Ministry of Health NZ - Certificaiton audit summary · Web viewTerraNova Homes & Care Limited - West Harbour Gardens Current Status: 23 October 2014 The following summary has been

TerraNova Homes & Care Limited - West Harbour Gardens

Current Status: 23 October 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

TerraNova Homes and Care Limited's West Harbour Gardens Residential Care is a 74 bed rest home and hospital located in West Harbour, Auckland. During the audit there were 60 residents living at the facility. Fifteen of those were receiving rest home level of care and 45 were receiving hospital level of care. Ten of the hospital-level residents are under the age of 65 years of age and receiving services under a Disability Support Services contract.

There are 85 staff employed. The facility is currently being managed by an interim manager while a permanent replacement is being sought. The interim manager is a registered nurse and is employed as an assistant clinical operations manager for TerraNova Homes and Care. A full-time clinical co-ordinator, also a registered nurse, is responsible for clinical operations.

Improvements are required around the complaints process, accident and incident reporting, education and training in relation to restraint minimisation, staff induction, short term care plans, staff handover, first aid and CPR training, infection control education and collating infection control surveillance data.

Audit Summary as at 23 October 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 23 October 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.

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

Organisational Management as at 23 October 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.


Continuum of Service Delivery as at 23 October 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.

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

Safe and Appropriate Environment as at 23 October 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 23 October 2014

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

Standards applicable to this service fully attained.

Infection Prevention and Control as at 23 October 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.


Audit Results as at 23 October 2014

Consumer Rights

Staff demonstrate good knowledge and practice of respecting residents’ rights in their day to day interactions. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Families interviewed expressed high satisfaction on how all staff work in a calm and caring manner and respect each resident.

There is one resident who identifies as Maori residing at the service at the time of audit. The service providers report there are no known barriers to Maori residents accessing the service. Services are planned to respect the individual culture, values and beliefs of the residents.

Written consents are obtained from the residents' enduring power of attorney (EPOA) or appointed guardians. Signed consent forms are sighted in all residents' files reviewed. Processes are in place for advance care planning and, as medically indicated, resuscitation directives are recorded.

The organisation provides services that reflect current accepted good practice. This is evidenced in the guidelines for the care of residents and observed during the audit. The care staff have completed, or are enrolled in, national unit standards for the National Certificate in Care of the Elderly. There is regular in-service education and staff access external education that is focused on aged care and best practice.

Linkages with family and the community are encouraged and maintained.

The right of the resident and/or their family to make a complaint is understood, respected and upheld by the service. There is one area identified as requiring improvement around the complaints process.

Organisational Management

The governing body for TerraNova Homes and Care Limited ensures services are planned, coordinated, and are appropriate to the needs of the residents. Day-to-day operations are being managed efficiently and effectively to ensure the provision of timely, appropriate and safe services to the residents.

Quality and risk management processes are documented and maintained, reflecting the principals of continuous quality improvement. Adverse, unplanned and untoward events are recorded and reported to those affected in an open manner. One area requiring improvement is around the accident/incident reporting process.

Residents receive appropriate services from suitably qualified staff. Human resources processes are managed in accordance with good employment practice, meeting legislative requirements. Areas identified as requiring improvement relate to the orientation programme and restraint education and training.

Residents' information is uniquely identifiable, accurately recorded, current, confidential and accessible when required.

Continuum of Service Delivery

The type and level of care required is clearly and accurately identified in pre-admission information. The service has policies and processes related to entry into the service.

Services are provided by suitably qualified and trained staff to meet the needs of residents. Residents have an initial nursing assessment and care plan developed by the registered nurse (RN) on admission to the service. The service meets the contractual times frames for the development of the long term care plan.

There is an area requiring improvement relating to implementation of short term care plans.The care plan evaluations are conducted at least six monthly on all aspects of the care plan.

Residents are reviewed by a general practitioner (GP) on admission to the service and at least three monthly, or more frequently to respond to any changing needs of the resident. The provision of services is provided to meet the individual needs of the residents. A team approach to care is provided ensuring continuity of services. Referrals to other health and disability services is planned and coordinated as required, based on the individual needs of the resident. The families interviewed report that interventions are consistently implemented and that the service manages the residents care needs. There is an area requiring improvement to ensure information at handover is complete for all residents.

The service has a planned activities programme to meet the recreational needs of the residents with a focus on residents with impaired cognitive function and younger residents. Residents are encouraged to maintain links with family and the community.

A safe medicine administration system is observed at the time of audit. The service has documented evidence that staff responsible for medicine management are assessed as competent to do so.

Residents' nutritional requirements are met by the service. Residents likes, dislikes and special diets are catered for with food available 24 hours a day. The service has a four week, summer/winter rotating menu which is approved by a registered dietitian.

Safe and Appropriate Environment

Residents are provided with safe, adequate, age appropriate facilities that are furnished to reflect the home like nature of the rest home and hospital level of needs, which are suited to both the

younger person with a disability and the older resident. There is a scheduled and reactive maintenance process and a long term maintenance programme in place. All residents’ rooms are being refurbished with thirty rooms completed at the time of the audit.

The facility meets the safety and independence needs of residents assessed as requiring rest home and hospital level of care. Residents were observed manoeuvring electric wheelchairs and walking, with and without walking aids, about the home. All resident rooms have external access to either a courtyard or the grounds/gardens. Umbrella coverings for seating areas are available. The grounds are fenced and single level to provide disability accesses.

Emergency education and training is undertaken annually and fire evacuations six-monthly according to policy. The facility has sufficient food and water supplies for at least three days in the event of an emergency. There is a required improvement around first aid and cardio-pulmonary resuscitation (CPR) training during the night shift.

Safe and hygienic cleaning and laundry services are provided for residents and the facility is clean, neat and tidy. All laundry is carried out by a contracted laundry service. The home has adequate heating and ventilation throughout.

Restraint Minimisation and Safe Practice

The use of restraint is actively minimised. Restraint is regarded as the last intervention when no appropriate clinical interventions, such as de-escalation techniques, have been successful.

During this audit, seven residents were using an enabler and seven residents were using a restraint. A restraint and enabler assessment process is in place to ensure restraint and enabler use is actively minimised.

Restraint use is recorded in an auditable format. A system of evaluation and review of any restraints used by residents takes place after the initial 72 hours when restraint was put into place and three-monthly thereafter. This review assesses the alternative strategies explored, desired outcome and whether it is being achieved, the duration of restraint, and the impact of the restraint on the resident, staff and family.

The restraint approval committee for the TerraNova facilities is responsible for the review of the restraint programme.

Infection Prevention and Control

There is a documented infection prevention and control programme which is approved and facilitated by the clinical coordinator. All required infection prevention and control policies and procedures are available for staff.

The clinical coordinator, who is the infection prevention and control co-ordinator, participates in relevant ongoing education. There are areas requiring improvement relating to adequate education for staff on infection prevention and control, and the ongoing collating of infections as part of the surveillance programme. The surveillance method and definitions of infection are detailed and the surveillance is appropriate to the service setting. All residents with suspected infections are discussed with the GP, registered nurses and caregivers in a timely manner. Overall infection rates and trends are discussed at the infection prevention and control and monthly staff meetings.

HealthCERT Aged Residential Care Audit Report (version 3.92)

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: TerraNova Homes and Care Limited

Certificate name: West Harbour Gardens Residential Care

Designated Auditing Agency: DAA Group Ltd.

Types of audit: Full certification audit

Premises audited: West Harbour Gardens Residential Care

Services audited: Hospital Care (Medical services, Geriatric services), Rest Home Care, Residential Disability Services (Intellectual and Physical)

Dates of audit: Start date: 23 October 2014 End date: 24 October 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: 60

Audit Team

Lead Auditor XXXXX Hours on site

16 Hours off site

8

Other Auditors XXXXXX Total hours on site

16 Total hours off site

8

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 32 Total audit hours off site 20 Total audit hours 52

Number of residents interviewed 8 Number of staff interviewed 17 Number of managers interviewed 3

Number of residents’ records reviewed

8 Number of staff records reviewed 10 Total number of managers (headcount)

5

Number of medication records reviewed

16 Total number of staff (headcount) 85 Number of relatives interviewed 3

Number of residents’ records reviewed using tracer methodology

3 Number of GPs interviewed 1

Declaration

I, XXXXXX, Director of Wellington hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of the Designated Auditing Agency named on page one of this report (the DAA), an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of the DAA Yes

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

c) the DAA 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 Yes

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

h) the DAA has finished editing the document. Yes

Dated Monday, 24 November 2014

Executive Summary of Audit

General Overview

TerraNova Homes and Care Limited's West Harbour Gardens Residential Care is a 74 bed rest home and hospital located in West Harbour, Auckland. During the audit there were 60 residents living at the facility. Fifteen of those were receiving rest home level of care and 45 were receiving hospital level of care. Ten of the hospital-level residents are under the age of 65 years of age and receiving services under a Disability Support Services contract.

There are 85 staff employed. The facility is currently being managed by an interim manager while a permanent replacement is being sought. The interim manager is a registered nurse and is employed as an assistant clinical operations manager for TerraNova Homes and Care. A full-time clinical co-ordinator, also a registered nurse, is responsible for clinical operations.

Improvements are required around the complaints process, accident and incident reporting, education and training in relation to restraint minimisation, staff induction, short term care plans, staff handover, first aid and CPR training, infection control education and collating infection control surveillance data.

Outcome 1.1: Consumer Rights

Staff demonstrate good knowledge and practice of respecting residents’ rights in their day to day interactions. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Families interviewed expressed high satisfaction on how all staff work in a calm and caring manner and respect each resident.

