Certification audit summary - Ministry of Health€¦ · Web viewRosedale Village Care Limited...

Rosedale Village Care Limited

CURRENT STATUS: 01-Aug-13

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

GENERAL OVERVIEW

Rosedale Village Hospital is privately owned by a husband and wife team. There are two directors and one alternative director who attends regular quality meetings at the facility. Rosedale Village Hospital offers 13 hospital level care beds and 20 rest home level care beds. On the days of audit 13 hospital level beds and 19 rest home level beds are occupied. There are independent living services offered from the same site which are not included in the scope of this audit review. All services are overseen by a general manager who is a registered nurse. She is supported by a registered nurse clinical manager who has worked at the facility since January 2013. Both staff are experienced in the roles they undertake.

There were no areas identified for improvement from the previous audit. There are three areas identified for improvement from this certification audit in regard to advance directives, medication management and food services. Contractual requirements related to residents' agreements are met by the service.

AUDIT SUMMARY AS AT 01-AUG-13

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short fallsStandards applicable to this service fully attained

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

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

Indicator Description Definition

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights Day of Audit

01-Aug-13

Assessment

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


Organisational Management Day of Audit

01-Aug-13

Assessment

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

Standards applicable to this service fully attained

Continuum of Service Delivery Day of Audit

01-Aug-13

Assessment

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


Safe and Appropriate Environment Day of Audit

01-Aug-13

Assessment

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


Restraint Minimisation and Safe Practice Day of Audit

01-Aug-13

Assessment

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


Infection Prevention and Control Day of Audit

01-Aug-13

Assessment

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


AUDIT RESULTS AS AT 01-AUG-13

Consumer Rights

Documented procedures, interviews with residents, family members and staff, together with observations, confirm that residents' rights are understood and met in everyday practice. Information on rights, advocacy, the facility, services provided and the complaints process is provided in the 'welcome pack'. The general manager and clinical manager meet with prospective residents and family members to discuss the Rosedale Village Hospital values and philosophy.

Individual resident's cultural, spiritual and other values and beliefs are identified as a component of the admission process and documented in the individual resident's care plan. There are documented policies and best practice guidelines to assist staff to provide culturally sensitive care. Family/whanau are encouraged to be involved. The general manager and the clinical manager have an open-door policy.

Informed consent requirements are clearly defined and residents, family and staff members interviewed confirm choice is given and informed consent is facilitated. An improvement is required in relation to advanced directives. Residents and family members are informed of changes in the residents' needs or health status in a timely manner. Staff are aware of how to access translators should they be required. Links with community resources are supported and facilitated. Visitors are free to come and go as requested by the resident.

There is a documented complaints process which is implemented to ensure all complaints are followed up and information is used as an opportunity to improve service delivery as appropriate. At the time of audit there are no outstanding complaints.

Organisational Management

The business plan identifies strategies used by the service to ensure that service planning is co-ordinated to meet residents' needs. The organisation's purpose, values, priorities and goals are clearly set out. Deficits to service are managed through corrective action planning as appropriate.

The day to day operation of the facility is undertaken by staff who are appropriately experienced and qualified. This allows residents' needs to be met in an effective, efficient and timely manner as confirmed during resident and family/whanau interviews and in the satisfaction survey results sighted.

Documented quality and risk management systems are implemented to assist residents, visitors and staff safety. Quality is reviewed and measured via the internal audit schedule, complaints management, and staff, resident and family/whanau annual satisfaction surveys. All quality and risk activities are monitored by the general manager and corrective actions are put in place as appropriate.

The service implements safe staffing levels and skill mix to ensure contractual requirements are met. Human resources management processes are implemented to reflect current good practice and meet legislative requirements. Staff members knowledge and skills are maintained through on-going education which is appropriate to their role.

Documentation in resident files occurs at least daily by the registered nurse and sooner where required, is written in ink, dated and signed by the applicable health professional. Health care assistants document each shift the care provided on a specific form. Health care assistants working in the rest home also have an electronic task list that is displayed on an electronic tablet which staff carry. Staff have individual passwords. Electronic and paper based records are stored securely.

Continuum of Service Delivery

There are clearly documented processes for entry to the facility. Admissions are managed in a timely manner.

Care and support is provided by a range of health professionals. This includes registered nurses, enrolled nurses, health care assistants, the general practitioner, physiotherapist, podiatrist and other visiting allied health professionals. Clear time frames for service provision are defined and monitored and residents confirm they are involved in setting goals.

Assessments and care plans are fully documented and interventions are consistent with good practice and desired goals. Care plans are reviewed every six months, or sooner if required. Short term care plans are well utilised and reviewed as required. Residents are routinely seen by the general practitioner (GP) at least every three months or sooner where clinically indicated. The GP provides a 24 hour on call service. Care is changed as required to meet individual residents' changing health needs.

Residents maintain access to a range of health services. Referrals and transfers are managed in a timely and appropriate manner and there is evidence that family are involved.

Individual activities are planned to meet the needs of the residents with previous interests, hobbies, culture and ability considered. The weekly activities plan is displayed and the programme is facilitated by three activities staff. Activity goals are detailed and ensure the provision of relevant and appropriate activities for each resident. Sufficient activities and outings are provided. Participation in activities is voluntary.

There is a current medication management policy. All medications are stored securely. Administration of medications is undertaken by registered nurses or enrolled nurses. These staff and one health care assistant have a current medication competency assessment. Medication records are legible, signed by the prescriber and reviewed at least three monthly by the GP. An improvement is required related to medication administration and documentation.

Catering services are provided by a contracted company. Food and nutritional needs of residents are assessed and the menu is reviewed by a dietitian. Special needs are catered for and monitored. An improvement is required related to labelling of refrigerated food, monitoring the temperature of chilled and frozen foodstuffs on delivery, the need for standardised recipes, and ensuring staff involved with food service have completed relevant food hygiene training.

Safe and Appropriate Environment

Rosedale Village Hospital has clearly documented emergency response processes which are understood and implemented by the service as required. This includes protecting residents, visitors and staff from harm as a result of exposure to waste or infectious substances generated during service delivery. Six monthly fire evacuations and emergency education is undertaken and all staff complete a fire questionnaire as part of orientation and annually to identify they are competent to perform the fire evacuation process safely. The building has a current building warrant of fitness and the service has an approved fire evacuation plan.

The facilities are fit for purpose and provide furnishings and equipment that are maintained to a high standard and are appropriate and accessible for both rest home and hospital level care residents. All rest home bedrooms are single occupancy with full ensuite facilities. Hospital level care facilities have single occupancy bedrooms with one bathroom between two rooms. Shower areas are centrally located. The dining and lounge areas meet residents' relaxation, activity and dining needs.

The facility is heated by both gas and electric heaters and is ventilated through opening doors and windows. There are appropriate outdoor areas that have seating and are sheltered for residents' use. All ground floor bedrooms have direct access to garden areas.

Restraint Minimisation and Safe Practice

The service has three bedside rails in use. Two are classified as restraint and one is an enabler. Policies and procedures implemented meet the required Health and Disability Services Restraint Minimisation and Safe Practice Standards. There are seven residents who have approved environmental restraint in place.

