the caregiver on duty and training on this has been given by the manager and a competency completed. It is a recommendation that staff undertake training in the handling and preparation of food.

Sighted the Nutrition Matters Dieticians Consultancy Service, letter dated July 2010 states that the menu meets the Ministry of Health and Healthy Eating Guidelines for older people. There is evidence of residents' dietary preferences being recorded and actioned. One resident has Type 1 diabetes and there is guidance on his meals and snacks from the diabetic specialist nurse. When spoken with two resident, one the resident with Type 1 diabetes, stated their food requirements and preferences 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.


Finding Statement


Timeframe:

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


Finding Statement


Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe manager purchases food on a weekly basis or more frequently if required. A staff member spoken with stated as things get low they write on the board for the manager to note. Sighted the kitchen is a good sized domestic kitchen with a pantry for dry goods. The staff decant dry goods into sealed containers, however they do not indicate on the container the expiry date of the item from the manufacturers packaging and this is seen as an area for improvement. The staff member spoke of stock rotation. There is a fridge and freezer in the kitchen and a further two in a store room at the back of the building. Food in the fridge not used that day is dated and food in the freezer is also dated. The fridge in the kitchen and a further fridge in the manager's lounge/office are used to store insulin. There is six monthly recording of the temperature of the fridge and freezer and this is seen as an area that requires improvement.

Food is disposed of via the incinerator and this is confirmed by the staff member spoken with. There are six monthly audits of food services including the temperature of hot and cold foods.

Finding Statement

The staff decant dry goods into sealed containers, however they do not indicate on the container the expiry date of the item from the manufacturers packaging. There is six monthly recording of the temperature of the fridge and freezer.

Corrective Action Required:Dry goods out of manufacturer’s containers are dated to ensure use within manufacturer’s expiry time. Fridges and freezers have their temperature monitored daily.


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 Substances

Consumers, 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



Sighted at document review the Waste Management Policy. This covers the segregation and management of all types of waste. It is observed that management of waste is by coloured containers. The waste is removed by an external contractor weekly or more frequently if required. This is confirmed by the manager and a caregiver interviewed regarding cleaning and waste removal. The organisation is involved in recycling of plastic, bottles, cardboard and newspapers. The manager stated that incontinence pads are double bagged; there is no resident using these products presently. A caregiver provided evidence of the use of personal protective equipment. Sighted are gloves in many areas of the rest home, vinyl aprons for use when cleaning and an apron for use when cooking. These are laundered weekly. There are masks in the infection control box and a pair of goggles in the laundry. Chemicals used for cleaning and laundry are seen stored in manufacturers labelled containers that contain emergency management information. These are stored in the locked laundry area.The requirement of ARC D19.3c 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 Specifications

Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

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


How is achievement of this standard met or not met? Attainment: PA LowThe building has a current building warrant of fitness which is sighted on the wall of the facility. The facility is a house which the present owners/managers have added to over the last 13 years. There is a main hall way with the residents' single rooms off the corridor. One resident's room

is up a few stairs beside the manager/owner's lounge office area. The rooms and hall way are of a size that allows for use of mobility aids and assistance of a carer. There are no residents that require the use of a hoist. The corridor is wide enough for the resident with an aid, such as a walker and a carer. In an emergency an ambulance trolley is able to enter all rooms. Each resident has their own room with a wash hand basin. Residents can bring in their own furnishings and fittings if they desire. Stethoscope, which has not been calibrated. This is an area requiring an improvement. There is a blood glucose monitor owned and used by the resident who has Type 1 diabetes. There is an electric bed, televisions and other electrical equipment, not all have electrical testing labels and those that do are expired. This is an area for improvement. The owner/business manager when spoken with stated that maintenance is carried out on an as needs basis and external contractors do this work; this includes, electrician, plumbing and building.There is a lounge room, and off this a separate dining area. Meals can be taken here or in the resident's room. A number of accessible external areas are available. Residents are seen moving freely around the facility and using the deck area off the lounge. Hot water temperature is monitored on a six monthly basis and the monitoring record show that temperatures are within legislative requirements. The manager spoke of action being taken when the hot water was above the limits. The prospective provider has no plans to change the present environment, but did speak of doing some interior decoration.