There is one resident who identifies as Maori residing at the service at the time of audit. The service providers report there are no known barriers to Maori residents accessing the service. Services are planned to respect the individual culture, values and beliefs of the residents.

Written consents are obtained from the residents' enduring power of attorney (EPOA) or appointed guardians. Signed consent forms are sighted in all residents' files reviewed. Processes are in place for advance care planning and, as medically indicated, resuscitation directives are recorded.

The organisation provides services that reflect current accepted good practice. This is evidenced in the guidelines for the care of residents and observed during the audit. The care staff have completed, or are enrolled in, national unit standards for the National Certificate in Care of the Elderly. There is regular in-service education and staff access external education that is focused on aged care and best practice.

Linkages with family and the community are encouraged and maintained.

The right of the resident and/or their family to make a complaint is understood, respected and upheld by the service. There is one area identified as requiring improvement around the complaints process.

Outcome 1.2: Organisational Management

The governing body for TerraNova Homes and Care Limited ensures services are planned, coordinated, and are appropriate to the needs of the residents. Day-to-day operations are being managed efficiently and effectively to ensure the provision of timely, appropriate and safe services to the residents.

Quality and risk management processes are documented and maintained, reflecting the principals of continuous quality improvement. Adverse, unplanned and untoward events are recorded and reported to those affected in an open manner. One area requiring improvement is around the accident/incident reporting process.

Residents receive appropriate services from suitably qualified staff. Human resources processes are managed in accordance with good employment practice, meeting legislative requirements. Areas identified as requiring improvement relate to the orientation programme and restraint education and training.

Residents' information is uniquely identifiable, accurately recorded, current, confidential and accessible when required.

Outcome 1.3: Continuum of Service Delivery

The type and level of care required is clearly and accurately identified in pre-admission information. The service has policies and processes related to entry into the service.

Services are provided by suitably qualified and trained staff to meet the needs of residents. Residents have an initial nursing assessment and care plan developed by the registered nurse (RN) on admission to the service. The service meets the contractual times frames for the development of the long term care plan.

There is an area requiring improvement relating to implementation of short term care plans. The care plan evaluations are conducted at least six monthly on all aspects of the care plan.

Residents are reviewed by a general practitioner (GP) on admission to the service and at least three monthly, or more frequently to respond to any changing needs of the resident. The provision of services is provided to meet the individual needs of the residents. A team approach to care is provided ensuring continuity of services. Referrals to other health and disability services is planned and coordinated as required, based on the individual needs of the resident. The families interviewed report that interventions are consistently implemented and that the service manages the residents care needs. There is an area requiring improvement to ensure information at handover is complete for all residents.

The service has a planned activities programme to meet the recreational needs of the residents with a focus on residents with impaired cognitive function and younger residents. Residents are encouraged to maintain links with family and the community.

A safe medicine administration system is observed at the time of audit. The service has documented evidence that staff responsible for medicine management are assessed as competent to do so.

Residents' nutritional requirements are met by the service. Resident’s likes, dislikes and special diets are catered for with food available 24 hours a day. The service has a four week, summer/winter rotating menu which is approved by a registered dietitian.

Outcome 1.4: Safe and Appropriate Environment

Residents are provided with safe, adequate, age appropriate facilities that are furnished to reflect the home like nature of the rest home and hospital level of needs, which are suited to both the younger person with a disability and the older resident. There is a scheduled and reactive maintenance process and a long term maintenance programme in place. All residents’ rooms are being refurbished with thirty rooms completed at the time of the audit.

The facility meets the safety and independence needs of residents assessed as requiring rest home and hospital level of care. Residents were observed manoeuvring electric wheelchairs and walking, with and without walking aids, about the home. All resident rooms have external access to either a courtyard or the grounds/gardens. Umbrella coverings for seating areas are available. The grounds are fenced and single level to provide disability accesses.

Emergency education and training is undertaken annually and fire evacuations six-monthly according to policy. The facility has sufficient food and water supplies for at least three days in the event of an emergency. There is a required improvement around first aid and cardio-pulmonary resuscitation (CPR) training during the night shift.

Safe and hygienic cleaning and laundry services are provided for residents and the facility is clean, neat and tidy. All laundry is carried out by a contracted laundry service. The home has adequate heating and ventilation throughout.

Outcome 2: Restraint Minimisation and Safe Practice

The use of restraint is actively minimised. Restraint is regarded as the last intervention when no appropriate clinical interventions, such as de-escalation techniques, have been successful.

During this audit, seven residents were using an enabler and seven residents were using a restraint. A restraint and enabler assessment process is in place to ensure restraint and enabler use is actively minimised.

Restraint use is recorded in an auditable format. A system of evaluation and review of any restraints used by residents takes place after the initial 72 hours when restraint was put into place and three-monthly thereafter. This review assesses the alternative strategies explored, desired outcome and whether it is being achieved, the duration of restraint, and the impact of the restraint on the resident, staff and family.

The restraint approval committee for the TerraNova facilities is responsible for the review of the restraint programme.

Outcome 3: Infection Prevention and Control

There is a documented infection prevention and control programme which is approved and facilitated by the clinical coordinator. All required infection prevention and control policies and procedures are available for staff.

The clinical coordinator, who is the infection prevention and control co-ordinator, participates in relevant ongoing education. There are areas requiring improvement relating to adequate education for staff on infection prevention and control, and the ongoing collating of infections as part of the surveillance programme. The surveillance method and definitions of infection are detailed and the surveillance is appropriate to the service setting. All residents with suspected infections are discussed with the GP, registered nurses and caregivers in a timely manner. Overall infection rates and trends are discussed at the infection prevention and control and monthly staff meetings.

Summary of Attainment

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

Standards 0 42 0 7 1 0 0

Criteria 0 92 0 8 1 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 0

Criteria 0 0 0 0 0 0 0 0

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

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

The right of the consumer to make a complaint is understood, respected, and upheld.

PA Low

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

PA Low Two complaints (one resident and one family) were discussed in the August staff meeting without evidence of either complaint being resolved. Neither complaint was logged in the complaints register.

Ensure complaints that are not immediately resolved are logged as formal complaints and the complaints procedure is followed.

180

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

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

PA Low

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

PA Low The file of a resident who is frequently falling was reviewed. For the month of September 2014, there was evidence in the resident’s progress notes of 10

Ensure staff complete an accident/incident form for each witnessed adverse event.

90


delivery, and to identify and manage risk.

falls with accident/incident forms completed for six of the ten falls. The progress notes did reflect appropriate follow-up actions that were undertaken by a registered nurse for the four other falls that were not recorded on an incident/accident from.

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

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

PA Low

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

PA Low Evidence of completed induction programmes are missing in four of the ten staff files sighted.

Ensure that evidence of completed induction programmes are held in staff files.

90

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

PA Low Education and training relating to restraint minimisation has not been completed for the past two years.

Ensure that restraint education and training takes place annually, as per TerraNova’s policies and procedures.

90

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

Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

PA Low

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

PA Low Three clinical staff report on interview that handover is rushed and that changes in residents’ care requirements during the morning shift are not always reported to new staff coming on duty.

Ensure handover at change of shifts is undertaken in a manner to ensure all relevant clinical details are handed over to the new staff coming on duty.

90

HDS(C)S.2008 Standard 1.3.8: Evaluation

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

PA Moderate


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

PA Moderate A resident’s file reviewed does not contain evidence of implementation of the daily weighing regime requested by the GP. The RNs on interview report that they had not commenced the short term care plan amendment as documented by the GP.

Ensure short term care plans are implemented as required.

90

HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems

Consumers receive an appropriate and timely response during emergency and security situations.

PA Low

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

PA Low There is a minimum of one staff member on duty with a current first aid and CPR certificate during the AM and PM shifts but not during the night shift and this is a required improvement.

Ensure there is a minimum of one person on-site 24 hours a day, seven days a week with a current first aid and CPR certificate.

180

HDS(IPC)S.2008 Standard 3.4: Education

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

PA Low

HDS(IPC)S.2008 Criterion 3.4.5 Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept.

PA Low The education programme for 2014 contains insufficient evidence of in house education for IPC.

Ensure all staff receive education relating to IPC annually and as required.

180

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 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in

PA Low The monthly collating of surveillance data has only been commenced in earnest since

Ensure ongoing collating of surveillance data on a monthly basis.

180


achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.

September since the appointment of the CC/RN

Continuous Improvement (CI) Report

Code Name Description Attainment Finding

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:The standard operating procedure records that all staff receive of copy the Code of Health and Disability Services Consumers' Rights (the Code) in the staff handbook, as part of orientation and annually through the compulsory in-service education. Staff compliance with the Code is assessed during appraisals and is on the audit calendar. Contracted allied health professionals are given a staff handbook prior to commencement of employment. Staff failure to maintain accountability for resident rights may result in disciplinary action.

The Code is displayed and available to all residents and monitored to ensure the rights of residents are respected. New residents and family are given a copy of the Code on admission and a copy is displayed on the wall in full view for residents, caregivers and visitors. On commencement of employment all staff receive induction orientation training regarding residents' rights and their implementation. The policy meets the intent of this standard.

The seventeen clinical staff interviewed (four registered nurses (RNs), eight caregivers, one diversional therapist, one cook, two cleaners, one maintenance person) demonstrate knowledge on the Code and its implementation in their day to day practice (as observed at audit). At the time of audit staff are observed to be respecting the residents’ rights in a calm manner that de-escalates and redirects those residents with cognitive impairment.

The DHB contract requirements are met.

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:The standard operating procedures identifies that a copy of the Code and information about the Nationwide Health and Disability Advocacy Service is provided to the resident and family on admission and that the admitting staff are to go through the Code with the resident/family within eight hours of admission.