Restraint education is offered to staff during orientation and annually thereafter. It is appropriate to the type of restraint used at the facility. The service maintains a process to determine approval of all types of restraint, including enablers. Restraint use is re-assessed three monthly for individual residents and a full quality review is undertaken annually to ensure the least restrictive type of restraint is being used and that policy is being complied with.

Assessment processes fully inform care planning and identify known risks. Restraint is only used for safety reasons and this is fully understood by clinical staff. There is a system in place to inform staff and management when the next assessment is due. Restraint is discontinued as appropriate.

Restraint use is reported at all levels of the organisation, as confirmed in meeting minutes sighted. Resident and family/whanau input is well documented in relation to all restraint and enabler use as appropriate.

Infection Prevention and Control

Rosedale Village Hospital has an infection prevention and control programme which was last reviewed early 2013. The clinical manager is responsible for facilitating the infection prevention and control programme. The clinical manager participates in on-going education on infection prevention and control. Relevant policies and procedures are available for staff and all policies are current.

Rosedale Village HospitalRosedale Village Care Limited

Certification audit - Audit Report

Audit Date: 01-Aug-13

Audit ReportTo: HealthCERT, Ministry of Health

Provider Name Rosedale Village Care Limited

Premise Name Street Address Suburb City

Rosedale Village Hospital 255 Rosedale Road Albany Auckland

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

Type of Audit Certification audit and (if applicable)

Date(s) of Audit Start Date: 01-Aug-13 End Date: 02-Aug-13

Designated Auditing Agency

The DAA Group Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXXRCN, BA, Lead Auditor 8086

16.00 8.00 01-Aug-13 to 02-Aug-13

Auditor 1 XXXXXXXNZ NN, NZ 8086, Infection preventionis

16.00 8.00 01-Aug-13 to 02-Aug-13

Auditor 2

Auditor 3

Auditor 4

Auditor 5

Auditor 6

Clinical Expert

Technical Expert

Consumer Auditor

Peer Review Auditor XXXXXXX

RN,MBA,NZQA US 8086

3.00

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

19.00 Total Audit Hours 51.00

Staff Records Reviewed 10 of 44 Client Records Reviewed (numeric)

6 of 32 Number of Client Records Reviewed

using Tracer

2 of 6

MethodologyStaff Interviewed 14 of 44 Management Interviewed

(numeric)2 of 2 Relatives Interviewed

(numeric)3

Consumers Interviewed 7 of 32 Number of Medication Records Reviewed

12 of 32 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

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

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

Dated this 30th day of August 2013

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

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

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

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

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

Services and Capacity

Kinds of services certified

Hospital Care Rest Home Care

Residential Disability Care

Premise Name Total Number of Beds

Number of Beds Occupied on Day of Audit

Number of Swing Beds for Aged Residen-tial Care

Rosedale Village Hospital

33 32 0

Executive Summary of Audit

General Overview

Rosedale Village Hospital is privately owned by a husband and wife team. There are two directors and one alternative director who attends regular quality meetings at the facility. Rosedale Village Hospital offers 13 hospital level care beds and 20 rest home level care beds. On the days of audit 13 hospital level beds and 19 rest home level beds are occupied. There are independent living services offered from the same site which are not included in the scope of this audit review. All services are overseen by a general manager who is a registered nurse. She is supported by a registered nurse clinical manager who has worked at the facility since January 2013. Both staff are experienced in the roles they undertake.

There were no areas identified for improvement from the previous audit. There are three areas identified for improvement from this certification audit in regard to advance directives, medication management and food services. Contractual requirements related to residents' agreements are met by the service.

1.1 Consumer Rights

Documented procedures, interviews with residents, family members and staff, together with observations, confirm that residents' rights are understood and met in everyday practice. Information on rights, advocacy, the facility, services provided and the complaints process is provided in the 'welcome pack'. The general manager and clinical manager meet with prospective residents and family members to discuss the Rosedale Village Hospital values and philosophy.

Individual resident's cultural, spiritual and other values and beliefs are identified as a component of the admission process and documented in the individual resident's care plan. There are documented policies and best practice guidelines to assist staff to provide culturally sensitive care. Family/whanau are encouraged to be involved. The general manager and the clinical manager have an open-door policy.

Informed consent requirements are clearly defined and residents, family and staff members interviewed confirm choice is given and informed consent is facilitated. An improvement is required in relation to advanced directives. Residents and family members are informed of changes in the residents' needs or health status in a timely manner. Staff are aware of how to access translators should they be required. Links with community resources are supported and facilitated. Visitors are free to come and go as requested by the resident.

There is a documented complaints process which is implemented to ensure all complaints are followed up and information is used as an opportunity to improve service delivery as appropriate. At the time of audit there are no outstanding complaints.

1.2 Organisational Management

The business plan identifies strategies used by the service to ensure that service planning is co-ordinated to meet residents' needs. The organisation's purpose, values, priorities and goals are clearly set out. Deficits to service are managed through corrective action planning as appropriate.

The day to day operation of the facility is undertaken by staff who are appropriately experienced and qualified. This allows residents' needs to be met in an effective, efficient and timely manner as confirmed during resident and family/whanau interviews and in the satisfaction survey results sighted.

Documented quality and risk management systems are implemented to assist residents, visitors and staff safety. Quality is reviewed and measured via the internal audit schedule, complaints management, and staff, resident and family/whanau annual satisfaction surveys. All quality and risk activities are monitored by the general manager and corrective actions are put in place as appropriate.

The service implements safe staffing levels and skill mix to ensure contractual requirements are met. Human resources management processes are implemented to reflect current good practice and meet legislative requirements. Staff members knowledge and skills are maintained through on-going education which is appropriate to their role.

Documentation in resident files occurs at least daily by the registered nurse and sooner where required, is written in ink, dated and signed by the applicable health professional. Health care assistants document each shift the care provided on a specific form. Health care assistants working in the rest home also have an electronic task list that is displayed on an electronic tablet which staff carry. Staff have individual passwords. Electronic and paper based records are stored securely.

1.3 Continuum of Service Delivery

There are clearly documented processes for entry to the facility. Admissions are managed in a timely manner.

Care and support is provided by a range of health professionals. This includes registered nurses, enrolled nurses, health care assistants, the general practitioner, physiotherapist, podiatrist and other visiting allied health professionals. Clear time frames for service provision are defined and monitored and residents confirm they are involved in setting goals.

Assessments and care plans are fully documented and interventions are consistent with good practice and desired goals. Care plans are reviewed every six months, or sooner if required. Short term care plans are well utilised and reviewed as required. Residents are routinely seen by the general practitioner (GP) at least every three months or sooner where clinically indicated. The GP provides a 24 hour on call service. Care is changed as required to meet individual residents' changing health needs.

Residents maintain access to a range of health services. Referrals and transfers are managed in a timely and appropriate manner and there is evidence that family are involved.

