itzroy Village anagement imited · Fitzroy of Merivale is a 30 bed rest home providing aged residential care services under an Occupation Right Agreement (ORA) arrangement in large

Fitzroy Village Management Limited

Current Status: 24 March 2014

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

General overview

Fitzroy of Merivale is a 30 bed rest home providing aged residential care services under an

Occupation Right Agreement (ORA) arrangement in large studio apartments. At the time of audit

there are 23 residents in the facility. All residents are assessed as requiring rest home level care

with one resident receiving a residential care subsidy. The facility also provides respite care.

The facility changed ownership in June 2013 and is presently operated by two owners, one of

whom is the registered nurse manager along with two registered nurses who job share. There is a

stable workforce of experienced care staff employed to provide day to day care. Residents, staff

and the general practitioner are complimentary about the seamless transition which has occurred

to the new ownership and the changes which have been implemented since then. Quality

management systems and service delivery are consistently implemented.

One area is identified as beyond the full attainment level expected, in that good practices are

implemented resulting in specific improvement in resident care outcomes. Three areas are

identified as requiring improvement. These relate to use of quality improvement trending data, the

infection surveillance programme and analysis of this data.

Requirements of the provider’s contract with the District Health Board are met.

Audit Summary as at 24 March 2014

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short falls Standards applicable to this service fully attained

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

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

Indicator Description Definition

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights as at 24 March 2014

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

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

Organisational Management as at 24 March 2014

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

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

Continuum of Service Delivery as at 24 March 2014

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

Standards applicable to this service fully attained.

Safe and Appropriate Environment as at 24 March 2014

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


Restraint Minimisation and Safe Practice as at 24 March 2014

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


Infection Prevention and Control as at 24 March 2014

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

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

Audit Results as at 24 March 2014

Consumer Rights

New residents at Fitzroy of Merivale are provided with information on the Code of Health and

Disability Services Consumers' Rights (the Code) and on the Nationwide Health and Disability

Advocacy Service. There are opportunities for further discussion with staff when required, with

discussions also occurring at the monthly residents’ meeting.

Residents interviewed report being treated with dignity and respect. There are no residents who

identify as Maori at the time of audit, however there is policy, links with local iwi and a Maori health

plan in place that supports staff to meet the needs of Maori residents. Personal preferences,

cultural and spiritual values are incorporated into the plan of care for each resident.

Open disclosure is part of an open communication practice at the facility. Residents state they are

kept well informed and feel able to express opinions and make requests of staff. They confirm they

are able to maintain links with family, friends and the community. Informed consent is obtained on

admission and consent for specific procedures obtained when necessary. Records of advance

directives and enduring power of attorney are kept on file and updated as part of regular reviews.

Complaints are effectively managed.

Good practices are established with up to date policies and protocols guiding practice, as well as a

number of examples of quality initiatives focussed system improvement and positive resident

outcomes implemented since the change of ownership.

There are no areas identified requiring improvement and meets requirements of ARRC

agreement.

Organisational Management

The service has a mission statement, philosophy and set of values. A current strategic business

plan with objectives is available. Key documents include organisational policies and procedures, a

quality plan, a risk management plan and a review process is in place to ensure currency.

Quality and risk management systems are established with internal audits, satisfaction surveys,

incidents and accident records, infection control, health and safety and issues around service

delivery being discussed at staff meetings and bi-monthly quality and risk meetings. Incident and

accident reports and internal audit results are being analysed and reviewed. The service is yet to

undertake an analysis of any trends identified over time to determine whether any improvement

has occurred, or whether the issues identified have been addressed. This is an area requiring

improvement. Hazard and risk registers are used and reviewed to ensure they reflect the current

needs of the service.

Human resource processes are supporting the employment of suitable employees. Practising

certificates of staff are current and a copy kept on file by the service. Training is made available to

staff with all support workers having completed or currently undergoing a national certificate in

aged care. Additional topics are provided at in-service training sessions. All new staff are required

to undertake an orientation programme, and records of this are retained. Staff rosters are seen to

meet the needs of the service and there is good registered nurse support as required.

Resident health records are seen to be maintained according to best practice and legislative

guidelines and requirements.

Continuum of Service Delivery

Entry processes, thorough nursing and medical assessment, care planning, implementation and

review are evident for residents. A multidisciplinary team approach led by the manager and two

registered nurses is focussed on provision of individualised care. Care plans are developed and

reviewed within the required timeframes. Progress is recorded and changes made to plans as

required, with numerous examples of reassessment and updating of plans evident at audit. A

stable workforce of well-trained care staff are responsible for the day to day care delivered

according to the plan developed by registered nurses or prescribed by the medical practitioner.

Resident interviews confirm that care meets their needs and preferences. Residents' files

reviewed evidence appropriate referral to other health services.

A trained diversional therapist and activities co-ordinator are responsible for the planned activity

programme. There is a monthly activity programme which is varied and is age and interest

appropriate. Outings and internal entertainment are regularly offered. Residents interviewed state

that activities are enjoyable, community participation is encouraged and families included where

desired.

Medication systems are established and implemented guided by up-to-date policies and

procedures. Supply, storage, administration and reconciliation of medicines meet legislation and

guidelines. A blister pack system is used, including for residents assessed as competent to self-

administer their medicines. Medication administration as observed on the day of the audit is

undertaken by senior care staff assessed as competent to undertake the task. Medication orders

follow good practice charting requirements and administration is recorded.

The meal service is contracted out and delivered to the site ready to serve. The menu has been

reviewed by the contractor’s dietitian in line with food guidelines for older people. At admission and

at each review, residents have a dietary assessment informed by monthly weight monitoring.

Special dietary needs are available if required. Personal preferences are catered for, and

residents provide feedback about menu content at residents' meetings. Residents interviewed are

satisfied with the meals provided. Residents are referred to a private dietitian if their weight

fluctuates or there is sustained weight loss. Appropriate storage, refrigeration and food preparation

is occurring.

Safe and Appropriate Environment

Methods of managing waste and of identifying and managing hazards are well documented and

meet requirements. Personal protective equipment is readily available and being used by staff.

The facility has a current building warrant of fitness. Electrical checks and equipment maintenance

checks have been undertaken within the past twelve months. The required earthquake repairs are

in progress and due for completion.

There is level access to the both facilities and internally throughout. Ramps and pathways are in

place to facilitate the use of walking aids and the pathways have recently been replaced.

Bathroom facilities are provided as ensuites in all residents’ rooms. The dining and lounge spaces

are open plan and comfortable.

Fire evacuation trials are up to date, security arrangements are in place and call bells are

operational. A check of emergency supplies and storage is undertaken during routine checks and

the service has sufficient to meet the needs of the residents.

Cleaning and laundry procedures and schedules are available and these systems are monitored

as part of the internal audit system. The laundry is contracted to a local service.

All residents’ bedrooms and living areas have windows that are able to be opened for ventilation

and a door to paved outside areas. Radiators are fitted throughout the facility for use in cooler

weather. There is a designated area outside for residents who choose to smoke.

Restraint Minimisation and Safe Practice

The facility has established policies and procedures to minimise restraint and ensure safe practice.

Enablers are defined and meet the requirements of the standard. There are no restraints or

enablers in use and management report that Fitzroy of Merivale is, and has been, restraint free.

Infection Prevention and Control

The service has recently adopted the infection control suite of policies from an outside contractor

and they have been adapted to the needs of Fitzroy and introduced into practice. The infection

prevention and control programme and its associated policies and procedures are discussed and

agreed at the quality and risk meeting and the 2014 programme has been agreed to by the facility

manager/owner.

Training related to infection prevention focuses on hand washing, work flow, waste management

and the use of personal protective equipment. Staff undergo annual hand washing audits and

complete a questionnaire on wider infection control information at orientation and annually

thereafter.

Surveillance procedures are detailed in the documents and discussed at bi-monthly quality and

risk meetings. The analysis of surveillance results is undertaken monthly and reported to the staff.

There are two areas relating to surveillance that need to be improved. These are around the use

of standard definitions for the identification of infections, and the trending and analysis of incidence

of infections over time to ensure any actions taken or changes made, have improved outcomes.

HealthCERT Aged Residential Care Audit Report (version 4.0)

Introduction

This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.