The eight residents and three family/whanau that are available for interview report that the Code is explained to them on admission and is part of the admission pack. Interviews with residents provide insight into their care, they are able to express that they are treated well and are happy at West Harbour Gardens. Nationwide Health and Disability Advocacy service information is part of the admission pack with brochures available at the entrance (sighted).

DHB contract requirements are met.

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 independence, dignity and respect policy includes the philosophy of maintaining the resident’s independence and encouraging individuality. The sexuality and intimacy policy provides guidance for staff on resident rights and staff responsibility for the safety of residents. Guidance on managing inappropriate behaviour is included. The process for accessing personal health information is detailed. The policy includes the principals detailed in the Privacy Act.

The three family/whanau members and eight residents interviewed report that they are treated in a manner that shows regard for their dignity, privacy and independence. All residents have a single room and interviews with residents/family are held in privacy. There is also lounges with a telephone for residents use or meetings.

The eight residents' files reviewed (four hospital, two resthome, and two younger persons with a disability (YPD) ) indicate that residents receive services that are responsive to their needs, values and beliefs. Eight residents and three family members report a high level of satisfaction with all level of care they receive.


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:The Maori health plan and Maori health care delivery standard operating procedure with a flow chart to guide care are sighted. The policies acknowledges the organisation’s responsibilities in their current operations to Maori residents. The TerraNova Group will respond in accordance to the Treaty of Waitangi taking into account He Korowai (Maori Health Strategy) and Whakatataka (Maori Health Action Plan 2002-2005.) The organisation is committed to identifying the needs of its residents and ensuring that staff are trained and capable of working appropriately with all residents in their care. The provision of culturally appropriate services and the identification and reduction of barriers are part of the organisation’s objectives. The individual facilities are responsible for promoting and pursuing consultation, involvement and participation with the local iwi and hapu. For individual Maori residents and their whanau, any cultural needs are to be assessed on admission and included within the care plan. The policies are based on the Te Whare Tapa Wha Guidelines for understanding the Maori culture as it relates to Health.

The staff report on interview that they attend in-service education on Maori values and beliefs (sighted). Policy includes information on tangi and death of a Maori resident and includes the Code in Te Reo Maori. There is one Maori resident on the day of the audit. He reports on interview that his cultural requirements are met and there is evidence in his file to support this.

DHB Contract requirements are met.

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:The spiritual, religious and cultural standard operating procedure documents that the admission process includes assessing specific cultural, religious and spiritual beliefs, which includes any cultural nutritional requirements. The staff are required to liaise with family/whanau within one week of admission to ensure cultural or religious visits continue as appropriate.

The cultural safety policy notes that care and services will be available to all persons assessed as requiring the level of residential care provided by this facility. All persons will have equal access to services and will not be discriminated against or prejudiced because of race, sex, creed, gender, religious beliefs, or other discriminatory factors.

The eight residents' files reviewed demonstrate consultation with both family and resident's on individual values and beliefs. The three family/whanau and eight residents report they are consulted with the assessment and care plan development. The seventeen of seventeen clinical staff interviewed demonstrate good knowledge on respecting residents’ culture, values and beliefs. The cultural needs of a resident who identifies as Maori is identified in the care plan.


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:The good employer policy details that discrimination occurs when a person is treated unfairly or less favourably than another person in the same or similar circumstances. Discrimination is noted to be unlawful if it is based on one or more of the following grounds: sex, disability, marital status, age, religious belief, political opinion, ethical belief, employment status, colour, family status, race, and sexual orientation, ethnic or national origins.

Staff files reviewed have job descriptions and employment agreements that have clear guidelines regarding professional boundaries. The three family/whanau and eight residents interviewed report they are happy with the care provided. The families interviewed expressed no concerns with breaches in professional boundaries, and all report high satisfaction with the caring, calming and patient manner of the staff.


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


Evidence: Policies identify that all aspects of care and service provision are discussed with the resident and their family/whanau prior to or at the admission meeting. Staff make adequate time to talk with residents and families (confirmed in interviews with eight caregivers and four RNs).

Evidence is seen on the 2014 education programme that staff are given training annually on all aspects of the residents rights and advocacy services. Evidence is seen of education given by the WDHB Gerontology Nurse as part of the Integrated Residential Aged Care Programme. This includes residents rights, promoting independence, aging process and cultural issues. Evidence of this is seen in staff files.

The clinical staff interviewed report they are given training in house and are given the opportunity to attend off site education sessions.

DHB Contract requirements are met.

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.


Evidence:

Finding:

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:The open disclosure policy is based on the principle that residents and their families have a right to know what has happened to them and to be fully informed. The cultural appropriateness standard operating procedure documents that residents and relatives who do not speak English shall be advised of the availability of an interpreter at the first point of contact with TerraNova staff. The interpreter service is to be made available to employees or residents or families of residents via the local DHB’s. There is a guideline sighted for accessing formal and informal interpreters.

The eight residents and three family/whanau report they have a right to full and frank information and open disclosure from service providers. The incident forms sighted record that the family are notified of the incident/accident. The eight residents’ files sighted provide evidence of family/whanau communications sheets and where required the general manager has email correspondence with family/whanau that do not live locally. Residents and family members interviewed state they have the opportunity to talk to management or staff.

The DHB contract 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:The informed consent standard operating procedure documents that the RN completing admission process is to discuss informed consent with resident, family/ whanau and advocate/representative as appropriate.

The policy also includes consent process for the collection and storage of health information, outings and indemnity, use of photographs for identification, sharing of information with an identified next of kin, and for general care and treatment. The resident’s right to withdraw consent and change their mind is noted. Information is provided on enduring power of attorney and ensuring where applicable this is activated. The informed consent policy provides further guidance on consent implication and processes when there are concerns about a resident’s competence. There are guidelines in the policy for advanced directives which meet legislative requirements. The consent can be reviewed and altered as the resident wishes.

The eight residents' files reviewed have consent forms signed by the enduring power of attorney (EPOA). The seventeen clinical staff interviewed demonstrate their ability to provide information that residents require, in order for the residents to be actively involved in their care and decision-making. Staff interviewed acknowledge the resident's right to make choices based on information presented to them. Staff also acknowledge the resident's right to withdraw consent and/or refuse treatment, with the staff demonstrating good knowledge on management of challenging behaviours.


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:The advocacy policy documents that all residents receiving care within the organisation's facilities will have appropriate access to independent advice and support, including access to a cultural and spiritual advocate whenever required. All residents and potential residents will be fully informed of the advocacy policy and services within the welcome pack.

The three family/whanau and eight residents interviewed report that they are provided with information regarding access to advocacy services. Family/whānau are encouraged to involve themselves as advocates (evidenced in interviews with three families). Contact details for the Nationwide Health and Disability Advocacy Service is listed in the client information booklet and with the brochure available at the entrances to the service. Related education is conducted as part of the in-service education programme.


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:There are no set visiting hours and family/whānau are encouraged to visit. The three family/whanau and eight residents interviewed report there are no restrictions to visiting hours and they are encouraged to visit at any time. Residents are supported and encouraged to access community services with visitors or as part of the planned activities programme.


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

Attainment and Risk: PA Low

Evidence:The complaints policy has a documented complaints process that complies with Right 10 of the Code. Residents and their families are provided with information relating to the complaints process during the residents’ entry to the service. Residents and families are encouraged to provide the service with feedback on the services received. Discussions with eight residents (three rest home, five hospital including one resident under the ‘Young Persons Disability (YPD) contract) confirms they were provided with information on complaints. Complaints forms are accessible in a visible location at the entrance to the facility.

A complaints register is in place that holds relevant documentation regarding each lodged complaint. There is evidence of each complaint being lodged and acknowledged in a timely manner. The complainant is also kept informed of the investigative process. Complaints are signed off by the facility manager when resolved.

The complaints register has listed 13 lodged complaints for 2014 (year-to-date). Three complaints (two which have been lodged with the Waitemata District Health Board (WDHB) are open and are under investigation. The remaining ten complaints have been signed off by the facility manager as closed. Corrective actions are identified where opportunities for improvements are identified. There is evidence of the complainant being kept informed during the complaints process.

There is evidence of two complaints (one resident and one family) that were discussed in the August staff meeting. These are not evidenced as resolved documented in the complaints register. This is a required improvement.

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:A complaints register is in place that holds relevant documentation regarding each lodged complaint. There is evidence of each complaint being logged and acknowledged in a timely manner. The complainant is also kept informed of the investigative process. Complaints are signed off by the facility manager when resolved.

The complaints register has listed 13 lodged complaints for 2014 (year-to-date). Three complaints (two which have been lodged with the Waitemata District Health Board (WDHB)) are open and are under investigation. The remaining ten complaints have been signed off by the facility manager as closed. Corrective actions are identified where opportunities for improvements are identified. There is evidence of the complainant being kept informed during the complaints process.

There is evidence of two complaints (one resident and one family) that were discussed in the August staff meeting but were not evidenced as resolved or evidenced in the complaints register. This is a required improvement.

Finding:Two complaints (one resident and one family) were discussed in the August staff meeting without evidence of either complaint being resolved. Neither complaint was logged in the complaints register.

Corrective Action:Ensure complaints that are not immediately resolved are logged as formal complaints and the complaints procedure is followed.

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

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:The strategic plan for TerraNova - West Harbour includes a vision, mission, values and philosophy. They provide care for up to 74 residents across rest home, hospital and residential disability service levels. There were 60 residents at the time of audit (15 rest home level and 45 hospital level of which 10 residents are under the young person’s disability (YPD) contract).