Individual activities are planned to meet the needs of the residents with previous interests, hobbies, culture and ability considered. The weekly activities plan is displayed and the programme is facilitated by three activities staff. Activity goals are detailed and ensure the provision of relevant and appropriate activities for each resident. Sufficient activities and outings are provided. Participation in activities is voluntary.

There is a current medication management policy. All medications are stored securely. Administration of medications is undertaken by registered nurses or enrolled nurses. These staff and one health care assistant have a current medication competency assessment. Medication records are legible, signed by the prescriber and reviewed at least three monthly by the GP. An improvement is required related to medication administration and documentation.

Catering services are provided by a contracted company. Food and nutritional needs of residents are assessed and the menu is reviewed by a dietitian. Special needs are catered for and monitored. An improvement is required related to labelling of refrigerated food, monitoring the temperature of chilled and frozen foodstuffs on delivery, the need for standardised recipes, and ensuring staff involved with food service have completed relevant food hygiene training.

1.4 Safe and Appropriate Environment

Rosedale Village Hospital has clearly documented emergency response processes which are understood and implemented by the service as required. This includes protecting residents, visitors and staff from harm as a result of exposure to waste or infectious substances generated during service delivery. Six monthly fire evacuations and emergency education is undertaken and all staff complete a fire questionnaire as part of orientation and annually to identify they are competent to perform the fire evacuation process safely. The building has a current building warrant of fitness and the service has an approved fire evacuation plan.

The facilities are fit for purpose and provide furnishings and equipment that are maintained to a high standard and are appropriate and accessible for both rest home and hospital level care residents. All rest home bedrooms are single occupancy with full ensuite facilities. Hospital level care facilities have single occupancy bedrooms with one bathroom between two rooms. Shower areas are centrally located. The dining and lounge areas meet residents' relaxation, activity and dining needs.

The facility is heated by both gas and electric heaters and is ventilated through opening doors and windows. There are appropriate outdoor areas that have seating and are sheltered for residents' use. All ground floor bedrooms have direct access to garden areas.

2 Restraint Minimisation and Safe Practice

The service has three bedside rails in use. Two are classified as restraint and one is an enabler. Policies and procedures implemented meet the required Health and Disability Services Restraint Minimisation and Safe Practice Standards. There are seven residents who have approved environmental restraint in place.

Restraint education is offered to staff during orientation and annually thereafter. It is appropriate to the type of restraint used at the facility. The service maintains a process to determine approval of all types of restraint, including enablers. Restraint use is re-assessed three monthly for individual residents and a full quality review is undertaken annually to ensure the least restrictive type of restraint is being used and that policy is being complied with.

Assessment processes fully inform care planning and identify known risks. Restraint is only used for safety reasons and this is fully understood by clinical staff. There is a system in place to inform staff and management when the next assessment is due. Restraint is discontinued as appropriate.

Restraint use is reported at all levels of the organisation, as confirmed in meeting minutes sighted. Resident and family/whanau input is well documented in relation to all restraint and enabler use as appropriate.

3. Infection Prevention and Control

Rosedale Village Hospital has an infection prevention and control programme which was last reviewed early 2013. The clinical manager is responsible for facilitating the infection prevention and control programme. The clinical manager participates in ongoing education on infection prevention and control. Relevant policies and procedures are available for staff and all policies are current.

1. Summary of Attainment

1.1 Consumer Rights

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

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

Standard 1.1.3 Independence, personal privacy, dignity and respect FA 0 4 0 0 0 7Standard 1.1.4 Recognition of Māori values and beliefs FA 0 3 0 0 0 7

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

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

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

1.2 Organisational Management

Attainment CI FA PA UA NA ofStandard 1.2.1 Governance FA 0 2 0 0 0 3

Standard 1.2.2 Service Management FA 0 1 0 0 0 2

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

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

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

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

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

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


1.3 Continuum of Service Delivery

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

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

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

Standard 1.3.4 Assessment FA 0 1 0 0 0 5

Standard 1.3.5 Planning FA 0 2 0 0 0 5

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

Standard 1.3.7 Planned activities FA 0 1 0 0 0 3

Standard 1.3.8 Evaluation FA 0 2 0 0 0 4

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

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

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

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

Continuum of Service Delivery Standards (of 12): N/A:0 CI:0 FA: 10 PA Neg: 0 PA Low: 2 PA Mod: 0 PA High: 0PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.4 Safe and Appropriate Environment

Attainment CI FA PA UA NA ofStandard 1.4.1 Management of waste and hazardous substances FA 0 2 0 0 0 6

Standard 1.4.2 Facility specifications FA 0 3 0 0 0 7

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

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

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

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

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

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

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


2 Restraint Minimisation and Safe Practice

Attainment CI FA PA UA NA ofStandard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6

Standard 2.2.1 Restraint approval and processes FA 0 1 0 0 0 3

Standard 2.2.2 Assessment FA 0 1 0 0 0 2

Standard 2.2.3 Safe restraint use FA 0 3 0 0 0 6

Standard 2.2.4 Evaluation FA 0 2 0 0 0 3

Standard 2.2.5 Restraint monitoring and quality review FA 0 1 0 0 0 1

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


3 Infection Prevention and Control

Attainment CI FA PA UA NA ofStandard 3.1 Infection control management FA 0 3 0 0 0 9

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

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

Standard 3.4 Education FA 0 2 0 0 0 5

Standard 3.5 Surveillance FA 0 2 0 0 0 8

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


Total Standards (of 50) N/A: 0 CI: 0 FA: 47 PA Neg: 0 PA Low: 3 PA Mod: 0 PA High: 0 PA Crit: 0UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 0 FA: 98 PA: 3 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Rosedale Village Care LimitedType of Audit: Certification audit

Date(s) of Audit Report: Start Date:01-Aug-13 End Date: 02-Aug-13DAA: The DAA Group LimitedLead Auditor: XXXXXXX

Std Criteria Rating Evidence Timeframe1.1.10 1.1.10.7 PA

LowFinding:Advanced directives are not always signed appropriately. Two residents have 'not for resuscitation' orders medically initiated by the GP as a component of the admission process. One is also signed by a family member. The residents have diminished competence and are unable to make an informed decision themselves.

Action:Ensure advanced directives meet legal requirements.

Six months

1.3.12 1.3.12.1 PALow

Finding:1) Three of twelve residents whose records reviewed have non-blister pack medications (e.g. oral Chlorvescent tablets (for dissolving in water) and panadol elixir) signed for with the blister pack medications administered. These are non-blister pack medications and a separate signing sheet is not currently being maintained. 2) The time and dose of PRN medication administration is not consistently documented. 3) Routine administration of non-blister pack medications including laxatives and panadol elixir cannot be consistently evidenced.

Action:Ensure medication management practices meets current accepted practice and legislative requirements.

Six months

1.3.13 1.3.13.5 PAModerate

Finding:1) Food currently stored in the refrigerator is undated. This includes open fresh salmon, tinned fish, whipped cream and assorted cheeses. 2) Two staff involved with food preparation have not undertaken food hygiene training. 3) Currently recipes are only available for baked items /desserts. 4) The temperature of chilled and frozen food stuffs is not being monitored on delivery.