Audit Report

Legal entity name: Fitzroy Village Management Limited

Certificate name: Fitzroy Village Management Limited

Designated Auditing Agency: The DAA Group Limited

Types of audit: Certification Audit

Premises audited: Fitzroy of Merivale Resthome

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 24 March 2014 End date: 25 March 2014

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: 23

Audit Team

Lead Auditor XXXXX Hours on site

12 Hours off site

8

Other Auditors XXXXX Total hours on site

12 Total hours off site

6

Technical Experts Total hours on site

Total hours off site

Consumer Auditors Total hours on site

Total hours off site

Peer Reviewer XXXXX Hours 4

Sample Totals

Total audit hours on site 24 Total audit hours off site 18 Total audit hours 42

Number of residents interviewed 5 Number of staff interviewed 12 Number of managers interviewed 1

Number of residents’ records reviewed

6 Number of staff records reviewed 9 Total number of managers (headcount)

1

Number of medication records reviewed

11 Total number of staff (headcount) 24 Number of relatives interviewed

Number of residents’ records reviewed using tracer methodology

1 Number of GPs interviewed 1

Declaration

I, XXXXX, Director of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of The DAA Group Limited, an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of The DAA Group Limited Yes

b) The DAA Group Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes

c) The DAA Group Limited has developed the audit summary in this audit report in consultation with the provider Yes

d) this audit report has been approved by the lead auditor named above Yes

e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes

f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable

g) The DAA Group Limited has provided all the information that is relevant to the audit Yes

h) The DAA Group Limited has finished editing the document. Yes

Dated Thursday, 17 April 2014

Executive Summary of Audit

General Overview

Fitzroy of Merivale is a 30 bed rest home providing aged residential care services under an Occupation Right Agreement (ORA) arrangement in large studio apartments. At the time of audit there are 23 residents in the facility. All residents are assessed as requiring rest home level care with one resident receiving a residential care subsidy The facility also provides respite care. The facility changed ownership in June 2013 and is presently operated by two owners, one of whom is the registered nurse manager along with two registered nurses who job share. There is a stable workforce of experienced care staff employed to provide day to day care. Residents, staff and the general practitioner are complimentary about the seamless transition which has occurred to the new ownership and the changes which have been implemented since then. Quality management systems and service delivery is consistently implemented. One area is identified as beyond the full attainment level expected, in that good practices are implemented resulting in specific improvement in resident care outcomes. Three areas are identified as requiring improvement. These relate to use of quality improvement trending data, the infection surveillance programme and analysis of this data. Requirements of the provider’s contract with the District Health Board are met.

Outcome 1.1: Consumer Rights

New residents at Fitzroy of Merivale are provided with information on the Code of Health and Disability Services Consumers' Rights (the Code) and on the Nationwide Health and Disability Advocacy Service. There are opportunities for further discussion with staff when required, with discussions also occurring at the monthly residents’ meeting. Residents interviewed report being treated with dignity and respect. There are no residents who identify as Maori at the time of audit, however there is policy, links with local iwi and a Maori health plan in place that supports staff to meet the needs of Maori residents. Personal preferences, cultural and spiritual values are incorporated into the plan of care for each resident. Open disclosure is part of an open communication practice at the facility. Residents state they are kept well informed and feel able to express opinions and make requests of staff. They confirm they are able to maintain links with family, friends and the community. Informed consent is obtained on admission and consent for specific procedures obtained when necessary. Records of advance directives and enduring power of attorney are kept on file and updated as part of regular reviews. Complaints are effectively managed. Good practices are established with up to date policies and protocols guiding practice, as well as a number of examples of quality initiatives focussed system improvement and positive resident outcomes implemented since the change of ownership. There are no areas identified requiring improvement and meets requirements of ARRC agreement.

Outcome 1.2: Organisational Management

The service has a mission statement, philosophy and set of values. A current strategic business plan with objectives is available. Key documents include organisational policies and procedures, a quality plan, a risk management plan and a review process is in place to ensure currency. Quality and risk management systems are established with internal audits, satisfaction surveys, incidents and accident records, infection control, health and safety and issues around service delivery being discussed at staff meetings and bi-monthly quality and risk meetings. Incident and accident reports and internal audit results are being analysed and reviewed. The service is yet to undertake an analysis of any trends identified over time to determine whether any improvement has occurred, or whether the issues identified have been addressed. This is an area requiring improvement. Hazard and risk registers are used and reviewed to ensure they reflect the current needs of the service. Human resource processes are supporting the employment of suitable employees. Practising certificates of staff are current and a copy kept on file by the service. Training is made available to staff with all support workers having completed or currently undergoing a national certificate in aged care. Additional topics are provided at in-service training sessions. All new staff are required to undertake an orientation programme, and records of this are retained. Staff rosters are seen to meet the needs of the service and there is good registered nurse support as required. Resident health records are seen to be maintained according to best practice and legislative guidelines and requirements.

Outcome 1.3: Continuum of Service Delivery

Entry processes, thorough nursing and medical assessment, care planning, implementation and review are evident for residents. A multidisciplinary team approach led by the manager and two registered nurses is focussed on provision of individualised care. Care plans are developed and reviewed within the required timeframes. Progress is recorded and changes made to plans as required, with numerous examples of reassessment and updating of plans evident at audit. A stable workforce of well-trained care staff are responsible for the day to day care delivered according to the plan developed by registered nurses or prescribed by the medical practitioner. Resident interviews confirm that care meets their needs and preferences. Residents' files reviewed evidence appropriate referral to other health services. A trained diversional therapist and activities co-ordinator are responsible for the planned activity programme. There is a monthly activity programme which is varied and is age and interest appropriate. Outings and internal entertainment are regularly offered. Residents interviewed state that activities are enjoyable, community participation is encouraged and families included where desired. Medication systems are established and implemented guided by up-to-date policies and procedures. Supply, storage, administration and reconciliation of medicines meet legislation and guidelines. A blister pack system is used, including for residents assessed as competent to self-administer their medicines. Medication administration as observed on the day of the audit is undertaken by senior care staff assessed as competent to undertake the task. Medication orders follow good practice charting requirements and administration is recorded. The meal service is contracted out and delivered to the site ready to serve. The menu has been reviewed by the contractor’s dietitian in line with food guidelines for older people. At admission and at each review, residents have a dietary assessment informed by monthly weight monitoring. Special dietary needs are available if required. Personal preferences are catered for, and residents provide feedback about menu content at residents' meetings. Residents interviewed are satisfied with the meals provided. Residents are referred to a private dietitian if their weight fluctuates or there is sustained weight loss.

Appropriate storage, refrigeration and food preparation is occurring.

Outcome 1.4: Safe and Appropriate Environment

Methods of managing waste and of identifying and managing hazards are well documented and meet requirements. Personal protective equipment is readily available and being used by staff. The facility has a current building warrant of fitness. Electrical checks and equipment maintenance checks have been undertaken within the past twelve months. The required earthquake repairs are in progress and due for completion. There is level access to the both facilities and internally throughout. Ramps and pathways are in place to facilitate the use of walking aids and the pathways have recently been replaced. Bathroom facilities are provided as ensuites in all residents’ rooms. The dining and lounge spaces are open plan and comfortable. Fire evacuation trials are up to date, security arrangements are in place and call bells are operational. A check of emergency supplies and storage is undertaken during routine checks and the service has sufficient to meet the needs of the residents. Cleaning and laundry procedures and schedules are available and these systems are monitored as part of the internal audit system. The laundry is contracted to a local service. All residents’ bedrooms and living areas have windows that are able to be opened for ventilation and a door to paved outside areas. Radiators are fitted throughout the facility for use in cooler weather. There is a designated area outside for residents who choose to smoke.

Outcome 2: Restraint Minimisation and Safe Practice

The facility has established policies and procedures to minimise restraint and ensure safe practice. Enablers are defined and meet the requirements of the standard. There are no restraints or enablers in use and management report that Fitzroy of Merivale is, and has been, restraint free.

Outcome 3: Infection Prevention and Control

The service has recently adopted the infection control suite of policies from an outside contractor and they have been adapted to the needs of Fitzroy and introduced into practice. The infection prevention and control programme and its associated policies and procedures are discussed and agreed at the quality and risk meeting and the 2014 programme has been agreed to by the facility manager/owner. Training related to infection prevention focuses on hand washing, work flow, waste management and the use of personal protective equipment. Staff undergo annual hand washing audits and complete a questionnaire on wider infection control information at orientation and annually thereafter. Surveillance procedures are detailed in the documents and discussed at bi-monthly quality and risk meetings. The analysis of surveillance results is undertaken monthly and reported to the staff. There are two areas relating to surveillance that need to be improved. These are around the use of standard definitions for the identification of infections, and the trending and analysis of incidence of infections over time to ensure any actions taken or changes made,

have improved outcomes.

Summary of Attainment

CI FA PA Negligible PA Low PA Moderate PA High PA Critical

Standards 1 42 0 2 0 0 0

Criteria 1 89 0 3 0 0 0

UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited

Standards 0 0 0 0 0 0 0 5

Criteria 0 0 0 0 0 0 0 8

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

HDS(C)S.2008 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.

PA Low

HDS(C)S.2008 Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

PA Low Currently the reports from the internal audit and monitoring processes do not include an analysis of trends over time to determine whether any improvement in outcomes has occurred or the identified issues have been addressed.

Ensure quality improvement data is analysed and evaluated to determine an improvement in outcomes has occurred or the identified issues have been addressed.

180

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

HDS(IPC)S.2008 Standard 3.5: Surveillance

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

PA Low

HDS(IPC)S.2008 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.