The organisation has developed a model of care called ‘clinical compass’ to ensure services are planned, coordinated, and appropriate to the needs of resident. This care model uses a matrix approach to delegate tasks and responsibilities delivered by teams of individuals owning portfolios developed for the aged care industry. Clinical portfolios include case management, documentation, hazard management, health and safety, pharmacy, restraint, weight management, wound management, and infection control.

The current facility manager is an interim manager for the facility until the vacancy for a facility manager position is filled. The previous facility manager resigned in September 2014. The interim manager is the assistant clinical operations manager for the organisation. She is assisted by a (facilities) operations coordinator, a clinical coordinator and a management consultant who is onsite approximately 20 hours a week to help ‘bridge the gap’ until a new facility manager is employed. The interim facility manager is a registered nurse who worked as a clinical manager at another aged care facility for three years prior to her appointment with TerraNova Homes and Care Ltd. Previous to this she owned her own home and community agency for five years in the United Kingdom. She regularly attends aged care forums and educational sessions. She has maintained over eight hours annually of professional development activities relating to managing an aged care facility.

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:During the temporary absence of the interim facility manager, the clinical coordinator is responsible for the clinical functions of the facility and the operations coordinator is responsible for the facility. The management team receives support from the TerraNova clinical operations manager who oversees operations across all TerraNova facilities.

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


Evidence:TerraNova - West Harbour has a well-established quality and risk management system. Interviews with staff and the review of meeting minutes demonstrate a service with a culture of quality improvements. The service has policies and procedures and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards.

Policies and procedures have been developed in line with current accepted best and/or evidenced-based practice and are reviewed regularly. The content of policy and procedures are detailed to allow effective implementation by staff. Policies are available in hard copy and via the TerraNova intranet. Document control includes: a) policy development; b) approval of policies; c) policy implementation; d) developing a new policy; and e) reviewing an existing policy. The document control system ensures policies and procedures are approved, up-to-date, readily available to staff and are managed to avoid the use of obsolete documents. Policies are reviewed a minimum of two-yearly with more frequent reviews occur for those policies that require more frequent updates (eg, clinical policies). TerraNova facility managers and clinical coordinators have input into policy updates. Policies are overseen by the TerraNova clinical operations manager who is also responsible for referencing policy to best practice. A document control form includes dates that policies are updated and dates that policies are to be removed from manuals and archived.

Quality and risk management systems are embedded into TerraNova’s standard operating procedures. The service documents and analyses incidents/accidents, unplanned or untoward events and provides feedback to the service and staff so that improvements are made. Surveillance data for infection prevention and control commenced in September 2014 (refer Standard 3.5). The internal audit programme monitors the environment, activities, water temperatures, pharmacy controlled drug audits, clinical records audit, staff records, food services, environmental safety, medication procedures, equipment calibrations, residents' cares, management of disturbing behaviours, housekeeping audit, residents’ rights and responsibilities, customer satisfaction, hand washing and standard precautions. The frequency of monitoring is determined by the internal audit schedule. Audit summaries and corrective action plans are completed where non-compliance is identified. Staff meeting minutes reflect communication regarding audit results and corrective action plans.

There is evidence of quality initiatives that have been undertaken. Examples include the recruitment of a diversional therapist to lead the activities programme (completed), the development, design and furniture for all residents’ rooms (30 rooms have been completed), interRAI training for the registered nurses (in process), the development of a cleaning programme for the facility (in process), and archiving documentation (in process). Falls prevention strategies are in place that includes the analysis of falls incidents and the identification of interventions. The most recent resident satisfaction survey (September 2014) reflects an improvement of 11% in the overall satisfaction levels of residents (from 68% in 2013 to 79%).

A comprehensive health and safety and risk management programme is in place. Hazard identification, assessment and management policies guides practice. The risk management programme ensures risks are identified and analysed. Risks are identified through staff, resident and family meetings, individual reports, health and safety (accident/incident) reporting, concerns/complaints, the internal audit programme, external auditing and participation in benchmarking programmes (eg, falls, skin tears, pressure injuries, medication error rates, residents on interRAI, infection rates). Risks are documented on the risk management plan. This includes the risk category, the impact rating, probability rating, management effectiveness, required actions, by whom, and completion date.

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:

Finding:

Corrective Action:


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:The incident and accident reporting policy identifies that as part of the organisation’s risk management strategy, serious or potentially serious or significant incidents/accidents/events are to be documented immediately, accurately and concisely to ensure that the incident/accident/event are to be investigated to prevent reoccurrence of any adverse events. The policy identified the serious (red flag) events that are to be reported.

The service collects incident and accident data. A TerraNova health and safety report form is the accident/incident form. It provides an account of the event, what actions were taken in response, who and when people were informed, any detail that will assist in determining how the incident occurred, and what actions were taken/are required to prevent recurrence. Individual reports are completed for each incident/accident with immediate action noted and any follow up action required. Accident/incident reports were reviewed for the month of September. One particular resident, a ‘frequent faller’, had evidence in the progress notes of 10 falls during the month of September 2014. Accident/incident forms were only completed for six of the ten falls. This requires improvement. For the four falls where an accident/incident form was not completed, there was evidence in the progress notes of appropriate follow-up actions taken by a registered nurse. All incidents and accidents forms reviewed are followed up by a registered nurse and the clinical coordinator and interim facility manager.

TerraNova has a reportable event policy. Policy identifies the events that need to be reported, by whom and the process to follow. Discussions with the interim facility manager confirm her awareness of the requirement to notify relevant authorities in relation to essential notifications.

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:The incident and accident reporting policy identifies that as part of the organisation’s risk management strategy, serious or potentially serious or significant incidents/accidents/events are to be documented immediately, accurately and concisely to ensure that the incident/accident/event are to be investigated to prevent reoccurrence of any adverse events. The policy identified the serious (red flag) events that are to be reported.

The service collects incident and accident data. A TerraNova health and safety report form is the accident/incident form. It provides an account of the event, what actions were taken in response, who and when people were informed, any detail that will assist in determining how the incident occurred, and what actions were taken/are required to prevent recurrence. Individual reports are completed for each incident/accident with immediate action noted and any follow up action required. Accident/incident reports were reviewed for the month of September. One particular resident, a ‘frequent faller’, had evidence in the progress notes of 10 falls during September 2014. Accident/incident forms were completed for only six of the ten falls and this requires improvement. For the four falls where an accident/incident form was not completed, there is evidence in the residents’ progress notes of appropriate follow-up actions taken by a registered nurse. All incidents and accidents forms reviewed were followed up by a registered nurse and were also reviewed by the clinical coordinator and interim facility manager.

Finding:The file of a resident who is frequently falling was reviewed. For the month of September 2014, there was evidence in the resident’s progress notes of 10 falls with accident/incident forms completed for six of the ten falls. The progress notes did reflect appropriate follow-up actions that were undertaken by a registered nurse for the four other falls that were not recorded on an incident/accident from.

Corrective Action:Ensure staff complete an accident/incident form for each witnessed adverse event.


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:Annual practising certificates, which include scope of practice, are validated with copies of certificates held in each health professional's personnel file. Current practising certificates were sighted for the registered nurses, physiotherapist, podiatrist, pharmacist and GPs.

Ten staff files were randomly selected for audit (five caregivers, two RNs, one activities coordinator, one cook, one cleaner). The appointment of service providers to safely meet the needs of the residents includes mandatory police checks and reference checks (evidenced in all ten staff files) for all applicants prior to their commencing employment. Employment contracts, signed job descriptions, and evidence of annual performance appraisals were also sighted in all ten files.

A planned and documented orientation programme is offered to all new employees to ensure that individual resident needs are met by staff with the appropriate knowledge and information. The orientation/induction programme includes a tour of the facility, buddy shifts with a staff member and commencement of designation-specific induction handbook procedures. The designation-specific procedures are to be completed within the first three months, with a three month appraisal to be completed which includes a review of the new staff member’s competence at their role. Within the first six months all caregivers are expected to complete the Aged Care Education (ACE) modules 1-4 (unless already completed prior to employment). Evidence of completed induction programmes were missing in four of the ten staff files and is a required improvement.

In service education is offered fortnightly or more frequently as requested. The in-service education programme includes facility-specific education sessions as well as the organisation-wide education offered as per education calendar. All staff are responsible to attend all of the sessions listed that are applicable to their role, at least annually. All staff are to complete their individual attendance record. The compulsory session topics are included initially in the orientation programme booklet. Appropriate external and professional courses are offered to staff. The care and activities staff are encouraged to complete the National Certificate in Aged Care. The organisation offers career pathways for ENs, RNs, and clinical coordinators. Mandatory training is scheduled for open disclosure, informed consent, abuse and neglect, complaints/advocacy, enduring power of attorney, privacy, cultural awareness, hazard identification, accident and incident reporting, manual handling, chemical training, spirituality, Aged Care Education (ACE) modules 1-4 for all caregivers. There is evidence to support that mandatory training is in place although education and training relating to restraint minimisation has not been undertaken by the service for the past two years and is a required improvement. Education and training on infection prevention and control is also due (refer finding Standard 3.4).

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:A planned and documented orientation programme is offered to all new employees to ensure that individual resident needs are met by staff with the appropriate knowledge and information. Interviews with all seventeen staff (eight caregivers, two cleaners, one cook, one diversional therapist, four registered nurses, one maintenance staff) confirms that a comprehensive induction programme is in place. The orientation/induction programme includes a tour of the facility, buddy shifts with a staff member and commencement of designation-specific induction handbook procedures. The designation-specific procedures are to be completed within the first three months; with a three month appraisal to be completed which includes the review of the new staff member's competence at their role. Within the first six months all caregivers are expected to complete the Aged Care Education (ACE) modules 1-4 (unless already completed prior to employment). Evidence of completed induction programmes for new staff were missing in four of the ten staff files and is a required improvement.