Action:Ensure all aspects of food management are undertaken to meet legislation, guidelines and current accepted practice.

Three months

Continuous Improvement (CI) Report

Provider Name: Rosedale Village Care LimitedType of Audit: Certification audit

Date(s) of Audit Report: Start Date:01-Aug-13 End Date: 02-Aug-13DAA: The DAA Group LimitedLead Auditor: XXXXXXX

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS

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

STANDARD 1.1.1 Consumer Rights During Service Delivery

Consumers receive services in accordance with consumer rights legislation.

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

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

How is achievement of this standard met or not met? Attainment: FAThe fourteen staff interviewed (one registered nurse (RN), one enrolled nurse (EN), the activities coordinator, eight health care assistants (HCAs), two cleaners and one HCA supervisor) are able to verbalise their knowledge of the Code of Health and Disability Services Consumers' Rights (the Code) and provide practical examples of how these are practiced/implemented daily. Staff are observed knocking on residents' doors, providing residents with choices, calling residents by their name, and respecting the residents' right to refuse components of care.The Code is included in staff orientation. It is also included in the annual in-service education programme. Several in-services have been held in 2013 and attendance records are sighted. The six of seven residents interviewed (three rest home and three hospital residents) and all three relatives interviewed (two rest home and one hospital) report that residents' are treated with respect and understand their rights. One hospital level care resident with diminished competence was unable to answer this question.

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

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

Finding Statement

Corrective Action Required:

Timeframe:

STANDARD 1.1.2 Consumer Rights During Service Delivery

Consumers are informed of their rights.

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


How is achievement of this standard met or not met? Attainment: FAStage one: The Human Rights Act 1993 is available to all staff in the policy manual. All residents will be given the Code of Health and Disability Services Consumers’ Rights on admission.Opportunities for discussion and clarification relating to the Code are provided to residents and their families as confirmed by interviews with the clinical manager, and six of six (three hospital and three rest-home) residents interviewed and all three family members interviewed. One rest home resident audited and her daughter confirm meeting with the manager prior to admission and being provided with 'the welcome booklet'. This contains detailed information on Rosedale Village, values, the Code, activities programme/events, meal times, security, visiting hours and independent advocacy services in a manner they could both understand. Discussions relating to residents' rights and responsibilities also take place as applicable following admission with the resident or family member individually. The other two family members interviewed confirm they (or another family member) have been provided with all relevant information. Information about the Code and the Health and Disability Advocacy Service, including contact details, is sighted available to residents and their families at the main reception area via brochures.A copy of the Code is included in the 'welcome pack' given to new residents (sighted). A narrative copy of The Code and residents responsibilities is included in the 'welcome pack'. This document includes a copy of the Rosedale Village advocacy policy and notes The Code/advocacy brochures are readily available and accessible in different languages and these are sighted. A copy of the Code in Russian is sighted laminated inside the front of the applicable resident's file.Education on communication and advocacy services was held on 11 June 2013 and attended by 13 staff (records sighted).

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


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


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STANDARD 1.1.3 Independence, Personal Privacy, Dignity, And Respect

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

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


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

Stage one: Policy recognises that privacy is a basic right of all individuals and that staff ensure that residents, and family/whanau have the right to personal privacy. The Neglect and Abuse Prevention policy ensures that all incidences of abuse are reported, investigated and corrective action plans instigated where required. All forms of abuse and neglect are itemised and preventive actions are shown.The apartments and hospital wing has all single rooms and this provides adequate private areas. Visual and auditory privacy is upheld in the single rooms. One resident's bed room in the hospital wing and all apartments have external phone line connections. The caregiver interviewed advised a portable phone is used in the hospital wing to enable residents to make private phone calls. Education on privacy takes place at orientation and on privacy and dignity as a component of the ongoing education programme (8 May 2013). Thirteen staff attended the May 2013 in-service. The fourteen staff interviewed (one RN, one EN, the activities coordinator, eight HCAs, two cleaners and one HCA supervisor) understand the residents’ rights to dignity, respect and privacy. This right is also emphasised by the general manager (GM) and the clinical manager (CM) during interview. Residents individual cultural, spiritual and other needs are identified as a component of the care planning process. All six (three hospital and three rest-home) residents' files reviewed during audit have noted the resident's individual needs or that the resident was asked and advises there are no specific needs. Six of seven residents interviewed and all three family members interviewed on this topic confirm care is timely and meets their individual's needs. One resident is unable to answer this question.Training is also provided to staff on abuse and neglect during orientation and as a component of the ongoing education programme in 2013 and attendance records sighted. All13 staff interviewed are aware of their responsibilities if they suspect a resident is being abused or neglected at any time.Residents are addressed in a respectful manner and by their preferred names. This is confirmed in interviews with all six residents (three rest-home and three hospital) and all three family members asked. Residents are encouraged by staff to be as active as is safely possible (confirmed in interviews with all six residents). Those interviewed confirm staff treat the residents with kindness and consideration at all times. One resident receiving hospital level care stated 'I am treated with respect'. ARRC contract requirements are met.

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


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


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


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


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STANDARD 1.1.4 Recognition Of Māori Values And Beliefs

Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

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


How is achievement of this standard met or not met? Attainment: FAStage one: There are documented guidelines for the provision of culturally safe services for Maori residents. The organisation recognises Te Whare Tapa Whā, the four corner stones of Maori health: Te Taha Tinana, Te Taha Wairua, Te Taha Hinengaro and Te Taha Whanau. The service has a Maori Health Plan in place. There are currently no residents who identify their ethnicity as Maori receiving care. The fourteen staff interviewed (one RN, one EN, the activities co-ordinator, eight HCAs,

two cleaners and one HCA supervisor) are aware of the need to provide culturally appropriate services and how to obtain supports for Maori residents where this is needed. The GM advises there are no known unique barriers that prevent Maori residents from accessing services.

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


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


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


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

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

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



Stage one: Policy identifies that all residents receive culturally safe services which recognise and respect their cultural, spiritual and ethnic values and beliefs.The admitting nurse gathers appropriate spiritual, religious, and cultural information that is relevant and sufficient to support the needs of residents. Ethnicity, cultural and spiritual needs are identified during the initial assessment and this is evident in the six residents' records sampled. Six of seven residents and all three family members interviewed indicate that they are consulted in the identification of spiritual, religious and/or cultural beliefs. A hospital level care resident audited was unable to answer this question due to memory loss. This resident's son confirms staff are aware of and meet the resident's spiritual values and needs. The resident's needs are recorded in the resident's care plan and includes that the resident does not celebrate Christmas or Birthdays and has an advanced directive which includes refusing the administration of blood or blood products (sighted).

Residents can access church services if requested. There is a Catholic services on site the last Wednesday of each month. There are six residents of the Jehovah’s Witness faith living in Rosedale Village. A number are reported by the activities coordinator to gather together on Saturday's in one of the lounges for support and sharing of faith. This includes one of the hospital level care residents interviewed who confirmed her spiritual needs are well met. The activities coordinator advised that 'dial up/phone in' Church services are accessed for resident's during the week who request this.Fifteen staff attended an in-service on cultural awareness and cultural safety held on 26 June 2013 (records sighted). The ARRC requirements are met.