PA Low Although policy documents describe the infections that will be recorded, standard definitions are not currently used by the service in order to ensure any data reported is accurate and the appropriate infections are being monitored.

Ensure standard definitions are used to define infections monitored as per current best practice guidelines.

180

HDS(IPC)S.2008 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.

PA Low The service is yet to determine whether there are any trends and undertake an analysis of any trends over time in order to determine if changes need to be made to their processes or the management of the resident.

Ensure surveillance results are trended and analysed over time in order to identify ways of assisting in the reduction and prevention of infections.

180

Continuous Improvement (CI) Report

Code Name Description Attainment Finding

HDS(C)S.2008 Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

CI

Code Name Description Attainment Finding

HDS(C)S.2008 Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice.

CI The service is demonstrating achievement of good practice beyond the expected full attainment level. There are examples of individual residents benefitting from evidence based care delivery and improved health and wellbeing from these specific interventions.

NZS 8134.1:2008: Health and Disability Services (Core) Standards

Outcome 1.1: Consumer Rights

Consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer

rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs.

Standard 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1) Consumers receive services in accordance with consumer rights legislation.

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

Attainment and Risk: FA

Evidence:

Staff interviewed understand consumer rights and are observed to apply this in practice with residents, for example by closing doors during conversations or during personal care. Staff are respectful and communicate in an appropriate and dignified manner, calling residents by their preferred names. Residents interviewed confirm that this occurs as a matter of routine and that their wishes and concerns are listened to and respected. There is a stable workforce and training in resident rights has occurred with a speaker from the Health and Disability Commission on site in the past year as part of the education calendar.

Criterion 1.1.1.1 (HDS(C)S.2008:1.1.1.1) Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.


Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2) Consumers are informed of their rights.

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


Evidence:

A package of information about Fitzroy of Merivale is provided to residents prior to admission to the facility and supported by a ‘revamped’ website which includes information on rest home care. The Health and Disability Services Consumers’ Rights (the Code) poster is displayed in public areas in the facility, as is information about the Nationwide Health and Disability Advocacy Service, which is clearly displayed and accessible to residents the lounge and hallway. Fitzroy of Merivale has an unrushed and calm atmosphere conducive to quiet discussion with the staff, family and friends, as observed during audit. The registered nurse or manager is responsible for discussing and explaining the Code as part of the admission process, a copy of the Code is provided at admission and residents are able to discuss any aspect of their rights of a regular basis through the monthly resident of meetings led by the diversional therapist. The registered nurse explains or reads the Code to the resident as part of the admission process.

Criterion 1.1.2.3 (HDS(C)S.2008:1.1.2.3) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.2.4 (HDS(C)S.2008:1.1.2.4) Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3) 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


Evidence:

The organisation has a policy on abuse and neglect sighted during stage one of the audit. This includes definitions, causes, referral processes, signs and symptoms, staff issues and actions and includes a statement of non-tolerance. Confidentiality and privacy procedures are documented and note that staff sign a confidentiality agreement when they commence their employment - this is validated on site. Physical privacy is well managed and the role of the privacy officer, who is the facility manager is described. Intimacy and sexuality in the elderly are also described in policy documents and cover issues such as respect, safety, consent and religious and spiritual preferences. A spirituality and counselling document covers spiritual needs, an overview about grief and loss and a list of resources for assisting residents to have their spiritual and/or any counselling needs met. Five residents interviewed (both individually and collectively) are complimentary about the way in which their personal privacy is respected by staff and their independence encouraged. This includes one resident who returned from leave on the day of audit, following a family visit to Auckland. Residents are able to participate in church services in the facility; however several are sufficiently independent to go out to nearby community and social activities. Some residents have their own vehicle or are well supported by family and friends. Residents also choose to participate (or not) in the facility activities programme. This is observed during audit and confirmed by residents spoken to.

Criterion 1.1.3.1 (HDS(C)S.2008:1.1.3.1) The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.2 (HDS(C)S.2008:1.1.3.2) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.6 (HDS(C)S.2008:1.1.3.6) Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.7 (HDS(C)S.2008:1.1.3.7) Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.


Evidence:

Finding:

Corrective Action:


Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4) 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


Evidence:

Presently, there are no residents who identify as Maori in the facility. Previously, a short term Maori resident is reported to not have identified any specific cultural needs, although the registered nurse interviewed is able to explain how to access additional support if required. A Maori health plan and ethnicity awareness policy and procedure includes definitions, information on cultural safety and family/whanau and tangata whenua support/whakawhanaungatanga. There is additional information on generic cultural care and interventions, specifics on links to Maori health providers and references to required staff training on cultural safety and the Treaty of Waitangi. Training has occurred in 2012 as part of the biannual education plan.

Criterion 1.1.4.2 (HDS(C)S.2008:1.1.4.2) Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.3 (HDS(C)S.2008:1.1.4.3) The organisation plans to ensure Māori receive services commensurate with their needs.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.5 (HDS(C)S.2008:1.1.4.5) The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6) 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


Evidence:

Policy and procedures on culturally safe care are attached to the Maori plan and ethnicity awareness policy and procedure. These include information about the cultural considerations and needs of a range of ethnic groups, cultural considerations of death and information on staff training about cultural safety. A glossary is appended to the policy document. Resident information packs are made available, and where required, interpreters and cultural representatives/advocacy services are contacted to ensure information is understood. The registered nurse reports this has not been required in the recent past. Residents (five of five) interviewed verify that cultural needs, values and beliefs are met at all times by the facility, management and staff. One resident with a European background has had this acknowledged with a local choir performing Austrian songs for her at Christmas. The diversional therapist uses the social history form to gather information and preferences as part of the individual plan of care.

Criterion 1.1.6.2 (HDS(C)S.2008:1.1.6.2) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7) Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e


Evidence:

Discussions with the manager, review of policy and the Fitzroy of Merivale code of conduct confirm that there are systems to manage any potential discrimination. Staff are made aware of professional boundaries during the employment process and when undertaking formal education such as the aged care education programme. They can describe a non-acceptance of gifts as one example. At interview, one resident describes a situation about “boundaries” which is known to, and is being addressed by the manager.

Criterion 1.1.7.3 (HDS(C)S.2008:1.1.7.3) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8) 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

Attainment and Risk: CI

Evidence:

Residents at Fitzroy of Merivale receive care and services of an appropriate standard. The manager, who is the co-owner, has been in her role for nine months and together with the two registered nurses, has made changes and improvements to care delivery in that time. This includes policy and procedure revision and purchase of a suite of documents linked to current good practice selected and customised to the facility’s requirements. The two registered nurses interviewed provide clinical support to the manager who is also a registered nurse. This ensures there is a seven day nursing presence on site and ready advice for any clinical needs.

Criterion 1.1.8.1 (HDS(C)S.2008:1.1.8.1) The service provides an environment that encourages good practice, which should include evidence-based practice.

Attainment and Risk: CI

Evidence:

A number of examples presented at audit demonstrate achievement of good practice beyond the expected full attainment. A quality improvement register is set up, with more than twenty examples of improvements which have been undertaken since the new owners took over management in June 2013. This includes a review of the improvement at two and six months post implementation which evidences an organisational focus on continuous improvement. Two examples, in particular, have directly improved individual resident care and outcomes, with the two month reviews already evidencing the positive impact. The first relates to a long term resident of the facility (since 2007). Personalised care and assessment, excellent communication with overseas based family, involvement of the multi disciplinary team and Psychiatric Services for the Elderly (PSE) at Older Persons’ Health, has resulted in implementation of evidence based practice, with additional support from a one-on-one carer. A 24 hour plan is also being implemented, led by the diversional therapist. This is proving to be an effective strategy that is meeting the needs of this resident, supporting her to prepare for bed and resulting in an improved sleep pattern over the past few weeks. Another resident has benefitted from the introduction of equipment following discharge from a tertiary service. This has been trialled and purchased to assist with positioning, along with implementation of other good practice nursing interventions. A multidisciplinary team meeting included the resident and family, discussed options and reviewed the effectiveness of the new equipment. The resident has increased bed mobility, is more independent and has had no further hospital admissions since its introduction.

Finding:

The service is demonstrating achievement of good practice beyond the expected full attainment level. There are examples of individual residents benefitting from evidence based care delivery and improved health and wellbeing from these specific interventions.

Corrective Action:


Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9) 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


Evidence:

Sighted the open disclosure policy (review date 2015) which provides direction for staff. Staff last received training in open disclosure, consent and resident rights training

in November 2013 from the Health and Disability Advocacy Services – records are sighted and six care staff are seen to have attended. Staff are able to describe how to obtain interpreter services if needed but report this is rarely required. Cultural and spiritual needs are assessed on admission and discussions had with the Needs Assessment Service Coordination (NASC) agency in order to identify any particular requirements for the resident entering services, this would include the need for language support or interpreter services. All contractual requirements are met.