Finding:Evidence of completed induction programmes are missing in four of the ten staff files sighted.

Corrective Action:Ensure that evidence of completed induction programmes are held in staff files.


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:In service education is offered fortnightly or more frequently as requested. The in-service education programme includes individual site education sessions offered as well as the organisation-wide education offered as per the education calendar. All staff are responsible to attend all of the sessions listed that are applicable to their role at least annually. All staff are to complete their individual attendance record. The compulsory session topics are included initially in the orientation programme booklet. Appropriate external and professional courses are offered to staff. The organisation offers career pathways for ENs, RNs, and clinical coordinators. Mandatory training is scheduled for open disclosure, informed consent, abuse and neglect, complaints/advocacy, enduring power of attorney, privacy, cultural awareness, hazard identification, accident and incident reporting, manual handling, chemical training, spirituality, Aged Care Education (ACE) modules 1-4 for all caregivers. Medication management training for 2014 includes transdermal patch alert (17 Jan 2014), medication administration and procedure (19 Feb 2014), medication management competency (30 Sept 2014), warfarin management training (6 June 2014), warfarin administration training (9 July 2014), and syringe drivers (8 Oct 2014). There is evidence to support that mandatory training is in place although education and training relating to restraint minimisation has not been undertaken by the service for the past two years and is a required improvement. Education and training on infection prevention and control is also due (refer Standard 3.4 finding).

Finding:Education and training relating to restraint minimisation has not been completed for the past two years.

Corrective Action:Ensure that restraint education and training takes place annually, as per TerraNova’s policies and procedures.


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 documented process is in place for determining staffing levels. Rosters are completed electronically (Time Target) which matches staffing levels to occupied beds. The interim facility manager and clinical coordinator are registered nurses who are available Monday – Friday on a full-time basis.

Registered nursing cover is provided seven days a week, 24 hours a day. There are a total of three wings, all within close proximity to each other. All three wings include a mix of rest home level and hospital level residents. Three RNs work during the morning (AM) (7am - 3pm) shift with one RN covering each wing. Two RNs cover the afternoon (PM) (3pm -11pm) shift and one RN covers the night shift seven days a week. Concerns have been raised by the GP regarding inadequate communication between the GP and nursing staff during handover (reference finding 1.3.8.3).

Five caregivers cover the long AM shift (7am – 3pm) and four work a short shift (7am – 1:30pm). Four caregivers cover the long PM shift (3pm – 11pm) and three work a short shift (3pm – 8pm). Three caregivers cover the night shift. Interviews with all eight residents (three rest home and five hospital with one under 65) and three relatives confirm that staff are available to meet their needs.

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:Policy is in place to define procedures for records management, which includes filing, maintenance, storage and disposal processes. A documented process ensures detailed resident information is collected during admission. This includes recording the residents’ relevant information for identification purposes (name, birth date, GP, and photographs). Information is maintained in a secure manner and respects residents’ privacy. All current resident information is held in an individual resident's file. Information contained is legible and includes the signature and designation of the service provider. Residents' files are integrated and include comments from all health professionals involved in providing care. Staff record information in a timely manner and ensure each shift is made aware of progress. Archived and current residents' files are stored securely and are accessible to authorised personnel only.

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:An 'Admissions Policy' is sighted and includes the procedure to be followed when a resident is admitted to the home. The NZACA standard Resident's Services Agreement is provided. Policy identifies that entry screening processes are documented and communicated to the resident and their family/whanau or representative.

The service has an admission/enquiry form that records the pre-admission information. An enquiry folder holds a record of enquiries. The resident admission agreement is based on an agreement which is individualised to the service. The eight residents' records reviewed (four hospital, two rest home, two YPD) have signed admission agreements by the resident, family or EPOA. The entry criteria sighted and the services website clearly identifies that the service provides rest home, hospital and YPD care. Vacancies are updated through Eldernet as required.


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:The clinical coordinator interviewed reports that the service will decline the referral on a clinical based decision. This can include behavioural issues based on resident safety. In the event that the service cannot meet the needs of the resident, the resident, family and NASC service will be contacted so that alternative residential accommodation can be found.

If the resident's needs exceed the level of care provided, they are reassessed and an appropriate service is found for the resident, this may also involve the crisis team. The admission agreement has a clause on when the agreement can be terminated and the need for reassessment if the service can no longer meet the needs of the resident. Records are kept if this event should occur.


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:Each stage of service delivery is undertaken by a registered nurse. The RN conducts the nursing assessment, develops the care plan, evaluates and reviews the care (with consultation with the caregiver, referral information, resident and family). The GP conducts medical assessments and reviews the resident's condition. The caregivers provide the majority of the personal care for the residents. The annual practising certificates (APCs) are sighted for all staff who require them.

Three RN are trained in interRAI electronic assessment for all residents. The eight residents’ files reviewed have routine initial assessments, lifestyle assessment, sets goals for the resident that identifies the physical, psycho-social, spiritual and cultural aspects of each resident, The assessment tools for each admission includes, nutrition, continence, pain, skin, pressure area risk and falls risk. Additional assessment tools for specific needs are utilised for residents with identified challenging behaviours at the initial assessment. The long term care plan is developed within three weeks in all eight residents' files reviewed. Evaluation of care is documented at least six monthly, as confirmed in the files reviewed of residents with admissions over six months. The long term care plans are individualised with the support needs, goals, interventions and evaluation for each resident that is responsive to residents with cognitive impairment. Changes have been made to the care plans to ensure interai and hard copies are consistent. Evidence is seen of bowel and incontinence management, XXXXX and diabetes assessments in residents files.

The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach. There is a handover between each shift which includes verbal and written handover sheet. The three of the seventeen clinical staff interviewed report there is insufficient information provided at handover to promote continuity of care. There is an area requiring improvement relating to handover between shifts and ensuring detailed information is shared with staff.

The three family/whanau and eight residents interviewed report high satisfaction with the care and services provided at the service.

Tracer Hospital:

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

Tracer Rest Home:


Tracer YPD:


DHB contract requirements are

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:Three clinical staff report on interview that not all relevant resident information is shared at handover.

Finding:Three clinical staff report on interview that handover is rushed and that changes in residents’ care requirements during the morning shift are not always reported to new staff coming on duty.

Corrective Action:Ensure handover at change of shifts is undertaken in a manner to ensure all relevant clinical details are handed over to the new staff coming on duty.


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:All assessment tools sighted are appropriate to the three levels of care provided. Initial assessment includes falls, skin integrity, challenging behaviour, nutritional needs, continence, communication, end of life, self-medication and pain. Assessments are undertaken by a RN.

The eight residents’ files reviewed have initial assessments that includes identifying behaviour particular to the resident. For specific residents who are assessed with challenging behaviours identified in the initial or ongoing care review, a specialised behaviour assessment is utilised. The behaviour assessments sighted include the triggers, description of the behaviour, contributing factors and solutions/de-escalation techniques.

The service has a continence assessment and management procedure, wound care management procedures, wound care protocols and behaviour management processes, which include seeking expert assistance, such as, mental health services, as required. Where a need is identified, interventions for this are recorded on the care plan. All of the files reviewed have falls risk assessments and pressure risk assessments.

The three family/whanau and eight residents interviewed report they receive excellent care that meets their needs.


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:The eight residents' files reviewed have care plans that address residents’ current abilities, level of independence, identified needs/deficits, and takes into account the residents’ habits, routines and idiosyncrasies. The seventeen clinical staff interviewed demonstrate knowledge on care planning and receive education as part of the inservice programme annually.

The care plans and diversional therapy plans sighted in the eight residents' files reviewed identify the resident's individual diversional, motivational and recreational requirements, with documented evidence of how these are managed over a 24 hour period. The eight residents' files reviewed demonstrate integration, with input from care, activities, medical and allied health services. The four RNs and eight caregivers interviewed report they usually receive adequate information to assist the continuity of care at handover observed includes updates of all residents. ( refer 1.3.3.4)

The three family/whanau and eight residents interviewed report a high level of satisfaction with the quality of care provided at the service.


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


Policies and procedures for managing challenging and disruptive behaviour and pain management are supported by relevant assessment tools. The grooming and personal hygiene policy also includes checks for skin integrity alongside the skin management policy which gives the process for promotion of skin integrity with assessment and management of any skin problems. The management and assessment of falls policy aims to minimise the risk of each resident falling and to enable efficient management of falls and residents who fall frequently. A suite of clinical management policies and procedures includes assessment on admission, weight and bowel management, clinical notes and referral information.

As observed on the day of audit and review of the eight care plans, support and care is flexible and individualised and focusing on the promotion of quality of life. The eight residents' files evidence consultation and involvement of the family. The three family/whanau and eight residents interviewed report that the service provides a supportive relationship with the resident that reduces anxiety and maintains a sense of trust, security and self-worth.

The service has adequate dressing and continence supplies to meet the needs of the residents. Observations on the day of audit indicate residents are receiving care that is consistent with the residents' needs. The clinical staff interviewed report that the care plans are accurate and up to date to reflect the resident’s needs.

DHB contract services are met.

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:The planned activities are provided through the organisational wide Life Enhancement Programme. The aim of the programme is to enable residents to enjoy social interactions in a safe and pleasant environment and assists the residents to remain both mentally and physically active, interested in others and keep their ‘id’ and ‘zest’ for life. The activities programme underpins the ‘atmosphere’ within each facility and is delivered by activities coordinators and caregivers. The service uses a specialised framework to empower the residents to re-stake value in the community engendering a purposeful feeling of personal fulfilment and value. The residents have opportunities to pursue interests they have developed within their lifetime, to develop new interests and forge new friendships in a caring environment. The life enhancement programme includes social clubs, wishing tree, ‘Spark of Life’ and holidays.