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


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STANDARD 1.1.7 Discrimination

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

ARHSS D16.5e


How is achievement of this standard met or not met? Attainment: FAStage one: Policy covers resident's personal preference on sexuality and intimacy respected. The Harassment and Discrimination Policy have guidelines for staff to ensure they report any concerns and maintain professional boundaries. The house rules describe the conduct expected of staff. A copy is sighted by the lead auditor in all staff personnel files reviewed during audit (refer to 1.2.7).

The six residents and all three family members interviewed on this topic confirm they are treated with dignity and respect and are not subject to discrimination or exploitation. Fourteen staff interviewed (one RN, one EN, the activities co-ordinator, eight HCAs, two cleaners and one HCA supervisor) are able to identify the types of behaviour which are not considered acceptable including accepting gifts or money from residents or pressuring the resident to complete any activity. The GM and CM confirm care staff are respectful of residents.

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


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STANDARD 1.1.8 Good Practice

Consumers receive services of an appropriate standard.

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


How is achievement of this standard met or not met? Attainment: FAStage one: The service has up to date, evidence based policies and procedures to guide staff actions.Changes have occurred recently with a new general practitioner (GP) being contracted (January 2013). The GP records have improved since the change as evidenced in the six residents' files sampled. Standing orders are no longer accepted in relation to medications, but rather the RN liaises with the GP via phone and verbal orders are obtained where applicable. These are signed by the GP on the next visit as evidenced in sampled files at audit.

There is a comprehensive education programme which is well attended by staff. The thirteen staff interviewed confirm the topics are appropriate to their roles. A rest home resident audited has a wound infection. The GM has commenced taking photographs of this wound to demonstrate ongoing improvements or deteriorations in the condition of the wound. The DHB wound care specialist has been involved with determining the best dressing/wound care products to be used on this wound. A rotating air mattress has been placed on this residents due to the increased risk of developing pressure areas due to a significant reduction in mobility. The CM advises there are seven rotating air mattresses which are available for use as required.

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


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STANDARD 1.1.9 Communication

Service providers communicate effectively with consumers and provide an environment conducive to effective communication.

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


How is achievement of this standard met or not met? Attainment: FAStage one; The resident's right to full and frank information is clearly identified in the Open Disclosure Policy. This includes the use of interpreter service if required.

The RN advises there is currently one resident who identifies their ethnicity as Russian. This resident is unable to communicate effectively in English. All other residents are able to speak English. The two caregivers caring for this resident and the RN interviewed confirms staff understand this resident's body language and gestures and are able to communicate with this resident effectively. There are two staff who also speak Russian and they assist with communication as/if the need arises. The staff also spend time talking to this resident in Russian for socialisation. The CM advises she has not required the use of a translator in the six months she has been employed at Rosedale Village. The CM is able to describe how an interpreter would be accessed via the local DHB should this be required.Incidents and adverse events are managed in an open manner and there is clear evidence of family contact in the six residents' progress notes sampled at audit. Examples sighted included open disclosure related to falls, bruising, changes in the resident's condition, need for hospitalisation, the development of an infection, and updates following the GP review/changes in medications. All staff are identifiable. Staff wear name badges and a uniform. The GM and the CM advises they have an open-door policy. Six of seven residents (three hospital and three rest home level care) and all three family members interviewed (one hospital and two rest home level care) confirm they have the opportunity to talk to management or staff and are able to request changes if needed. One resident is unable to answer this question. The three family members interviewed also confirm that they (or another family member) are always contacted if there are changes in a resident's health status or if an untoward event has occurred. There is a communal portable phone available for residents (sighted). Residents receive adequate information regarding the services they will be provided. All residents (or family) sign a resident agreement which outlines subsidies and services that are provided. Sighted in all six resident file's reviewed. ARRC Contract requirements are met.

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


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


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STANDARD 1.1.10 Informed Consent

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

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


How is achievement of this standard met or not met? Attainment: PA LowStage one: Advanced directives related to resuscitation are described in policy to meet legislative requirements. Specific informed consent forms sighted for refusal for treatment and self-medication. Policy states that consent must be obtained prior to all service provision.

Signed consent forms are sighted in all six residents' files sampled at audit. The six residents and the family members of the two residents audited confirm there are discussions with the management team in relation to consents as a component of the admission process. The two family members confirm they or another family member participated in meetings with the manager and that information is communicated in a clear and timely manner. The residents confirm they are provided with ongoing choice and can refuse aspects of care or treatment if they want. This is evident with a number of residents refusing some offers of some medication.Two residents whose records reviewed have a documented living will. A copy is held in both residents' files. Two residents whose records reviewed have 'not for resuscitation orders' documented by the general practitioner(s). One form had the resident is 'not for CPR' box ticked and the box 'CPR is

at the medical staff discretion'. On one other occasion the resident have two not for resuscitation forms. One is signed by the GP only and the second was signed by a family member and the GP (the resident had diminished competence). These GP initiated 'not for CPR' decisions occurred as a component of routine admission process/care review for both residents and not as a component of a current treatment plan. Both residents are noted on both forms as being unable to sign due to diminished competence.The GM has reviewed all residents' files during audit to remove invalid advanced directives and has updated applicable resident's care plans. Communication with staff and family members on the changes is planned but yet to occur. Ensuring advanced directives are obtained and documented in accordance with accepted good practice and legislative requirements is an area requiring improvement.

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


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


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

Audit Evidence Attainment: PA Risk level for PA/UA: LowTwo resident's whose records reviewed have a documented living will. A signed and dated copy is held in both residents files. Two residents whose records reviewed have 'not for resuscitation orders' documented by the general practitioner(s). One form had the resident is 'not for CPR' box ticked and the box 'CPR is at the medical staff discretion'. On one other occasion there are two not for resuscitation form's in a resident’s folder. One was signed by the GP and another copy was signed by a family member and the GP. Both residents are noted on the form to be unable to sign due to diminished competence. These GP initiated 'not for CPR' decisions occurred as a component of routine admission process/care review and not as a component of a current treatment plan. The GP interviewed agreed that the practices related to advanced directives could be clearer.

The GM has reviewed all resident files to remove invalid advanced directives during audit and has updated relevant residents care plans. Communication with staff and family members on the changes is planned but yet to occur. Ensuring advanced directives are obtained and documented in accordance with accepted good practice and legislative requirements is an area requiring improvement.

Finding Statement

Advanced directives are not always signed appropriately. Two residents have 'not for resuscitation' orders medically initiated by the GP as a component of the admission process. One is also signed by a family member. The residents have diminished competence and are unable to make an informed decision themselves.

Corrective Action Required:Ensure advanced directives meet legal requirements.