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

Audit Evidence Attainment: PA Risk level for PA/UA: LowThe building has a current building warrant of fitness which is available on the wall of the facility. The equipment sighted included wheelchair, scales (domestic) which are calibrated by the owner, a thermometer and sphygmomanometer with a stethoscope, which have not been calibrated and this is an area for improvement. There is a blood glucose monitor owned and used by the resident who has Type 1 diabetes.

There is an electric bed, televisions and other electrical equipment; not all have electrical checking labels and those that do are expired. This is an area for improvement. The owner/business manager when spoken with stated that maintenance is done on an as needs basis and external contractors do this work; this includes, electrician, plumbing and building.

Finding Statement

The thermometer and sphygmomanometer have not been calibrated. There is an electric bed, televisions and other electrical equipment that have not been tested for electrical safety and labelled accordingly. Those pieces of equipment that are labelled have dates for rechecking that are expired.

Corrective Action Required:Equipment is calibrated on a regular basis as per the manufacturer's requirements. All electrical equipment has maintenance checking labels as required.


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 Facilities

Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

ARC E3.3d ARHSS D15.3c


How is achievement of this standard met or not met? Attainment: FAThe facility has two toilets and one shower for the use of residents. These are situated off the main hall and accessible to residents' rooms and the dining room and lounge area. Two residents spoken with stated that the toilet and shower facilities are adequate. There is a separate toilet/shower for the use of staff and visitors.

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 Areas

Consumers 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: FAEach resident has their own room. These are seen as of a good size and with adequate space for use of walking aids and with the assistance of a carer.

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 Dining

Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

ARC E3.4b ARHSS D15.3d


How is achievement of this standard met or not met? Attainment: FAThere is a lounge room and off this is a dining room. This meets the requirements of the residents. Two residents spoken with stated that these areas are adequate and they use their single rooms for private conversations. This is confirmed by a staff member spoken with.

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 Services

Consumers 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: FAAt document review the Cleaning/Housekeeping Procedures is sighted this covers damp dusting, use of specific coloured mops for different areas. Vacuum cleaning and storage of chemicals. This is observed during the audit and confirmed by a caregiver. There is also a Laundry Policy which covers the segregation of laundry, washing and storage of laundry. The laundry is visited with a caregiver and there is clear instructions on the use of washing machine and drier.

A caregiver stated that all cleaning and laundry chemicals are stored in the laundry and this is sighted. The laundry has a lock which is high up on the door and is kept locked when the laundry is not in use.The prospective provider provided evidence of the monitoring of the laundry and cleaning services. Two residents and two relatives stated that the facility and linen is clean. The requirements of the ARC 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 Systems

Consumers 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: FADocuments on emergency and security are seen at document review. These are:1. The security policy which covers staff securing the facility at night, afternoon and evening staff will carry a powerful torch on security rounds and have ready access to a telephone for emergency calls. The steps to take in the event of an intruder are outlined. 2. The Smoking policy, states staff and residents are to smoke outside, at night residents are to be supervised while smoking. The manager stated that they have no resident who smokes presently. 3. There is an occupational health policy this covers legislative requirements.4. The Emergency Plan lists number for services in an emergency, fire, St John’s ambulance, policy civil defence. earthquake, theft/burglary bomb threat, power failure.Sighted the fire service approved fire evacuation plan for the building. There are six monthly fire evacuation drills and the results are seen. The manager provided the file that contains the fire evacuation plan and the fire drill review forms; the last fire drill was carried out in March 2013. There is fire alarm and fire fighting equipment in the main corridor, and exits are marked. Staff have training on emergencies at orientation and emergency flip charts are available on emergency situations. A caregiver spoke of the emergency supplies and these are sighted in a garage the emergency supplies of blankets, water, plastic bags and food. There is also a portable barbecue available for cooking and torches for lighting. A first aid kit is kept in the laundry. Each resident's room has a call bell and there is a call bell in the toilets and shower. The call bell ring can be directed to different areas. During the day, this is directed more to the lounge and dining areas, where staff are; at night it is diverted to the manager's accommodation at the end of the building. The manager spoke of one resident who has dementia and who has begun to wander. This resident has a personal alarm but has been removing this. The main outside door is alarmed to alert when opened, however this resident managed to wander outside using another door. All external doors are now alarmed.