There are three activity coordinators and diversional therapist who cover seven days. The weekly activities plan (sighted) is developed based on the resident’s needs, interests, skill and strengths. The activity coordinators assist with the planned activities seven days a week, with the programme that is developed by a diversional therapist. The diversional therapist reviews and evaluates the individual resident’s activities and the overall activities programme at least six monthly. The activity staff evaluate and review the individual resident’s participation in activities on a monthly basis.

The sighted activities programme covers cognitive, physical and social needs. The activities are modified to suit the individual needs and capabilities of each resident. There are group and individual activities that focus on sensory activities and reminiscence. The activity staff interviewed report they try to engage residents’ interests and long term memories. The activities staff gave an example of a resident whose past occupation is as a musician, and they encourage this resident to play the piano. The activity staff report that this gives the residents a sense of purpose, belonging and meaningful activities reflect normal life interests. The activity staff report that they gauge the level of interest in activities as they are occurring and have the flexibility to change activities based on the residents’ response.

The service provides easy access to outside areas that enable the resident to wander safely. There are tactile objects and plants in the outside areas. There is a courtyard that allow residents to wander safely.

The eight residents' files reviewed have activities and social assessments that identify the resident's individual diversional, motivational and recreational requirements over a 24 hour period.

Daily activities attendance sheet is maintained and reviewed at the end of each month to assess the enjoyment and interest of the residents. The goals are updated and evaluated in each resident's file six monthly. The participation in activities is recorded on a daily basis. Where possible residents' independence is encouraged to maintain links with family and community groups. Families are encouraged to attend activities. Families take their relative to religious services as appropriate and the service has a chaplain that visits twice a week.

The three family/whanau and eight residents interviewed report that they enjoy a range and variety of planned activities.

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

Attainment and Risk: PA Moderate

Evidence:Eight of eight residents’ files reviewed have a documented evaluation that is conducted within the past six months. Evaluations are reviewed for all of the issues in the care plan. These evaluations are resident focused and indicate the degree of achievement or response to supports/interventions and progress towards meeting the desired outcomes.

If a resident is not responding to the services/interventions being delivered, or their health status changes, then this is discussed with their GP. Residents' changing needs are clearly described in seven of seven care plans reviewed. Short term care plans are sighted for wound care, pain, infections, changes in mobility, changes in food and fluid intake and skin care. These processes are clearly documented on the short term care plan, medical and nursing assessments, in seven residents’ progress notes reviewed.

The ten clinical staff interviewed demonstrate good knowledge of short term care plans. However, there is an area for improvement relating to the need to ensure short term care plans are implemented as required.

The three family/whanau and eight residents interviewed report that they can consult with the staff at any time if they have concerns or there are changes in the resident's condition.

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.

Attainment and Risk: PA Moderate

Evidence:The GP reported on interview that he requested daily weighing of a resident and this had not been implemented.

Finding:A resident’s file reviewed does not contain evidence of implementation of the daily weighing regime requested by the GP. The RNs on interview report that they had not commenced the short term care plan amendment as documented by the GP.

Corrective Action:Ensure short term care plans are implemented as required.


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:The residents are provided with options if required to access other health and disability services (eg, public or private). There is one GP who visits the service twice weekly, although residents are able to maintain their own GP if they wish. The RNs or the GP arrange for any referral to specialist medical services when it is necessary. The GP and RNs interviewed report that referral services respond promptly to referrals sent. Records of the process are maintained as confirmed in residents' files reviewed, which include referrals and consultations with the mental health services, gynaecology, general medicine, psychiatrist, radiology, gerontological nurse specialist, podiatry and dietitian. The GP interviewed reports that appropriate referrals to other health and disability services are well managed at the service.

DHB contract requirements are met

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:Risks are identified prior to planned discharges (confirmed by interview with the RNs). A transfer form is used that identifies risks. There is open communication between the service and family/whānau related to all aspects of care, including exit, discharge or transfer. If there are any specific requests or concerns that the family or resident want discussed, these are noted on the transfer form. The discharge form and care plan summary is provided that covers all aspects of care provision and intervention requirements, including any known risks or concerns. A copy of the resident's individual risk profile, individual file front page, medication profile form and allergies records, a summary of medical notes and a copy of any advance directives also accompany the resident if they are transferred to hospital. The service uses the DHB’s processes and forms for admission and discharge to and from the acute care hospital.


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:The medication management policy provides guidance on medication reconciliation, prescribing, ordering, checking, storage, administration, and documentation of medications. The process for disposing expired/unwanted medications is also noted. Residents have a right to refuse medications. Where a resident refuses medications this must be documented and communicated. Errors are required to be reported via the incident reporting system. The management of controlled drugs is included and includes weekly checks of balance and six monthly quantity stock count. Residents who have been assessed as safe to self-administer medications (a template assessment form is available) are able to self-administer. The assessments are repeated on at least a three monthly basis. The policy notes the medical practitioner is to review all residents’ medications on the three monthly basis and document the review.

Medications for residents are received from the pharmacy in a pre-packed delivery system. A safe system for medicine management is observed on the days of audit (RN administering the lunch time medications). Medicines are stored in locked medicine trolleys in the store room. Medicines that require refrigeration are stored in a separate fridge.

The sixteen medicine charts are reviewed by the GP at last three monthly, with this review recorded on the medicine chart. All prescriptions sighted contain the date, medicine name, dose and time of administration. All the sixteen medicine charts have each medicine individually prescribed. There is a specimen signature register maintained for all staff who administer medicines. All the medicine files reviewed have a photo of the resident to assist with the identification of the resident. All medicine signing sheets are completed on the administration of medicines.

There are documented competencies sighted for the staff (RN and caregivers) designated as responsible for medicine management. The RNs administering medicines at the time of audit demonstrates competency related to medicine management

Evidence is seen in two of the eight residents’ files who are requiring XXX or XXXX that there is a clearly documented care plan and safe management plan for both XXX and XXXXX Staff involved in medication management have received education on XXXX and XXXX management as part of the 2014 inservice education programme(sighted)

There are no residents who self-administrator their medication at the time of audit. A process is available should this be requested by a resident and this meets requirements. Standing orders are used at this facility and also meet current legislative requirements.


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

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:The food services manual identifies an assessment is conducted when a resident is admitted to identify any dietary needs and food preferences. The policy details the principals of food safety, ordering, storage, cooking, reheating and food handling. Staff infection prevention and control requirements are also detailed. Guidance is provided on pureed diets, soft diets, diabetic diets, light diet, reducing diet and a normal diet, portion sizes, as well as practices to ensure residents remain appropriately hydrated. Practices to clean the kitchen and associated equipment is included.

The Kitchen and Food Handling policy states the food handling areas and practices will meet the requirements of the Food Act 1981. It includes guidelines for cleaning with a separate cleaning schedule, temperature requirements, hygiene standards for staff, purchasing of food, checking, storage and waste handling. Regular monitoring and surveillance of the food preparation and hygiene is to be carried out.

There is a four week rotating menu with summer and winter variations. The menu is reviewed by a dietitian (sighted).

The service is managed by two cooks who work over seven days and who are supported by six kitchen hands.

When unintentional weight loss is recorded, the resident is referred for a dietitian review (evidenced in residents' files reviewed).

A nutritional profile is completed for each resident by the RN upon entry and this information is shared with the kitchen staff to ensure all needs, wants, dislikes and special diets are catered for. There is food and nutritional snacks available 24 hours a day. The three family/whanau and eight residents interviewed report they are satisfied with the food and fluid services.

All aspects of food procurement, production, preparation, storage, delivery and disposal complies with current legislation and guidelines. Fridge and freezer recordings are observed daily and recorded at least weekly, with the recordings sighted meeting food safe requirements. The kitchen staff have undertaken food safety management education appropriate to service delivery.


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:Documentation provided includes processes for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and requirements. Safety and emergency information is available for the cleaning and laundry chemicals used, sighted in both sluice rooms and in the laundry area. Hazardous substances and cleaning chemicals are stored in locked closets and locked filing cabinets. All cleaning products and chemicals sighted during the audit are clearly labelled. Staff undergo training relating to the safe storage and disposal of healthcare waste, both hazardous and non-hazardous products (last provided on 17 May 2013). Two of two cleaners and eight of eight caregivers interviewed are knowledgeable regarding chemicals and demonstrated knowledge about the appropriate use of personal protective equipment such as gloves, aprons, masks and boots. Continence pads are double bagged and placed in the general refuse bin.

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:All required equipment displays current electrical safety testing - last tested March 2014. There is a planned preventative maintenance programme in place and interviews with the management and care staff provides evidence that the process for repairs and maintenance is known, implemented and works well. Maintenance staff are employed and respond to reactive maintenance required. There is an annual calibration record of medical equipment, which includes the blood glucose monitor, scales, sphygmomanometer, thermometers and hoists, with calibration last occurring April 2014. Fire equipment checks are current; fire hoses were checked in October 2014. All areas visited are in a good condition and well-maintained. The interim facility manager reports that a refurbishment and redecoration plan has been implemented.

A current warrant of fitness is in place (expiry date 16 November 2015).

The facility meets the safety and independence needs of residents assessed as requiring rest home and hospital level of care. Residents were observed manoeuvring electric wheelchairs and walking, with and without walking aids, about the facility. All resident rooms have external access to either a courtyard or the grounds/gardens. Umbrella coverings for seating areas are available. The grounds are fenced and single level to provide disability accesses. One resident, confined to a wheelchair, indicated that he can access all areas and grounds of the facility.