Timeframe:Six months

STANDARD 1.1.11 Advocacy And Support

Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

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


How is achievement of this standard met or not met? Attainment: FAStage one: The service has an Advocacy and Support policy to ensure that the right of resident is recognised related to advocacy and support persons or services.Consumer rights training, including the right to advocacy/support has been provided for staff during 2013 as part of the in-service programme and records of this are sighted. Some of the training sessions have been provided by the H&DC advocates. Thirteen staff interviewed are aware of the resident's right to independent advocacy. The Nationwide Advocacy Services pamphlet is displayed in the foyer of Rosedale Village and sighted. All six residents and the three family members interviewed confirm being aware of their right to access independent advocacy services. The ARRC agreements requirements are met.

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


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STANDARD 1.1.12 Links With Family/Whānau And Other Community Resources

Consumers are able to maintain links with their family/whānau and their community.

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


How is achievement of this standard met or not met? Attainment: FAVisitors are observed to be made welcome. Interviews with six of six residents and all three family members confirm that the resident may entertain their visitors in one of the lounges, or in the privacy of their own rooms. Visiting may occur at any time and visitors are required to sign in and off the premises. Where a family member visit after hours staff need to grant access as the doors are secure. This is verified by the six residents and three family members interviewed. The family member of the rest home resident audited advises previous discussions had occurred with staff and the GP about the possibility of the resident being depressed. Further social interaction was agreed and the family authorised a referral to the Salvation Army who are providing a weekly social visitor. The family member are also funding a bureau caregiver to come for one hour a week of personal company and individualised activities. The resident and family member are very happy with these arrangements.Links with community resources are supported and facilitated. Families are encouraged to take their resident out if able. One resident is sighted during audit to return from an outing to the Davenport Naval Base. The resident is wearing all his military medals and states he had a 'wonderful day'. Bus trips go into the community and staff ensure that all residents who wish to participate are provided with opportunities. A evening 'happy hour' for residents also sighted occurring during audit. Family members are attending. Arrangements for attendance at specialist appointments and the GP rooms are facilitated by staff as and when required. There is a variety in the activities and social programmes in place which includes guest entertainment.

Criterion 1.1.12.1 Consumers have access to visitors of their choice.


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


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STANDARD 1.1.13 Complaints Management

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy states that all complaints will be documented, followed up and trends analysed in order for corrective action to be taken if appropriate. All complaints are handled in a professional manner by the manager or an appropriately designated person. They are facilitated and resolved in a fair, simple and efficient way. Everybody has the right to complain, which can be in writing or verbal, and complaints can also be made anonymously, although this means that these cannot be responded to individually.

The complaints process is included in the resident's welcome information and discussed as part of the admission process.Stage two: The general manager (GM) confirms complaints management is discussed as part of the admission process. A copy of the complaints form is available at the entrance of the facility and is included in the welcome pack given to all new residents. Interviews with three of three family/whanau members (two rest home and one hospital) and six of seven residents (three rest home and four hospital, one resident had memory loss and could not answer all questions appropriately) confirm their understanding of the right to make a complaint. Interviews with 14 of 14 staff (eight Health Care Assistants (HCAs), one registered nurse (RN), one enrolled nurse (EN), one laundry and one cleaning staff member, one maintenance person and one activities coordinator) and two of two members of management, the General Manager (GM) and the clinical manager (CM) confirm their understanding of complaints management to meet policy requirements. The complaints register identifies there has been one complaint made in 2013 related to either rest home or hospital level care residents. This complaint was made to the portfolio manager at Waitemata District Health Board (WDHB). It relates to a chair being used in a resident's bedroom which a family

member thought was not suitable. All follow-up is documented and identifies that an independent review by the Waitemata District Health Board (WDHB) portfolio manager found that Rosedale Village had undertaken all actions including a physiotherapy assessment of the resident, to ensure the chair was suitable, prior to the complaint being made to the DHB. The DHB did not uphold the complaint. It is evident in the documentation sighted for complaints related to the village residents, that corrective actions are put in place when required. There are no outstanding complaints at the time of audit.Monthly resident committee meetings which include village and care residents, and monthly resident meetings held for care residents are used as a forum for residents to voice any concerns. This is well documented in meeting minutes sighted. Family/whanau, residents and staff confirm they have access to the GM at any time either face to face or via telephone if required should a complaint be made.

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


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


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

STANDARD 1.2.1 Governance

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy clearly sets out the authority, accountability and responsibility of the General Manager (GM). Stage two: Services described in the strategic business plan clearly identify how residents' needs are met. The organisation's mission statement, values, business objectives (2013/2014), management goals, operating goals, long term building maintenance strategy, marketing plan and financial budgets and goals are clearly shown. Planning includes a Continuous Quality Improvement (CQI) programme which covers all aspects of service delivery areas. Overall service delivery is overseen by the GM who was appointed in December 2012. She has many years management experience within the aged care industry. She is supported by a clinical manager (CM) who commenced the role in January 2013. The CM is also experienced in the age care field. Both the GM and CM are registered nurses with current practising certificates (sighted). Job descriptions sighted for both roles identify the authority, accountabilities and responsibilities for each position. The results of the 2013 resident satisfaction survey and interviews with three of three rest home, four of four hospital residents and three of three family/whanau members confirm they are very happy with the services offered and that their needs are met.

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


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


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STANDARD 1.2.2 Service Management

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy states In the case of General Manager’s absence from the facility, timely arrangements are made to relocate the absentee’s duties to a suitable person or to a management member of the staff. The second in charge has been charged with these duties. If required, the Ministry of Health will be notified.Stage two: Interviews with two of two members of management confirm that succession planning occurs so that when the GM is on leave the CM undertakes this role with the assistance of the director/owners as appropriate. This is shown in the job descriptions sighted in the CM's file. There is one related to the role of the CM and one related to cover for the GM as required.When the CM is away the role is undertaken by another RN with assistance from the GM.

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


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STANDARD 1.2.3 Quality And Risk Management Systems

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: The organisations quality assurance document identifies their commitment to quality. The General Manager and Clinical Manager are the nominated quality officers at Rosedale Village and as such will set the lead in implementing and maintaining the continuous quality improvement (CQI) programme and systems. Risk Management policies and procedure identify the risk management process undertaken by the organisation to ensure they are documented; risk rated, analysed and evaluated. Quality and risk management plan are sighted. A hazard register for all areas of care and a hazardous substances register is sighted. CQI meeting minutes have a set agenda which identifies that all key components of service are explicitly linked to quality management systems. Stage two: Monthly CQI meeting minutes identify that the GM, CM and one director discuss, analyse, evaluate and put corrective action plans in place as required if a non-conformity is identified. The CQI group also ensure policies and procedures are up to date and reflect current good practice and meet legislative requirements. The GM has a planning document to show when policy reviews are due. All staff have computer access and hard copy of policies available to them at any time. A monthly report is presented to the directors on all aspects of quality and risk.