Criterion 1.1.9.1 (HDS(C)S.2008:1.1.9.1) Consumers have a right to full and frank information and open disclosure from service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.9.4 (HDS(C)S.2008:1.1.9.4) Wherever necessary and reasonably practicable, interpreter services are provided.


Evidence:

Finding:

Corrective Action:


Standard 1.1.10: Informed Consent (HDS(C)S.2008:1.1.10) 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


Evidence:

There is policy and procedure documentation about informed consent processes, the use of an Enduring Power of Attorney (EPOA) and Advance Directives for resuscitative status. The documentation includes forms for obtaining informed consent and/or advance directive as required. Staff training in informed consent was last completed in April 2013. Review of six residents’ files confirms that it is standard practice to include a copy of an enduring power of attorney (where this is in place) and the residential care contract. Residents are invited to complete a form indicating their preference for future health care needs and these are present in all files reviewed. This form is reviewed as part of the multidisciplinary team meeting held six monthly and documented on the form. Verbal consent is accepted for day to day interventions and for flu vaccinations. This is documented for one resident who has recently received flu vaccination in the facility.

Criterion 1.1.10.2 (HDS(C)S.2008:1.1.10.2) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.4 (HDS(C)S.2008:1.1.10.4) The service is able to demonstrate that written consent is obtained where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.7 (HDS(C)S.2008:1.1.10.7) Advance directives that are made available to service providers are acted on where valid.


Evidence:

Finding:

Corrective Action:


Standard 1.1.11: Advocacy And Support (HDS(C)S.2008:1.1.11) 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


Evidence:

Fitzroy of Merivale has a residents' advocacy policy (sighted), which includes the resident's right to access an independent advocate, or a person of their choice to represent them in any matter. Staff training in advocacy support has been provided in 2013 by representatives of the Health and Disability Commissioner.

Residents (five) interviewed are aware of the advocacy service but also state that they liked to use family to support them. One resident interviewed, with no family in the area has an appointed power of attorney if needed. Residents have also discussed, advocacy and support in resident meetings, which are held monthly (minutes sighted). There is evidence in the residents’ files sampled (six) that family members are involved and provide support to residents as required.

Criterion 1.1.11.1 (HDS(C)S.2008:1.1.11.1) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.1.12: Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12) 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


Evidence:

Residents interviewed verify that they are able to have visitors at any time. Several residents have their own sitting-room, therefore, visitors do not cause disruption to other residents and state that they can enjoy the comfort of their own space. One resident comments that she is in touch with her family daily, by telephone and through very regular visits. Residents interviewed verify they can continue with usual activities outside the facility if they choose. One resident confirms she is socially very busy with the facility and outside activities she undertakes, she is very happy with this and states she is never short of something to do. Two other residents interviewed also continue to drive and can access shopping and social activities or visit friends. Interview with the diversional therapist and review of the monthly programme confirms there are regular group trips scheduled outside the facility (eg, to the shops, family celebrations and recently to a llama farm in a rural area). During the audit days residents were observed participating in activities and going out regularly.

Criterion 1.1.12.1 (HDS(C)S.2008:1.1.12.1) Consumers have access to visitors of their choice.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.12.2 (HDS(C)S.2008:1.1.12.2) Consumers are supported to access services within the community when appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.1.13: Complaints Management (HDS(C)S.2008:1.1.13) 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


Evidence:

The service maintains a complaints register that includes dates and actions taken. There are three minor complaints listed since the new owners took over in June 2013 and all have been resolved and closed. The manager reports the majority of complaints or feedback is verbal, although a suggestion box and form are available to complete.

Monthly resident meetings have been reinstated to facilitate communication between the residents and management. Minutes sighted maintain a record of discussions and actions taken. A resident satisfaction survey was undertaken in January 2013 and the raw data results support a high degree of satisfaction with the service and new management. The survey results are yet to be formally collated and analysed. All ARC requirements are met.

Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1) The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3) An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.


Evidence:

Finding:

Corrective Action:


Outcome 1.2: Organisational Management

Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.

Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1) 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


Evidence:

A mission statement, service provider philosophy, a vision statement and a set of values are documented, have been reviewed for the current year and are sighted during stage one audit. These refer to priorities of dignity, valuing each person as an individual, respecting people’s rights, maintaining excellence in service provision, continuous quality improvement, providing a safe and secure environment and ensuring staff competency. This is clearly stated on information brochures and the website to ensure it is known to the wider community. A strategic business plan has four goals that are consistent with the mission, values, philosophy and vision for the service as they focus on providing quality services that meet expectations, ensuring governance and management is sound, having competent staff and improving partnerships with other service. Sighted the strategic plan for 2014. This is noted to have been discussed at the bi-monthly quality and risk management meeting (sighted minutes from 29 Jan 2014). The service is managed by the owner who is a registered nurse (RN) and the facility manager (FM). She is noted to have a current annual practising certificate (APC) and has a long history of public health nursing, and quality and risk management in both aged care and as an independent contractor. She and her business partner purchased the facility in June 2013. The requirements of the ARC are met.

Criterion 1.2.1.1 (HDS(C)S.2008:1.2.1.1) The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3) The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.


Evidence:

Finding:

Corrective Action:


Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2) 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


Evidence:

One of the RNs deputises for the Facility manager in her absence. She is noted to have had 14 years’ experience managing aged residential care facilities across the region. This role is noted to be reflected in her job description and is known to staff.

Criterion 1.2.2.1 (HDS(C)S.2008:1.2.2.1) During a temporary absence a suitably qualified and/or experienced person performs the manager's role.


Evidence:

Finding:

Corrective Action:


Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3) 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

Attainment and Risk: PA Low

Evidence:

A comprehensive quality and risk management plan dated 2014 is sighted. This has a set of objectives, interventions to be undertaken to achieve the objectives, notes the person(s) responsible and includes a timeframe for each. This sits alongside a quality and risk management programme document with quality focused objectives, details of quality management, a quality strategy and information on implementation of the system. The quality coordinator is recorded as the manager and the quality improvement team includes the manager/health and safety representative, two registered nurses, the restraint coordinator and the diversional therapist and is appropriate to the service. This group meets bi-monthly and minutes are maintained and sighted. The quality and risk management is also opened to staff to attend. Policy, procedures, protocols and guidelines as required in section D5.4 of the ARRC agreement are in place and copies sighted. The service has recently adopted and personalised policies from an outside contractor. These are provided in both hard copy and electronically. The FM reports if any policies are changed to meet the specific needs of Fitzroy, they are required to notify the provider of the policies who will make the appropriate changes and send them through to the service. This is how the control of documents is maintained. Policy manuals are kept in the staff room and an orientation sheet attached. Staff are required to familiarise themselves with policy documents and sign the sheet. The new policy documents have a suite of forms that support the implementation of the policies – these are now being introduced and utilised in order to fully implement the new policies. There is a quality programme and internal audit matrix, which notes the months in which the different internal audits are scheduled. Eighteen different internal audit tools are sighted with examples of these being environment and equipment, performance improvement assessment, staff training, care plan, diversional therapy, restraint minimisation and infection prevention and control. The use of a quality improvement/corrective action form (copy sighted) is described in the quality and risk management programme and utilised by staff undertaking the monitoring. Review of quality and risk management minutes verify there is a set agenda that includes health and safety, incidents/accidents/near misses, complaints, infection control, internal audits, staff training and the quality improvement register. Items are discussed, issues identified and actions noted to address any shortfalls or opportunities for improvement identified. Currently the reports from the internal audit and monitoring processes do not include an analysis of trends over time to determine whether any improvement in outcomes has occurred or the identified issues have been addressed, and this is identified as an area requiring improvement. A health and safety programme, hazard management flow chart and occupational hazards by location are all sighted during stage one audit. A risk management schedule is sighted and includes a range of potential and actual risks from environment and equipment, to resident safety and service delivery, financial, staffing and legal liability for example. Monitoring processes and frequency are noted in the schedule. There is also a 2014 risk register with a description of each identified risk, the category of each, the level of risk and timeframes for review is sighted. Strategies are discussed at the quality meetings and the risk register is reviewed as required. (Last seen to have occurred in the quality meeting minutes dated 29 Jan 2014). The hazard register for Fitzroy Village Management Ltd is sighted and is noted to have been last reviewed in January 2014. Staff are encouraged to attend the quality and risk management meetings. Memos are sent to all staff to update them on any quality issues are addressed at this time and staff meetings are held four monthly to keep staff informed.

All contractual requirements are met.

Criterion 1.2.3.1 (HDS(C)S.2008:1.2.3.1) The organisation has a quality and risk management system which is understood and implemented by service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.3 (HDS(C)S.2008:1.2.3.3) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.4 (HDS(C)S.2008:1.2.3.4) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5) Key components of service delivery shall be explicitly linked to the quality management system.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.6 (HDS(C)S.2008:1.2.3.6) Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.


Evidence:

Data is collected from the internal audits and monitoring programmes and results are collated and reported at quality and risk management meetings. Currently there is no consistent trending of these results, or analysis of trends over time, to determine whether any improvement has occurred as a result of actions taken, or whether the issues identified through these processes have been addressed.