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:There are a total of thirteen toilets, eight showers and two separate bathroom facilities for the residents. The toileting/showering/bathing facilities are located in each of the three wings and the lounge area of the facility to prove convenient access. The showers and toileting facility are disabled accessible. Hand basins are located in the residents’ rooms. Hot water temperatures are monitored regularly by maintenance staff and are kept below 45 degrees Celsius.

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:The facility has 70 single rooms. All rooms are of a sufficient size for residents to safely move around and for any equipment required. Thirty rooms have recently been refurbished with new vinyl flooring and new paint. Rooms are refurbished when they become vacant. All eight residents (three rest home level and five hospital level including one under 65) interviewed confirm that they are satisfied with the space in their rooms.

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:The facility is a single level building with an open plan dining and lounge area centrally located. Lounge areas are located in each of the three wings. The grounds provide adequate access and facilities for residents and visitors. All eight residents (three rest home and four hospital including one under 65) interviewed confirm the facility has excellent facilities, for themselves and visitors.

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:All laundry from the Auckland based TerraNova Group sites is collected, managed, processed and returned by an independent laundry service. The laundry service contract is managed by the TerraNova Executive Team and identifies the responsibility and accountability of each party to the agreement. There are standard operating procedures for the cleaning service.

Chemical product information is displayed in the laundry area and two sluice rooms. The chemical supplier provides a monthly report of the effectiveness of the products. Six-monthly housekeeping audits are completed. All eight residents interviewed indicated satisfaction with the cleaning and laundry services. Cleaning chemicals are stored in locked closets and locked filing cabinets. All chemicals that are decanted into smaller containers are labelled with the manufactures supplied label.

Laundry services are outsourced. Laundry receiving and disposal areas are provided for the pickup of the dirty laundry and receiving of the clean laundry.

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:A medical emergency flow chart; emergency/disaster management policy; emergency procedures in the event of an earthquake, cyclone, bomb threat, loss of electricity; and civil defence policy and procedures are in place.

Emergency education and training is undertaken annually and fire evacuations six-monthly according to policy. The most recent fire drill took place on 1 July 2014. The facility has sufficient food and water supplies for at least three days in the event of an emergency.

There is a minimum of one staff member on duty with a current first aid and CPR certificate during the AM and PM shifts but not during the night shift and this is a required improvement. CPR and first aid training for staff is underway. There is a first aid kit available.

Emergency procedures identify that alternative energy and utility sources are available. More than three days food supplies are available at any given time in case of an emergency. There is emergency lighting throughout the site which is battery operated. The drinking water containers store at least three litres of water for every person each

day for a minimum of three days. There are adequate spare blankets as sighted in the linen cupboards. There is a well-stocked civil defence kit located in the garage/storage shed area of the facility. Staff have access to torches, spare batteries and lights.

All resident areas have a call bell system. Call bells are located in each room by the bed and in the bathing/toileting facilities, which are within reach. When the call bell is activated an audible alert and visual light indicate on the call bell panel. Floor mats are also in place in selected residents' rooms to indicate that they have moved out of bed. All eight residents interviewed (three rest home level and five hospital level including one under 65) report if they ring the bell it is answered by staff within an acceptable time frame.

Policies and procedures relating to security are in place. The grounds of the facility are fenced with the gates locked at night by the staff. Entrance to the facility after hours is maintained through the main entrance which has a call bell for night time security. One resident who is at risk of absconding wears a tracking device.

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:A medical emergency flow chart; emergency/disaster management policy; emergency procedures in the event of an earthquake, cyclone, bomb threat, loss of electricity; and civil defence policy and procedures are in place. An approved fire evacuation plan is in place. Emergency education and training is undertaken annually and fire evacuations six-monthly according to policy. The most recent fire drill took place on 1 July 2014. The facility has sufficient food and water supplies for at least three days in the event of an emergency. Staff with current CPR certificates were sighted on the AM and PM shifts but not during the night shift.

Finding:There is a minimum of one staff member on duty with a current first aid and CPR certificate during the AM and PM shifts but not during the night shift and this is a required improvement.

Corrective Action:Ensure there is a minimum of one person on-site 24 hours a day, seven days a week with a current first aid and CPR certificate.


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:The facility has individual heating in each resident’s room and community areas including the bathrooms. Each resident room has a minimum of one opening window and opening glass door for ventilation. The facility is clean, warm, safe, well-maintained, homelike and comfortable. All eight residents interviewed report the facility remains at a comfortable temperature throughout the year.

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

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:The restraint minimisation policy identifies that an enabler is the voluntary use of any equipment, devices or furniture, and consented by the consumer following appropriate assessment that limits normal freedom of movement, with the intent of promoting independence, comfort and/or safety. During the audit there were seven residents using a restraint and seven residents using an enabler. Interviews with all eight caregivers and four RNs confirm their understanding of the difference between a restraint and an enabler under the restraint minimisation and safe practice standard.

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:


Outcome 2.2: Safe Restraint Practice

Consumers receive services in a safe manner.

Standard 2.2.1: Restraint approval and processes (HDS(RMSP)S.2008:2.2.1)Services maintain a process for determining approval of all types of restraint used, restraint processes (including policy and procedure), duration of restraint, and ongoing education on restraint use and this process is made known to service providers and others.

ARC D5.4n ARHSS D5.4n, D16.6


Evidence:The restraint minimisation policy identifies that all TerraNova facilities have a designated restraint coordinator for each facility who has had education and training on restraint and is backed up by the chairperson of the restraint committee, and an established restraint approval, review, minimisation committee which meets on a two-monthly basis or more regularly if indicated. Documentation related to restraint use includes restraint/enabler and de-escalation management forms, and restraint/enabler and de-escalation monitoring forms. Restraint policy also states that annual restraint minimisation training is in place for all caregiving staff with particular emphasis on restraint alternatives to reduce the need for restraint intervention and safe restraint use (refer finding 1.2.7.5).

The restraint coordinator for TerraNova West Harbour is a registered nurse. She has been in her role for nine months. She has a clear understanding of the TerraNova restraint minimisation policy and procedures and is supported by the TerraNova restraint approval committee. Restraint use is regularly discussed in the RN and staff meetings (meeting minutes sighted).

Criterion 2.2.1.1 (HDS(RMSP)S.2008:2.2.1.1)The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.2: Assessment (HDS(RMSP)S.2008:2.2.2)Services shall ensure rigorous assessment of consumers is undertaken, where indicated, in relation to use of restraint.



Evidence:The restraint assessment process includes documenting any risks related to the use of the restraint, the behaviours displayed which indicate the need for restraint, any existing advance directives (where applicable), any previous episodes of restraint use (if any), cultural implications, and possible alternative strategies that were trialled prior to initiation of the restraint. Two residents’ files where restraint is in use were randomly selected. They both reflect evidence of a comprehensive restraint assessment with links to the residents’ care plans.

Criterion 2.2.2.1 (HDS(RMSP)S.2008:2.2.2.1)In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to:(a) Any risks related to the use of restraint;(b) Any underlying causes for the relevant behaviour or condition if known;(c) Existing advance directives the consumer may have made;(d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes;(e) Any history of trauma or abuse, which may have involved the consumer being held against their will;(f) Maintaining culturally safe practice;(g) Desired outcome and criteria for ending restraint (which should be made explicit and, as much as practicable, made clear to the consumer);(h) Possible alternative intervention/strategies.


Evidence:

Finding:

Corrective Action:


Standard 2.2.3: Safe Restraint Use (HDS(RMSP)S.2008:2.2.3)Services use restraint safely



Evidence:Residents are re-assessed after the initial 72 hour period of using a restraint to ensure it is safe and appropriate. Systems are in place for monitoring residents while restraint is in use. The frequency and extent of monitoring is determined on an individual basis and depends on the type of restraint in use. Residents are monitored every two hours at a minimum, as evidenced in the two residents’ files reviewed where restraint is being used.

A restraint register is in place. Seven residents were using an approved restraint (bedrails, low bed, lap belt or t-belt) and seven residents were using an approved enabler (bed rails, lap belt).

Criterion 2.2.3.2 (HDS(RMSP)S.2008:2.2.3.2)Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made:(a) Only as a last resort to maintain the safety of consumers, service providers or others;(b) Following appropriate planning and preparation;(c) By the most appropriate health professional;(d) When the environment is appropriate and safe for successful initiation;(e) When adequate resources are assembled to ensure safe initiation.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.4 (HDS(RMSP)S.2008:2.2.3.4)Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to:(a) Details of the reasons for initiating the restraint, including the desired outcome;(b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint;(c) Details of any advocacy/support offered, provided or facilitated;(d) The outcome of the restraint;(e) Any injury to any person as a result of the use of restraint;(f) Observations and monitoring of the consumer during the restraint;(g) Comments resulting from the evaluation of the restraint.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.5 (HDS(RMSP)S.2008:2.2.3.5)A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.4: Evaluation (HDS(RMSP)S.2008:2.2.4)Services evaluate all episodes of restraint.



Evidence:The restraint coordinator monitors the review of safe restraint practice. A system of evaluation and review of the restraint/enabler for the resident takes place after the initial 72 hours and three-monthly thereafter. This review process assesses any alternative strategies explored, the desired outcome and whether it is being achieved, whether the restraint used is the least restrictive option, the duration of the restraint, the impact the restraint has on the resident, and if policies and procedures are being followed correctly.