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 Heating

Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

ARC D15.2f ARHSS D15.2g


How is achievement of this standard met or not met? Attainment: FAThe manager stated that the facility is heated by a heat pump and there is also a wood burner in the lounge room. There are thermometers seen around the facility to record the ambient temperature - sighted to be at 20 degrees Celsius on the day of audit. Each resident's room has an external opening window and doors can be left open for ventilation.

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 MINIMISATIONSTANDARD 2.1.1 Restraint minimisation

Services 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: FASighted at document review the Restraint Minimisation Policy, which states restraint will only be used in an emergency and after all options have been tried. The definitions include enablers and meet the requirements of the standard. Education on restraint occurred last year by an external provider this related to de-escalation and management of challenging behaviour. The prospective provider is able to state the definition of enabler as voluntary and used only for the time required. There are no residents using enablers. Restraint has only been used once in the facility a long time ago. This was confirmed by the GP and a caregiver spoken with.

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 management

There 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: FADocument review - sighted the Infection Control Plan. This stated a RN has responsibility for infection control and outlines the responsibilities. The infection control committee is made up of the manager and the RN. Infections are documented by the RN and discussed at the staff meeting that is held four times a year. A six monthly report on infections within the facility, if they are treated, and what they were treated with, are documented and reviewed. The new manager provided evidence of this occurring. The manager stated that residents have the annual 'flu' vaccination. Consent forms are seen for last year’s vaccination and the manager stated that they have gone out for signing for this year. Staff are encouraged to have the 'flu' vaccination and discouraged to work with infections. They have not put signs on the doors warning visitors to stay away if they have an infection, however, this is not seen as an issue. The manager stated that the DHB sent out an email when there is Norovirus or respiratory infections prevalent in the area. The requirement of ARC D5.4e is 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 programme

There 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: FASighted at document review is the Infection Control Policy. This states the Partners are committed to infection control principles and standard precautions. Hand washing facilities are around the home. Residents with a compromised health status will be identified at an early stage as at risk of developing an infection. The Infection Control Officer/ RN is responsible for co-ordination of infection control activity with the support of the manager. Antibiotic usage, whether as active treatment or prophylactic treatment, will be the decision of the resident’s GP. Surveillance will include recording of all residents' infections noting the date, type of infection, treatment sought and outcome. These will be correlated annually as part of the Infection Control and Quality Improvement programme. The infection Control committee (RN and Manager) will meet four times per year, at a minimum, and be responsible for the Infection Control programme. Protective gear includes disposable aprons, disposable masks, eye goggles and disposable gloves. Specialist infection control advice will be sought where solutions cannot be determined. In the first instance this will be through MedLab and in the second instance, the Infection Control Nurse at Nelson Hospital.This is confirmed with the manager. The prospective provider will continue with the assistance of the RN she is proposing to employ. This will include continuing with the six monthly audits of hand washing, food handling, and soiled linen. The March 2013 audits are seen. The staff meeting minutes identify infections being discussed.

The requirement of ARC D5.4e are met.

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


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STANDARD 3.3 Policies and procedures

Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a


How is achievement of this standard met or not met? Attainment: FAThe manager provided the infection control policies and procedure manual. This covers all areas of prevention and precautions to meet the requirements of the standard. The manager stated that an outbreak is seen as two or more residents with an infection. The present policy covers gastroenterology outbreak. It is a recommendation that this be extended to cover other outbreaks, such as respiratory. Sighted the infection control box which contains extra gloves and masks. A caregiver spoken with stated an awareness of the infection control policies and procedures and the where abouts of the infection control box.

The requirement of ARC are met.

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


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STANDARD 3.4 Education

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



How is achievement of this standard met or not met? Attainment: FAThe manager from NNS when spoken with by telephone stated that they provide some education on infection control within the RNs' scope of practice, which includes health and safety, such as hand hygiene, wound management and vaccinations. Sighted in one staff member's file attendance at external infection control training, provided through New Zealand Health Care Providers and provided by an infection control specialist nurse. Other staff files have infection control as part of orientation. Two staff interviewed stated that they have had infection control training.

The requirement of ARC 5.4e is met.

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


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


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


How is achievement of this standard met or not met? Attainment: FAA six monthly review of infections is undertaken by the manager/care giver. The last report which is for 2012 is sighted. This identifies the number of infections, by type, any treatment noted and general analysis of the data. There were five infections listed in 2011and two urinary tract infections documented for 2012. The prospective provider states she will continue this practice.

Criterion 3.5.1 The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.


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Criterion 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.


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