Finding:

Currently the reports from the internal audit and monitoring processes do not include an analysis of trends over time to determine whether any improvement in outcomes has occurred or the identified issues have been addressed.

Corrective Action:

Ensure quality improvement data is analysed and evaluated to determine an improvement in outcomes has occurred or the identified issues have been addressed.

Timeframe (days): 180 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7) A process to measure achievement against the quality and risk management plan is implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.8 (HDS(C)S.2008:1.2.3.8) A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.9 (HDS(C)S.2008:1.2.3.9) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4) 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


Evidence:

An adverse event management policy is sighted during stage one audit. This details responsibilities, information about an investigations workflow, analysis of reporting and documentation considerations, including use of the adverse event reporting form. A policy on open disclosure is in the index of policies and procedures and sighted (review date 2015) and staff have received training in open disclosure. The incident reporting process is well established and meets contractual requirements. The facility manager (FM) is able to describe the process for the tracking and investigation of adverse events and the processes for informing family members. Adverse events are documented on an incident form and collated monthly. The FM reports any issues identified as requiring action are addressed as soon as they are identified. These are then seen to be reported back to the quality and risk management meeting (minutes sighted) and actions discussed. Incidents are investigated to determine whether there are any actions required to mitigate further risk to any identified party, and follow-up is undertaken to ensure this occurs. The documentation of any corrective action is occurring. Collation is occurring but analysis over time to ensure any trends are identified, changes in practice or shortfalls in service delivery or equipment requirements is not yet consistent and has been identified as an area requiring improvement (see CAR 1.2.3.6).

A review of the incidents demonstrates where there are a number of falls; these are often attributed to one individual resident. Staff are able to give an example of this where a current resident has had an increased number of falls, they have had the resident reassessed as requiring a higher level of care and they are waiting to have a meeting with the family to determine the best alternative for placement. This is scheduled to occur in the next week. Open disclosure is seen to occur and an example sighted supports this. A medication error was made, the appropriate action is noted to have occurred, the incident documented and the resident’s daughter informed and provided with written documentation of the error. All contractual requirements are met

Criterion 1.2.4.2 (HDS(C)S.2008:1.2.4.2) The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.4.3 (HDS(C)S.2008:1.2.4.3) The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.


Evidence:

Finding:

Corrective Action:


Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7) 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


Evidence:

The three registered nurses hold current annual practising certificates and records are kept on file. Position descriptions are in place, up to date and describe roles, responsibilities and levels of accountability for all current staff. Professional qualifications are also recorded for the GPs, physiotherapists and the pharmacist utilised by the service. Performance appraisals are scheduled on an annual plan. Review of nine staff files indicate two have had appraisals completed, four are not yet due as they have been employed in the last year, and the remainder are scheduled to occur. The current manager has only owned the facility for nine months and has a plan in place to complete the performance appraisals by the end of the first year. Appointment of new staff reflect policy documents and good recruitment practices. Police vetting is consistently undertaken and the documentation of referee checks is seen to be implemented in all but one staff files reviewed. New caregivers are required to undertake Aged Care Education (ACE) training following appointment, if they have not already completed their training. A record of this is maintained and all staff meet this requirement. All except one are seen to have completed this. Orientation checklists are utilised and are noted to be signed off by the staff member working with the new employee, as they become familiar with the processes and procedures. All files reviewed demonstrate this occurs. A training schedule exists to record staff education and includes an annual plan of competency updates for medication, first aid and fire training, as well as those priorities of the service. All staff are noted to have completed their annual updates or are scheduled to do so. Dates for scheduled training are included in documents sighted and a record of training is seen to be kept in all nine staff files sighted. The FM is able to show how the service receive training updates from the local DHB to enable forward planning for specific subjects such as wound care management. Staff are paid to attend education sessions, including in-house training. All contractual requirements are met

Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2) Professional qualifications are validated, including evidence of registration and scope of practice for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3) The appointment of appropriate service providers to safely meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4) New service providers receive an orientation/induction programme that covers the essential components of the service provided.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.5 (HDS(C)S.2008:1.2.7.5) A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8) 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


Evidence:

A policy and procedure on annual leave and rostering notes the facility manager is responsible for staffing levels and routine rostering and that staffing levels will be determined in consultation with the registered nurse. It also notes that the requirements of the ARRC agreement will be upheld. Staff/skill mix expectations are outlined in the policy document, as are sections on the routine roster, support staff and replacing staff. Guidelines regarding consecutive days, holidays and changes of shift are also documented. An acuity tool is used to determine resources required. The roster is developed by the FM. The current roster is as follows and staffing levels documented are across seven days per week: AM: 1 RN 3 caregivers 1 Diversional therapist (10.30am -5.30pm, Mon - Fri) 1 kitchen staff (9am – 1.30pm) 1 cleaner/ housekeeper (8.30am – 2pm, Mon - Thurs) plus the FM Mon – Fri, 8 – 5pm PM: 2 caregivers and a servery assistant

Night: 1 caregiver plus an RN on call The hours for the weekend are the same with the exception of the diversional therapist. Three caregivers interviewed report the service is well staffed and they feel well supported by senior staff and RNs. All ARC requirements are met.

Criterion 1.2.8.1 (HDS(C)S.2008:1.2.8.1) There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.


Evidence:

Finding:

Corrective Action:


Standard 1.2.9: Consumer Information Management Systems (HDS(C)S.2008:1.2.9) 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


Evidence:

Interviews with the owner/manager and two registered nurses (RN) and review of six resident files confirms that information is gathered from the time of referral to the service. This includes full assessment information provided by the contracted assessment service and any hospital discharge information (where relevant). Residents newly admitted to the service have information recorded on the day of admission and an initial care plan within 24 hours of admission (six of six files reviewed have the completed documentation). The residents' records contain information to safely identify the resident, uses sticky labels or names on each side of the page and records include all key information. The care plan. Audits are completed twice yearly. A recent example. Identified a number of aspects of the plan which had not been completed. The resident resided at Fitzroy of Merivale for three months. Corrective action follow-up requirements are noted and actioned.

Integrated hard copy health care records are consistently arranged in a single folder in sections separated by dividers. Resident progress is documented by care staff and, if required, by the RN. The General Practitioner (GP) and allied health also document in the residents' notes, with any health related correspondence included. Residents' records are kept secure in the office which is observed to be kept locked (keypad) when staff are not present. During the review of six hard copy residents’ files, it is evident that entries are dated, legible, include the author's signature and designation. Archived records are stored in a locked cupboard on site. Documents are dated for easy retrieval.

Criterion 1.2.9.1 (HDS(C)S.2008:1.2.9.1) Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.7 (HDS(C)S.2008:1.2.9.7) Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.9 (HDS(C)S.2008:1.2.9.9) All records are legible and the name and designation of the service provider is identifiable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.10 (HDS(C)S.2008:1.2.9.10) All records pertaining to individual consumer service delivery are integrated.


Evidence:

Finding:

Corrective Action:


Outcome 1.3: Continuum of Service Delivery

Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent

with current legislation.

Standard 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1) 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


Evidence:

A package of information about Fitzroy of Merivale is provided to residents prior to admission to the facility and is supported by a ‘revamped’ website which includes information on rest home care. The manager takes time to discuss entry in which residents purchase an occupation right agreement. Residents are assessed for rest home care prior to entry to the facility. Admission and entry information (sighted) for the rest home is detailed and includes the facility admission policy and forms. Three residents whose files were reviewed have been admitted to the facility within the past six months – all required documentation is included and is complete. The resident having respite care does not have an admission agreement completed as she wishes to discuss this with family.

Criterion 1.3.1.4 (HDS(C)S.2008:1.3.1.4) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2) 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


Evidence:

Potential residents must be assessed as suitable for rest home level of care and admission is dependent on a suitable room vacancy at the time entry is required. The contracted assessment service is involved in the process including where entry is declined.

Criterion 1.3.2.2 (HDS(C)S.2008:1.3.2.2) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3) 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


Evidence:

The two facility RNs interviewed complete a comprehensive suite of nursing assessments (records sighted) on admission to the facility. There is also an assessment completed prior to entry by the Older Persons Health Needs Assessment and Service Co-ordination (NASC) agency at Princess Margaret Hospital (records sighted). Six resident files reviewed confirm a comprehensive care plan is developed by the registered nurse within the required time frame in accordance with ARRC requirements, or in the case of the short term resident, a short term care plan is in place, as the expected duration of stay is for three weeks. The plan is based on a range of validated, nursing assessments including pain, falls risk, pressure risk, continence, safe handling and a brief nutritional assessment. Residents sign off on the care plan and any subsequent reviews which are present in the six files sampled. There is demographic information and a care plan, including diagnosis and problems, outcomes and interventions for all support needs including, communication, mobility, social needs, personal care, ethnicity and cultural requirements, spirituality, pain management, transportation requirements, and dietary needs. An evaluation is completed at least six monthly. An additional sheet with “care plan goals for special problems” is used for any additional needs which arise and is used as a short term care plan, for example, skin tears, wounds or antibiotic treatment for an infection, such as urinary tract infection (two of two short term care examples are sighted). Information is detailed and in one example, includes goals, side-effects, allergies, changes in continence and safety for a resident with a UTI. There is a well-used family contact record sheet in each file sighted. Care staff are observed referring to the care plan content during the audit days, and clarifying content and changes with the RN. A handover between morning and afternoon shifts is observed to occur and as a mechanism to discuss resident care needs and any updates or alteration to a resident's care.