The quality and risk management system implemented by the service includes regular internal audits, complaints response, regular data collection and trending for key performance components of service such as complaints, incidents and accidents, restraint, health and safety and infection control, and hazard identification processes. Data is collated and analysed and is used as an opportunity to improve services via corrective actions which are put in place for any deficit that is noted. Quality improvements show the issue found, the corrective action taken to address the issue and the date the action was put in place. All actions show anticipated improvements and a timeframe for re-evaluation is set. Documentation sighted identifies the success of the corrective actions put in place. For example it was noted in the cleaning audit (2 April 2013) that labels on decanted chemical bottles were perishing and difficult to read. All the bottles had new labels put on them. A spot check was conducted on the 17 April 2013 which identified that 100% compliance was obtained and all labels on decanted chemical bottles can be read. Another example relates to staff confidentiality (31 January 2013). Staff were discussing one resident with another resident. Corrective action planning includes a memo going out to all staff and additional staff education being put in place from a representative of the advocacy service (6 February 2013). The GM and CM undertook spot questions with staff regarding confidentiality and all staff were able to verbalise their full understanding. There have been no further concerns related to breach of confidentiality. Staff interviews confirm their understanding of the CQI processes in place. Staff are kept fully informed both verbally and in writing of all quality issues and surveillance data results from the key performance components of service. This is confirmed in meeting minutes and monthly reports sighted for adverse events, health and safety, complaints management, infection control and restraint. Staff are kept well information via data results being posted on the staff room notice board, regular monthly staff meetings, during per shift handover, documentation in the handover book and the use of hand held electronic tablets (ETs- Netsoft Rescall). During staff interviews they discussed quality improvements, such as the purchase of a new hoist and more regular, better structured staff education as factors that ensure resident needs are safely met in a timely manner.

The service has a resident committee which meets monthly and is used as a conduit for information sharing. There is a representative from the rest home and hospital on the committee and any issues ore concerns are discussed and taken to management as required. There is also a resident meeting held monthly for rest home and hospital level care residents. The minutes identify that all matters are discussed as appropriate and that the same agenda headings are used for resident meetings as for the CQI meetings. Actual and potential risks are identified and documented in the hazard register. They are communicated to staff and residents as appropriate. Hazards are reviewed by the CQI committee and any newly identified hazards that cannot be eliminated are added to the register. Staff confirm during interview that they understand and implement documented hazard identification processes. The 2013 resident satisfaction survey results show that residents are satisfied with services provided for them at Rosedale Village. The only negative comment relates to the temperature of the coffee at morning tea time. (This is one person only). The GM confirms that if the resident informs the staff they will ensure the coffee is replaced.

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


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


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


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

This shall include, but is not limited to:

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.


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


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


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


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

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

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


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STANDARD 1.2.4 Adverse Event Reporting

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: The service has an Open Disclosure policy which identifies all staff involved in resident’s care must maintain honest communication. All events where a resident is harmed as a result of a mistake or error must be acknowledged to the resident and their support person as soon as possible after the event is identified in a timely, open and honest manner. All incidents and accidents are recorded on a specific form, which is managed by the clinical coordinator who ensures family/whanau are informed. Policy identifies the need for essential notification reporting and the authority events are to be reported too.

Stage two: The GM verbalises her knowledge an understanding of statutory and regulatory obligations in relation to essential notification reporting. All incidents and accidents are recorded on a specific detailed form. Adverse event data is trended and shared with staff and management on a monthly basis in each of the following sections:-falls -includes times of falls-skin tears-bruising

-medication error-abrasions-handling errors-other.

Fourteen of 14 staff interviews and a review of 2013 incident and accident forms show that appropriate reporting is undertaken. The service is able to demonstrate that incident and accident data is used as an opportunity for improvement. Resident' files (three hospital and three rest home) have a specific form to show the number of incidents and accidents they have over a one year period. If a trend is noted, appropriate corrective interventions are put in place and the success of the intervention is measured. Short term care plans are put in place to any event that is expected to be resolved within five days. For example it was noted that there were three resident falls in June and five in the first two weeks of July 2013. Part of the corrective action included the purchase of five sensor mats which were put in place immediately (15 July 2013) This resulted in no further falls being recorded for the last two weeks of July. The residents who have sensor mats in use have this clearly identified on their plan of care as confirmed in care plan reviews. The incident and accident form clearly shows that family/whanau are informed and if the GP is notified. This is also shown on the family/whanau contact sheet in the resident's clinical file as confirmed in six of six (three hospital and three rest home) file reviews. Resident and family/whanau interviews confirm their is good communication. This is supported by the results of the resident satisfaction survey results sighted with 100% positive comments related to communication.

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


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


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STANDARD 1.2.7 Human Resource Management

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: The Staff Recruitment and Employment policy identifies actions taken to attract the best person for each role. Staff induction requirements are clearly set out in the quality policy. Stage two: There is a system in place to record annual practising certificates for staff who require them. Annual practising certificates are sighted for one GP, three pharmacists, one podiatrist, one physiotherapist, seven RNs, two ENs, and the Tai Chi instructor. A review of ten of ten staff files (the CN, GM, two RNs, one EN, one cleaner, one maintenance person and three HCAs) and interviews with 14 of 14 staff confirm that the orientation process prepares staff for the roles they undertake. Documented orientation covers all aspects of service relevant to the role the employee undertakes. All files contain signed employment agreements, job descriptions, completed orientation covering issues such as health and safety, house rules, emergency management, infection control, restraint minimisation competencies and medication competencies as appropriate. Other aspects of clinical care, and confidentiality are also included.

All RNs and ENs are required to hold up to date first aid and CPR and this is monitored by the GM. All staff are offered first aid courses paid for by the service. Of the ten staff files reviewed only the maintenance person does not hold a current first aid certificate. Four staff, one being the diversional therapist have completed their Age Care Education papers. The GM is an approved Health Ed Trust assessor.

Every individual staff member has an up to date list of education undertaken. Education is related to the role the staff member performs and both onsite and offsite education is advertised for all staff. Staff interviews confirm they are satisfied with the amount and type of education offered and that during annual appraisals they have an opportunity to identify any specific area of education they wish to pursue. They confirm that all education and training is advertised in the staff room (sighted) and that they are encouraged and supported by management to attend ongoing education. Advertised education includes New Zealand Age Care Association seminars and education. The GM is registered with WDHB and undertakes her personal development and recognition programme (PDRP) to ensure she meets all requirements of the Health Practitioner Competency Assurance Act 2003 to maintain her senior nurse status. All ten of the staff files reviewed had appropriate appraisals which are kept up to date by the GM. She has a system in place to identify when staff appraisals are due.