Criterion 2.2.4.1 (HDS(RMSP)S.2008:2.2.4.1)Each episode of restraint is evaluated in collaboration with the consumer and shall consider:(a) Future options to avoid the use of restraint;(b) Whether the consumer's service delivery plan (or crisis plan) was followed;(c) Any review or modification required to the consumer's service delivery plan (or crisis plan);(d) Whether the desired outcome was achieved;(e) Whether the restraint was the least restrictive option to achieve the desired outcome;(f) The duration of the restraint episode and whether this was for the least amount of time required;(g) The impact the restraint had on the consumer;(h) Whether appropriate advocacy/support was provided or facilitated;(i) Whether the observations and monitoring were adequate and maintained the safety of the consumer;(j) Whether the service's policies and procedures were followed;(k) Any suggested changes or additions required to the restraint education for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.4.2 (HDS(RMSP)S.2008:2.2.4.2)Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.


Evidence:

Finding:

Corrective Action:


Standard 2.2.5: Restraint Monitoring and Quality Review (HDS(RMSP)S.2008:2.2.5)Services demonstrate the monitoring and quality review of their use of restraint.

ARC 5,4n ARHSS D5.4n, D16.6


Evidence:The restraint approval group for the TerraNova facilities is responsible for the review of the restraint programme. This includes the review of restraint policies and procedures and review of the education programme for staff regarding the use of restraints and enablers. This group meets by teleconference two-monthly. Episodes of restraint use, trends and progress made in minimising restraint are reviewed to ensure the restraint/enabler is only used when necessary, appropriate and safe.

Criterion 2.2.5.1 (HDS(RMSP)S.2008:2.2.5.1)Services conduct comprehensive reviews regularly, of all restraint practice in order to determine:(a) The extent of restraint use and any trends;(b) The organisation's progress in reducing restraint;(c) Adverse outcomes;(d) Service provider compliance with policies and procedures;(e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice;(f) If individual plans of care/support identified alternative techniques to restraint and demonstrate restraint evaluation;(g) Whether changes to policy, procedures, or guidelines are required; and(h) Whether there are additional education or training needs or changes required to existing education.


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 infection control policies and procedures identify that the organisations care clinical operation’s manager is responsible for developing the organisation’s Infection Control Policies and Procedures. Each site will have an Infection Control Committee, to meet at least three monthly, incorporated with Quality Improvement and Health & Safety Committee, responsible for Policies and Procedures implementation. The onsite Infection Control Team is to consist of clinical, management, housekeeping and kitchen staff. If deemed necessary a GP, pharmacy and Infection control specialist may be invited to attend.

The infection Control Programme include surveillance based on systematic data collection to identify infections in residents

• A system for detection, investigation and control of institutional outbreaks of infectious diseases.

• An isolation and precautions system to reduce the risk of transmission of infectious agents.

• The Infection Control policies and procedures

• Continuing education in infection prevention and control

• Disease reporting to public health authorities.

• Compliance with national regulations and standards (NZS 8142:2001)

The policy identifies that the infection control programme is to be reviewed at least annually.

The infection control policy notes :

- implement policies/protocols/guidelines which are both practical and acceptable to reducing the risk of infection both to residents and staff.

- providing an advisory and educational service on infection control practices to staff, residents, and visitors, participating in monitoring of significant infections, adherence to policies and environmental risks.

- seek education to stay up to date with current safe practices.

- provide new staff with relevant information during induction/orientation ensuring that they are aware of infection control principles in this facility.

- seek advice from GP and Laboratory services in the event of an outbreak. The RN is responsible to for gaining infection control/infectious disease/microbiological advice and support, where this is not available within the organisation

- an infection control coordinator is identified. The responsibilities of this person are identified in the infection control manual.

- surveillance for residents with infections will be undertaken.

The policy notes staff and residents are offered annual influenza vaccinations.

The service has a documented infection control programme which is reviewed annually (evidence sighted). There is an annual quality review of the whole programme. The infection control programme minimises the risk of infections to residents, staff and anyone else visiting the facility.

The clinical coordinator and a RN have the role of infection prevention and control co-ordinators.. The infection control position description (sighted) has clear guidelines for the accountability and responsibility in the infection control manual. The infection control co-ordinator monitors for infections, uses standardised definitions to identify infections, surveillance, changes in behaviours, monitoring of organisms related to antibiotic use and the monthly surveillance record. Infection control is a standing agenda item in the staff meetings. If there is an infectious outbreak this is reported immediately to staff, management, and where required, to the DHB and public health departments.

The infection control committee (IPCC) meets monthly and feedback is given at the staff meeting. The sighted agenda and minutes for the IPCC meeting contains the infection surveillance control data, rate, and interventions. The infection control co-ordinator and GP interviewed report that the staff have good assessment skills in the early identification of suspected infections. Residents with infections are reported to staff at handover, have short term care plans and documentation in the progress notes.

A process is identified in policy for the prevention of exposing providers, residents and visitors from infections. Staff and visitors suffering from infectious diseases are advised not to enter the facility by notices at entrances. When outbreaks are identified in the community, notices are placed at the entrance not to visit the service if the visitor has come in contact with people or services that have outbreaks identified. Sanitising hand gel is available throughout the facility and there are adequate hand washing facilities for staff, visitors and residents. Residents suffering from infections are encouraged to stay in their rooms if required, though the infection control coordinator reports that this can be difficult at times with residents with cognitive impairment.

The four RNs and eight caregivers interviewed are able to demonstrate good infection prevention and control techniques and awareness of standard precautions, such as hand washing and use of PPE.


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:The infection control officer for each site may be the manager/clinical co-ordinator or a RN with a particular interest in infection control. They are the person on site who, with the committee, is responsible for ensuring staff implementation of infection control actions, monitoring the progress of the infection control programme. The infection control officer will have appropriate skills and expertise to carry out their function.

The clinical coordinator and a RN have the role of infection prevention and control co-ordinators. External specialist advice on infection prevention and control issues is available, if and when required, from the DHB infection control nurse specialist, the diagnostic service, GP, pharmacist and the Ministry of Health as required. The infection control co-ordinators undertake courses in infection prevention and control through the in-service education programme and updates from the DHB.

DHB contract requirements 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:The organisation currently follows the procedures as developed by an infection diagnostic service.

An infection control policy sets out the expectations the organisation will use to minimise infections. A RN manages an infection control programme which is comprehensive and includes preventative, interventionist and management strategies for infection control. This is supported by an infection control manual and a large suite of policies and procedures that deal with specific areas including antibiotic use, MRSA screening, bandaging, wound management, blood and body spills, cleaning disinfection and sterilisation, laundry and standard precautions. They are easily understood and appropriate for services requirements.

Observations at the onsite audit identify the implementation of infection prevention and control procedures. Staff demonstrate safe and appropriate infection prevention and control practices.


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:Infection control education is included in orientation and as part of the ongoing in-service education sighted on the provider's calendar.

The infection prevention and control (IPC) education is provided by the infection control co-ordinator and external specialists as required. The service accesses specialist advice through the DHB. The infection control co-ordinator demonstrates knowledge of current accepted good practice in infection prevention and control

The three RNs and seven caregivers interviewed demonstrate good knowledge of infection prevention and control. Resident education is conducted as required. The infection control coordinator reports that if the resident has cognitive impairment, education with the residents can be difficult, though during personal care delivery residents are prompted with infection control measures, such as hand washing after toileting.

The staff have received inservice education on urinary tract infection and scabies in 2014.There is an area for improvement relating to staff education on the core IPC education annually and as required for IPCC.


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:The IPCC/RN and the IPC team have only recently been appointed. There is insufficient evidence of staff education relating to IPC in 2014.

Finding:The education programme for 2014 contains insufficient evidence of in house education for IPC.

Corrective Action:Ensure all staff receive education relating to IPC annually and as required.


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:The surveillance and auditing policy documents that the organisation will, through surveillance, monitor the incidence of infections by recording the type and rate of infections that occur. The analysis of this information will determine if there are actions that can be taken to prevent or reduce the occurrence of infections. The Infection Control

Committee is to review the monthly surveillance statistics and the possible causes of infections. The committee will identify any issues that may be contributing to infection and any changes that may need to be made. These are to be documented in the minutes of the meeting and the Risk Management Report, and the infection control officer at each site will report any findings/changes to the manager of their site prior to implementation.

The monthly collating of surveillance data has only commenced in earnest since the appointment of the CC/RN. There is an area for improvement relating to the collating of surveillance data to ensure this is ongoing and imbedded in the programme. All staff are required to take responsibility for surveillance activities as shown in policy. Monitoring is clearly described in the quality plan and management meetings, to describe actions taken to ensure residents' safety.

Since September there is a monthly infection surveillance report. The service monitors urinary tract infections (UTIs), eye infections, upper and lower respiratory tract infections, wound infections, multi-resistant organisms, diarrhoea and vomiting and other infections. The monthly analysis of the infections includes comparison with the previous month, reason for increase or decrease and actions taken to reduce infections. The analysis includes the feedback that is provided to staff.

The facility’s surveillance programme/results is benchmarked by an external contracted company.


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:

Finding:

Corrective Action:


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:The collating of surveillance data has only commenced since September 2014 and is embedded in the risk management programme. Evidence is seen in the surveillance documentation that this is only current from September 2014. On interview the new IPCC report that they have only commenced the collection and collation of surveillance data since September 2014.

Finding:The monthly collating of surveillance data has only been commenced in earnest since September since the appointment of the CC/RN

Corrective Action:Ensure ongoing collating of surveillance data on a monthly basis.


Documents

Ministry of Health NZ - Certificaiton audit summary · Web viewTerraNova Homes & Care Limited - West Harbour Gardens Current Status: 23 October 2014 The following summary has been