A multidisciplinary team care plan review is undertaken six monthly and fully documented. Family members or a support person preferred by the resident is invited to attend. One example is sighted and this included a conversation and participation by a family member in Australia by telephone. This was particularly useful due to the resident’s changing needs and healthcare status. A telephone interview with the contracted house General Practitioner (GP) who has been providing services to Fitzroy of Merivale for 15 years, confirms a high level of confidence and satisfaction with the care delivered. He notes, reliable and experienced staff, good leadership and timely approaches and appropriate referrals to attend when resident health changes. He is also particularly complimentary about the changes initiated (e.g. medication management) and improvements made since the change of ownership in June 2013 using terms such as "impressed" and "positive changes" with lots of effort put in by the new management. A recent general practitioner survey, completed in January 2014 also comments on professional practice, the multidisciplinary team approach and received 11 of 14 responses from attending doctors. The registered nurse will contact the relevant GP practice in a timely manner if there is an issue. This is usually by telephone but also by fax as observed during the audit. The ‘house doctor’ visits weekly. There is also evidence of referrals to other health professionals, as necessary, such as for orthotics, specialist appointments and dental services. Tracer methodology: XXXXXX This information has been deleted as it is specific to the health care of a resident.

Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.3 (HDS(C)S.2008:1.3.3.3) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.4 (HDS(C)S.2008:1.3.3.4) The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4) 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


Evidence:

There is a comprehensive selection of validated, nursing assessment tools in use including pain, falls risk, pressure risk (Braden), continence, safe handling guide and a brief nutritional assessment. These documents are well used as a basis for care planning in the six file samples used (e.g. falls risk and nutritional screen resulted in a specific plan for both examples). The document is revisited as part of each review or when the resident’s condition changes, with dates and a note added to explain the

change. This is consistently undertaken in the files sampled, with the care plan modified accordingly.

Criterion 1.3.4.2 (HDS(C)S.2008:1.3.4.2) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.5: Planning (HDS(C)S.2008:1.3.5) 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


Evidence:

Six resident files are reviewed including a respite care resident. In each case, assessment has led to the formulation of an appropriate care plan. Care plans are developed electronically under key template headings. Handwritten additions are made to the plan when changes occur, or the plan is completely rewritten. This occurs consistently as each support needed heading can be developed or amended individually. There is evidence of a clear link between assessment and development of an appropriate plan in the files sampled. In one example of a resident with increasing ‘sun downing’ behaviour, a plan has been implemented in which one on one care is provided between 6:30 p.m. and 8:30 p.m. daily and has resulted in a more relaxed bedtime routine and improved sleep patterns. This situation is being well-managed while awaiting a reassessment for the resident. There is also evidence of changes to the plans when progress is not as expected. This includes planning, increased nutrition for a resident with weight loss. Of merit is the recent implementation by the diversional therapist of a 24 hour plan for one resident with sun downing behaviours. Although this is a very recent initiative, it is being trialled as a means to guide staff on the best ways to support the resident when they are more anxious and restless. Care plans are updated at least six monthly, with several examples noted in which this has occurred more frequently, according to the resident’s changing needs. This includes changes to plans as a consequence of multidisciplinary reviews every six months.

Criterion 1.3.5.2 (HDS(C)S.2008:1.3.5.2) Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.5.3 (HDS(C)S.2008:1.3.5.3) Service delivery plans demonstrate service integration.


Evidence:

Finding:

Corrective Action:


Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6) 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


Evidence:

Fitzroy of Merivale has a range of policies and procedures as required by the ARRC agreement. This includes clinical policies forms and assessments which have recently been purchased (February 2014). These are being evaluated; the organisation is taking a cautious approach to ensure that the documents in use reflect their practices.

The two registered nurses develop and update care plans based on the ongoing assessment process, taking into account the resident’s progress and health status. Each of the six files includes a plan of care/interventions using a hard copy template for all key care need areas on the long term or short term care plans (sighted). Progress notes document interventions completed and, in addition, there are specific additional forms in use such as a wound care sheet for residents requiring wound interventions, or other interventions such as blood glucose monitoring. Care staff are observed to refer to the plan for additional detail of care needs. Residents interviewed (five) confirm they have input into their plan of care, participate in reviews such as the multidisciplinary team (MDT) meeting and have family input and support for this. Examples of this are noted in records of MDT meetings sighted. Policies and procedures as required by the ARRC agreement

Criterion 1.3.6.1 (HDS(C)S.2008:1.3.6.1) The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.


Evidence:

Finding:

Corrective Action:


Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7) 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


Evidence:

Fitzroy of Merivale have a trained diversional therapist (working three days per week) and an activities officer (working two days per week) from 10.30am till 5.30pm. The facility has a van to enable residents to participate in activities outside the facility and this was in use for an outing on one of the audit days. Residents are provided with the monthly programme and daily activities are displayed. Resident meetings are a means to determine the types of activities preferred by residents. The two staff providing planned activities hold a first aid certificate and carry a mobile phone when on outings. A social assessment is undertaken during the first three weeks of residence and added to as more information becomes available. This provides a framework for developing a plan which reflects the interests and preferences of the resident. The plans are included in the resident clinical record and supported by a participation sheet

which is used to inform progress reporting each month. This is well done in the files reviewed. A monthly programme is developed to reflect the seasons and holidays. A person is contracted to undertake Tai Chi sessions weekly. The facility has board games, a resident computer (with a range of games and internet access), and an active Mah Jong and card group. Visiting groups such as the local school and entertainers also visit. Residents interviewed say they enjoy the programme on offer, but also enjoy going out to other community activities whenever they can.

Criterion 1.3.7.1 (HDS(C)S.2008:1.3.7.1) Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8) Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

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


Evidence:

Residents and family members are involved in the multidisciplinary team meetings as part of the evaluation process. The registered nurses monitor resident progress and document this in the clinical records and progress notes, either in hard copy, or more major changes are updated electronically. Changes are also noted in the short term care plan for a respite care resident. There are a number of examples noted in which the plan of care has been amended in response to resident progress from the ongoing assessment. This includes review of nursing assessment tools used to guide care planning. Initial care plans are amended and used to inform the ongoing care plan, which is evaluated at least every six months. In four of the six files reviewed, there is evidence of evaluation within the six month period as required by the ARRC agreement. This includes sign off of the care plan “extensions” for problems such as a completed course of antibiotics following an infection and the resident’s response to the intervention. The RN’s or manager also lead the multidisciplinary team (MDT) meetings.

Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3) Where progress is different from expected, the service responds by initiating changes to the service delivery plan.


Evidence:

Finding:

Corrective Action:


Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9) 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


Evidence:

Examples of referral to other health professionals are evidenced in the files sampled. This includes orthotics, dietician, urology clinic, dental services or acute care services. One resident deteriorated over several days following a fall. There are examples of communication with the GP (x2) and appropriate transfer to for acute hospital treatment when her condition continued to deteriorate. The GP interviewed also confirms that staff contact him as a matter of routine for any concerns about resident health and well-being.

Criterion 1.3.9.1 (HDS(C)S.2008:1.3.9.1) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.10: Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10) Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


Evidence:

Documentation sighted for a resident transferred for acute tertiary care confirm that appropriate information is provided by the facility to ensure care is co-ordinated and risks minimised.

The file of a discharged resident inspected at audit also confirms information is provided to other facilities to facilitate continuity of care.

Criterion 1.3.10.2 (HDS(C)S.2008:1.3.10.2) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12) 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


Evidence:

A suite of recently purchased documents are being integrated into the current policies and protocols. This covers all essential components of the medication management system, including competency checks and a range of forms (e.g. competency to self-administer). Fitzroy of Merivale consistently implements policies into practice as evidenced by inspection of the medicines management system, staff interviews (two RNs and two caregivers) and review of practices. This includes prescribing, dispensing, administration, review, storage, disposal and medicines reconciliation. The service uses the Pharmaceuticals blister pack system supplied by a pharmacy for the last several years. This service provides advice, staff training as well as completing pharmacy prescriptions, supply and removal of out of date stock. Eleven medication files reviewed confirm the system is thorough and consistently implemented. The blister packs and the medication record are stored in a locked trolley in the medication room that is also number lock secure (sighted). Storage is available for refrigerated medicines (none on the day of audit) and controlled drugs. There are limited stock items stored on site, no standing orders used and stock rotation is maintained. Controlled medicines are stored on site in blister packs in the controlled drug safe. Weekly physical stocktakes and quality stock counts are consistently undertaken weekly. Controlled drug administration sheets are colour coded for ease of recognition. Copies of faxed medication orders are not present in any of the files reviewed and all have evidence of review by the GP in the past three months. Administration practices observed are in accordance with procedure. Senior care staff who are deemed competent undertake medication administration. Competency is reviewed

annually (sighted). Staff education provided by a pharmacy educator occurred in February 2014. Residents assessed as competent to self-administer do so, with four residents self-administering oral medication, eye drops and inhalers on the day of audit. A check sheet is used to record completion of the weekly pack, an assessment tool updated three monthly and secure storage by one resident observed. Medication reconciliation is undertaken with the delivery of the new packs. The registered nurse documents the checks made on arrival at the facility for both new residents to the facility and the regular delivery each month. This includes the number of packs and the pack content against the prescription. Eleven medication records reviewed at audit include photo identification which is signed as a true likeness three monthly (sighted for all residents present in the facility for longer than three months), pharmacy alert stickers attached to administration sheets (where relevant), sample signatures, allergies and indications for pro re nata (PRN) included. Consistently implemented signatures and dates of prescribers commencing or discontinuing medications are on the charts reviewed. A file audit of five charts in January 2014 identified some areas of improvement which have been effectively addressed. The photo identification and pharmacy alert stickers are good examples of practical efforts to improve medication administration safety.

Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each stage they manage.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5) The facilitation of safe self-administration of medicines by consumers where appropriate.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13) 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


Evidence:

Food service related documents sighted during stage one audit include food safety, a food safety checklist, food storage, food service staff responsibilities and a comprehensive one on food services and the elderly, which provides information on the nutritional needs and fluid requirements of this age group. An admission food and assessment form is sighted as is a weight management policy stating weights will be monitored monthly or more frequently as needed. Kitchen cleaning, food flow charts, kitchen protocols and a preferred supplier list are in place. Fitzroy of Merivale contracts its food services to Medirest at the adjacent Nurse Maude facility. Breakfast is served by the facility and main meals are transported to the facility in a temperature controlled trolley twice daily and served from a bain marie (observed during the audit. There is a four week menu cycle used, which has been reviewed by a Medirest dietician (sighted). Presently, there are no special diets required for the residents; however individual preferences and choices are catered for. Temperature monitoring of food is undertaken and recorded. Inspection confirms that these temperatures are within the safe delivery and serving temperatures specified. A safe food handling session has been provided to staff in February 2014 by the Medirest advisor. Residents’ weights are monitored monthly (as evidenced in the six files reviewed). Action is taken if weight problems arise. For example, two residents are presently experiencing a sustained weight loss. Referral to a private dietetic service has resulted in assessment and recommendations and supplementation which are being implemented. Follow up of both residents is scheduled. The service has also implemented a date stamp to record weights. Residents interviewed report that meals are of a good standard, are served hot (or cold) and are enjoyable. Food satisfaction is monitored by the manager, who states she is happy with the quality of meals provided. Residents also provide feedback at their monthly meeting. Food storage on site is limited to a supply cupboard with cereals, canned goods and drink concentrates. On the day of audit, the kitchen freezer storing bread and ice-cream, has not been maintaining the correct temperatures. Management have purchased a new freezer which is being delivered (Invoice sighted).

Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1) Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2) Consumers who have additional or modified nutritional requirements or special diets have these needs met.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5) All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.


Evidence:

Finding:

Corrective Action:


Outcome 1.4: Safe and Appropriate Environment

Services 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.

Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1) 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


Evidence:

A waste disposal policy and procedure document is sighted. This notes the weekly collection of recycling items by the local council collection and of general waste by a contractor. Kitchen waste, medical waste and liquid waste have detailed disposal instructions. A chemical storage policy and procedure is also sighted. The service have contracts in place for the removal of sharps and the provision of chemicals for cleaning and laundry. The contractor of chemical products provides training on their use. Staff are able to describe the processes for the collection and disposal of waste throughout the service. Personal protective equipment is seen to be available and used by staff. A hazard register is in place an updated as hazards are identified. Mitigation strategies are in place to minimise any risk to residents and staff. The ARC requirements are met.

Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1) 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.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.1.6 (HDS(C)S.2008:1.4.1.6) Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2) 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


Evidence:

The facility has a current building warrant of fitness (sighted) and is due to expire on 09/07/2014. The building is currently undergoing earthquake repairs which have largely been completed. The main corridor is being wall papered and the radiators are to be re installed and the work will be finished. A fire safety evacuation plan is in place and the last evacuation was undertaken on 21 February 2014 and the building took 4 minutes to evacuate (the fire safety service letter sighted). A maintenance person/gardener is employed by the service 20 hours per week to keep the equipment and grounds in good order. Electrical safety checks and equipment checks are seen to be undertaken. Where equipment requires repair, this completed and recorded. Hot water testing is done monthly, last in February, when the plumber was called to make some adjustments to the tempering valves. Retesting was in progress at audit. The home has mostly level access and outside areas that are developed specifically for the safe use of the residents. There are ramps in place to allow for residents to move freely around the building with mobility aids if necessary. New paths are in place and there are separate small seating areas to allow for residents to safely mobilise within their ability. Ramps and handrails are installed where required, to facilitate this. All resident rooms open out onto outside spaces. A transportation policy informs on the considerations to be made when transporting residents. The facility has a van used to transport residents and the drivers licence of the diversional therapist and the activities support person is kept on file. Contractual requirements are met.

Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1) All buildings, plant, and equipment comply with legislation.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.4 (HDS(C)S.2008:1.4.2.4) The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.6 (HDS(C)S.2008:1.4.2.6) Consumers are provided with safe and accessible external areas that meet their needs.


Evidence:

Finding:

Corrective Action:


Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3) 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


Evidence:

All resident rooms have walk in ensuite showers and toilets that are readily accessed with mobility aids. There is an accessible toilet available for resident and visitors use near the living area. ARC requirements are met.

Criterion 1.4.3.1 (HDS(C)S.2008:1.4.3.1) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4) 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


Evidence:

All residents have spacious individual rooms, opening onto paved outside areas and include a bed and sitting area with an ensuite toilet and shower. These are sufficiently large to enable residents to mobilise with the support of mobility aids as required. The rooms are seen to be personalised and they are encouraged to bring in some of their own furnishings if they wish. Review of resident satisfaction surveys indicate residents are very happy with their rooms. Residents utilising mobility aids are seen to be moving indendently around their rooms and throughout the facility. The requirements of the ARC are met.

Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1) 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.


Evidence:

Finding:

Corrective Action:


Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5) 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


Evidence:

There is a large communal dining room as well as a communal sitting area with a piano available, for residents to gather should they wish. There are a number of outside seating areas that are able to be used by residents. ARC requirements are met.

Criterion 1.4.5.1 (HDS(C)S.2008:1.4.5.1) Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6) 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


Evidence:

A policy on linen handling is sighted within the infection prevention and control policies and procedures. This document informs of a dirty to clean process, notes the way to handle and manage dirty and soiled linen and how to manage different types of linen. Care of garments, use of the washing machine and laundry cleaning guidelines are described. The laundry service is contracted to outside contractors who are noted to meet the requirements of AS/NZ 4146. Some minimal laundering of delicates is carried out in the small laundry on site. Staff are required to check the laundry as it is returned form the contractor to separate it for the individual residents. They report checking it at

this time to ensure they have been effectively laundered. Cleaning is provided by designated housekeeping staff. At interview, the cleaner is able to describe the required processes and tasks. There is a job sheet she works to plus a list of activities to be completed. A trolley is provided for the cleaners’ use and includes bottles of the chemicals used as well as PPE. The cleaner is able to describe the training provided and the considerations for the handling of cleaning products, the use of doses to ensure correct dilution and the management of waste and body fluid spills. Review of the cleaner’s staff file demonstrates she has received training from the chemical supply company. Cleaning processes are monitored through the environmental audits are undertaken six monthly. On review of this it is noted that feedback is provided to the cleaning staff if there are any issues identified. Chemicals are stored in the laundry and supply cupboard, both of which are seen to be locked and accessed by staff using keypad access. Resident satisfaction surveys indicate there is a high level of satisfaction with the laundry processes and residents are satisfied with the level of cleanliness in the facility. ARC requirements are met.

Criterion 1.4.6.2 (HDS(C)S.2008:1.4.6.2) The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.6.3 (HDS(C)S.2008:1.4.6.3) Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.


Evidence:

Finding:

Corrective Action:


Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7) Consumers receive an appropriate and timely response during emergency and security situations.

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


Evidence:

There is an emergency plan in place, a fire policy and evacuation plan. There is a fire service letter reporting on the latest trial evacuation 21/02/2014 and is noted to have taken 4 minutes. The next trail is scheduled for July 2014. The facility keeps an updated list of residents and any special needs they may have in the event an evacuation is required (sighted). The FM reports this is updated when there is any change to the residents in the homes or when a resident’s mobility needs change (last updated 21/03/2014) and the RNs and support staff are responsible for ensuring care plans describe the care and support required. Staff are required to complete first aid and fire training and attend trial evacuations to ensure they are competent to respond to emergency situations and a record of this is maintained by the service. Alternative energy supplies that are available in the event of the main supplies failing include two gas barbecues for cooking purposes, torches for lighting and spare blankets for warmth. Stocks of additional food and water are available. The contract for the provision of meals to the service includes the supply of emergency food should the need arise. The call bell system is in place and functional. This is linked to a pager system. These are worn by the care staff and send a message to them stating which room the call bell has been activated from. Staff are seen to respond quickly to the alert on their pager. Residents report staff respond to the call bell in a timely manner. Security arrangements include locking doors, shutting windows and drawing curtains at nightfall. The windows in residents’ rooms have security stays on them that prevent them from being opened beyond a safe width. Sensor lights are installed around the outside of the facility. A security company is contracted to provide security checks of the building and are noted to alert staff if there is a resident’s window open. A CCTV camera is in place to monitor the front entrance. The screen can be viewed from the staff office to alert staff to any caller. All ARC requirements are being met.

Criterion 1.4.7.1 (HDS(C)S.2008:1.4.7.1) Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.3 (HDS(C)S.2008:1.4.7.3) Where required by legislation there is an approved evacuation plan.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.4 (HDS(C)S.2008:1.4.7.4) Alternative energy and utility sources are available in the event of the main supplies failing.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.5 (HDS(C)S.2008:1.4.7.5) An appropriate 'call system' is available to summon assistance when required.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.6 (HDS(C)S.2008:1.4.7.6) The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.


Evidence:

Finding:

Corrective Action:


Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8) 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


Evidence:

All rooms (including resident bedrooms) are spacious and light with large opening windows for natural light and ventilation. Radiators are fitted throughout the facility for warmth in the cooler months.

Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1) Areas used by consumers and service providers are ventilated and heated appropriately.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2) All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.


Evidence:

Finding:

Corrective Action:


NZS 8134.2:2008: Health and Disability Services (Restraint Minimisation and Safe Practice) Standards

Outcome 2.1: Restraint Minimisation

Services demonstrate that the use of restraint is actively minimised.

Standard 2.1.1: Restraint minimisation (HDS(RMSP)S.2008:2.1.1) Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


Evidence:

According to restraint use policies and procedures sighted during stage one audit, the service is committed to maintaining a restraint free environment. Relevant definitions for enablers and different forms of restraint are in the policy. Approved restraints for use in this facility if required are bed rails, a waist belt around resident and chair or a lazy-boy (fall-out) chair. Associated documents, guidelines and forms for the assessment and authorisation for enabler and restraint use, monitoring, review and evaluation of restraints used are all sighted. At audit, it is confirmed that there are no restraints or enablers in use in the past year and the outcome of the standard to minimise restraint use is achieved. Therefore 2.2 and 2.3 are not audited.

Criterion 2.1.1.4 (HDS(RMSP)S.2008:2.1.1.4) 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.


Evidence:

Finding:

Corrective Action:


NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards

Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1) 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


Evidence:

The members of the infection control team and their roles are documented within the policies and procedures for infection prevention and control. An annual review process is described and a document on the coordination of infection control describes the role of the infection control coordinator. An infection control related visitors' policy is sighted and relates to managing the risks associated with any visitor(s) and resident(s) with an infection. The RN, who deputises for the FM, is also responsible for infection control within the facility. Lines of accountability are included in the sighted policy documents. The infection prevention and control programme is documented and is verified by both the RN responsible for IC and the FM, as agreed to by the owners. The service has recently adopted the infection control suite of policies from an outside contractor and they have been adapted to the needs of Fitzroy and introduced into practice. The RN advises that in the service has notices to place on the door asking visitors not to enter if they have suspected outbreak of a disease such as norovirus (sighted). Alcohol hand gel is available at the entrance and throughout the facility and staff and visitors are encouraged to use it. ARC requirements are met.

Criterion 3.1.1 (HDS(IPC)S.2008:3.1.1) 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.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.3 (HDS(IPC)S.2008:3.1.3) The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.9 (HDS(IPC)S.2008:3.1.9) 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.


Evidence:

Finding:

Corrective Action:


Standard 3.2: Implementing the infection control programme (HDS(IPC)S.2008:3.2) There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



Evidence:

According to the infection control coordination document the infection control coordinator, who is a registered nurse, reports to the facility manager about any infections. The IC coordinator has attended training on outbreak management (specifically Norovirus), management of residents with ESBL and surveillance. The monitoring and management of infection control sits with a committee, whose membership is clearly defined in the documents. Infection Control is an agenda item at the bi - monthly quality and risk management meetings and minutes include discussion on issues identified and, surveillance results. The team consists of the FM, the RN responsible for IC, cleaning staff, kitchen staff member, care givers, activities coordinator and a medical liaison person from Southern Laboratories. Requirements of the ARC are met.

Criterion 3.2.1 (HDS(IPC)S.2008:3.2.1) 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.


Evidence:

Finding:

Corrective Action:


Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3) 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


Evidence:

A suite of policies and procedures relating to infection control are available. Examples of these are sighted during stage one audit and include communicable disease management, disinfection and sterilisation, hand hygiene, outbreak and isolation, pet management, transmission based pre-cautions, apron use and an antimicrobial policy. The indexes provided for review show there is also an infection prevention and control section in the safe and appropriate environment in-house policy and procedure manual. All sighted are document controlled, have been reviewed February 2014 and due for further review February 2015.

Criterion 3.3.1 (HDS(IPC)S.2008:3.3.1) There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.


Evidence:

Finding:

Corrective Action:


Standard 3.4: Education (HDS(IPC)S.2008:3.4) The organisation provides relevant education on infection control to all service providers, support staff, and consumers.



Evidence:

The service has a training schedule that includes infection control as a requirement for training at least annually from an outside educator. The last session noted was provided by an IC nurse specialist and nine staff are seen to have attended including the RN responsible for IC. She also reports having ready access to the Southern Laboratory staff, the GP and the infection control team at CDHB if she requires advice or support. Education material is provided to residents as the need arises and the residents meeting is a forum that can be used to communicate this if required.

Three care staff interviewed report they have hand washing audits undertaken intermittently and are informed of the results and given training at the time if any issues are identified. They are able to describe the principles of standard precautions, isolation management of residents and the use of personal protective equipment (PPE).

Criterion 3.4.1 (HDS(IPC)S.2008:3.4.1) Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.


Evidence:

Finding:

Corrective Action:


Criterion 3.4.5 (HDS(IPC)S.2008:3.4.5) 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.


Evidence:

Finding:

Corrective Action:


Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5) Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.


Evidence:

Surveillance of infection at Fitzroy is described in the infection control policy and procedures. This notes how infections will be recorded, analysed and monitored and lists those to be included in the surveillance records as urinary tract (UTI), chest infections (lower respiratory tract), eye infections and soft tissue (wounds). Standard definitions are not currently used by the service in order to ensure any data reported is accurate and this is identified as an area for improvement. There is an accompanying document on the general identification and prevention of infection and the policy states they will also monitor and report any incidence of multi-drug resistant organisms. Infections are identified through the results of swabs or samples sent to the laboratory. Results are sent to both the service and the GP. Surveillance records sighted demonstrate numbers of infections are identified by type per month and reported to the quality and risk meeting. Frequent occurrences for individual residents are noted and discussed. The service is yet to determine whether there are any trends and undertake an analysis of any trends in order to determine if changes need to be made to their processes or the management of the resident (see also CAR 1.2.3.6). This is identified as an area requiring improvement. ARC contractual requirements are met.

Criterion 3.5.1 (HDS(IPC)S.2008:3.5.1) 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.


Evidence:

Although policy documents describe the infections that will be recorded, standard definitions are not currently used by the service in order to ensure any data reported is accurate and the appropriate infections are being monitored.

Finding:

Although policy documents describe the infections that will be recorded, standard definitions are not currently used by the service in order to ensure any data reported is accurate and the appropriate infections are being monitored.

Corrective Action:

Ensure standard definitions are used to define infections monitored as per current best practice guidelines.


Criterion 3.5.7 (HDS(IPC)S.2008:3.5.7) 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.


Evidence:

Although frequent occurrences of infection for individual residents are noted and discussed, the service is yet to determine whether there are any trends and undertake an analysis of any trends over time in order to determine if changes need to be made to their processes or the management of the resident. (This is linked to the CAR in 1.2.3.6)

Finding:

The service is yet to determine whether there are any trends and undertake an analysis of any trends over time in order to determine if changes need to be made to their processes or the management of the resident.

Corrective Action:

Ensure surveillance results are trended and analysed over time in order to identify ways of assisting in the reduction and prevention of infections.