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


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


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


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


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STANDARD 1.2.8 Service Provider Availability

Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

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


How is achievement of this standard met or not met? Attainment: FAStage one: There is a documented staffing rationale which states:• In every hospital there shall be at all times on duty at least one registered nurse, The distribution of care staff over a 24 hour period shall be in accordance with the needs of residents and as required by the Contractual Agreement with the DHB.• The layout of the facility must also be taken into consideration when determining the number and the distribution of care staff required to meet the needs of the resident. Refer to staffing levels and skill mix.Current staffing levels are: AM SHIFT – Clinical Manager Monday to Friday Clinical Co-Coordinator Saturday to Wednesday 1 RN 4 Caregivers 7am-3pm 1 Caregiver 7am – 10am 1 Activities Co-Coordinator 10am - 3.pm (Mon –Fri) + Ancillary staff

PM SHIFT - 1 RN1 EN

2 Caregivers 3pm-11pm 1 Caregiver 4 - 9pm + Ancillary staff

NIGHT SHIFT – 1 RN 1 EN or Senior Caregiver 1 Caregiver

Ancillary staff include:Kitchen staffActivities coordinatorLaundryHousekeepingMaintenance staff

Stage two: A review of four weeks roster identify that staffing numbers exceed the requirements shown in the DHB contractual requirements. Planned and unexpected leave is covered and replacement staff are shown on the rosters sighted. All shifts have at least one RN on duty at all times. This is confirmed during interviews with 14 of 14 staff. Staff also confirm they have adequate time on each shift to complete all duties. Ten of ten staff file reviews identify that with the exception of the newly appointed maintenance person all staff have a current first aid certificate. Interviews with seven of seven residents (four hospital and three rest home) and three family/whanau members confirm all their needs are met and staff are always available when required.

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


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STANDARD 1.2.9 Consumer Information Management Systems

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy states that personal information will be collected, stored and used in a secure and appropriate manner and in accordance with the Privacy Act and the Health information Privacy Code.Progress notes are maintained and records are integrated. The RN advises entries are required at least daily or sooner where the resident is unwell, or family communications occur, or there is an adverse event/incident. Records sighted are legible, dated, signed and the designation of the staff member noted in the five residents' files sampled. Health care assistants are not documenting in progress notes but instead document the cares provided on a 'daily care monitoring record' and resident's bowel chart which are regularly reviewed by the RN/EN. The RN or EN summarises overall care provided in the progress notes. The 'daily care monitoring form' is retained in the clinical record. In addition, the rest home level care residents care needs are also noted electronically on an electronic tablet (ET) that all applicable HCAs carry. Each HCA has a unique logon and password. The tablet advises the HCAs of who they are allocated to care for during the shift and the cares that are required to be provided for each individual resident. As each care task is completed the HCA signs this off on the ET. Where tasks are not able to be completed for whatever reason they are required to make a commentary entry. The care givers have access to the paper based copy of the care plans as well. The GM and CM advise the information maintained electronically is currently slightly different to that documented on the care record where the detail of care provided (e.g. volume of fluids administered and condition of the resident's skin is noted). Only the GM and CM have access to the computer programme which records all the electronic records. The CM advises at the moment there is some duplication between paper based and electronic records for rest home residents, however the intent moving forward is to move to using the

electronic records for rest home clients. The CM advises if staff leave the facility and they have inadvertently not returned their ET all records on the tablet are wiped to ensure confidentiality. Residents' paper files are held securely in the nurses’ office which is locked (sighted). Archived records are stored securely and a requested archived records are readily obtained from the archived area by either the GM or CM. In the event of transfer to hospital, the District Health Board yellow envelopes are being used (sighted). The ARRC contract requirements are being met.

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


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


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


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


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OUTCOME 1.3 CONTINUUM OF SERVICE 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

Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy identifies all residents who enter the care unit must have a Needs Assessment Service Coordination (NASC) assessment for either rest home or hospital level care.Six residents' files are sampled. Evidence of the completed admission documents and needs assessments are sighted in all six residents' files. All needs assessments sighted confirm appropriate placement of all residents requiring rest home or hospital level care.The CM interviewed confirms Rosedale Village has been operating for many years and is well known within the community and health services and this is evidenced by the occupancy rates. The GM advises they receive regular enquiries about available beds and records of enquiries are maintained electronically (sighted). A copy of the completed needs assessment is required to be provided to the GM or CM prior to residents being accepted to ensure that residents admitted are within the scope of service provided and 'fit' the villages values, philosophy and current resident mix. The GM advises there are currently three residents on a 'waiting list' for access to the service.The residents admission agreement is held in the resident's file and sighted at audit for the six residents whose records are reviewed. The ARRC requirements are met.

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


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STANDARD 1.3.2 Declining Referral/Entry To Services

Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate.

ARHSS D4.2


How is achievement of this standard met or not met? Attainment: FAStage one: Policy outlines the reasons entry may be declined. Reasons for refusal can be: • If the home cannot cater for the level that the applicant is assessed for.• If the applicant has serious psychiatric problems.• If the applicant requires 24 hour registered nursing care and there are no hospital beds available.• If the applicant shows behaviour that could disrupt the other residents.The GM and CM interviewed advise residents are declined when there are no vacancies or if the resident has a level of care than cannot be safely provided on site (e.g. requiring dementia level care). The GM advises at times prospective residents are placed on a waiting list for the next available bed rather than being declined. There are currently three prospective residents on a waiting list and the wait list process agreed with the resident and family member. Records of enquiries and outcomes are maintained (sighted). The GM advises the referrer and enquirer is kept well informed and alternative options discussed as applicable.

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


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STANDARD 1.3.3 Service Provision Requirements

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Documentation identifies:- a care plan is developed to meet the written specific resident requirements.- each resident’s health and personal care needs are assessed on admission in order to establish an initial care plan to cover a period of up to 3 weeks, and the Registered Nurse input and agreement is sought and provided in developing and evaluating the initial care plan in order to ensure continuity of relevant established support, care and treatments.- the assessment utilises information gained from the resident, their nominated representative (where applicable), and information provided by the relevant NASC Service and/or previous provider of health and personal care services along with observations and examinations carried out at the facility- input is sought from the family/whanau- cultural advice and/or guidance has been sought in order to maintain and practice cultural safety.All six residents' files and the staff files sampled by the lead auditor confirm that each stage of service provision is completed by a suitably qualified person. Annual practising certificates are sighted for applicable staff and contractors. All assessments and care plans are developed and reviewed by the registered nurse. Daily interventions and support with activities of daily living are implemented with the help of trained caregivers. A diary is used to track patient appointments with specialists. The CM maintains a book detailing when residents are due for monthly or three monthly GP reviews, six monthly care plan reviews or follow-up of previously identified issues (sighted).

Timeframes for service delivery are defined and met as evident in five out of six residents' files sampled. An initial assessment is performed on admission by the RN and a medical assessment conducted by the GP normally on the day of admission or within forty eight hours. A short term plan is developed and implemented for the first three weeks to guide staff. One exception to this is noted. The rest home resident audited did not have an initial nursing assessment, GP review and care plan documented within required timeframes. The resident was admitted late 2011. The CM advises this was prior to her employment and she is aware of the ARCC requirements. The ARCC requirements have been discussed with the nursing staff at an in-service in March 2013 which was attended by seven staff. The RN interviewed is able to articulate the organisation's and DHB contractual expectations as related to the admission of new residents. The timeframes of the most recent admission (April 2013) complies with ARCC contract requirements.The long term care plan is developed within three weeks and implemented to meet the identified needs and goals of the six residents whose records are reviewed. Short term care plans are also developed as and when required and care plan reviews are completed (at a minimum) every six months. GP reviews are completed either monthly or three monthly and sooner when clinically indicated. The GP documents if a resident is stable and suitable for three monthly routine review. The GP will see residents prior to this time if they are unwell.The GP interviewed confirms her involvement in specialist referrals and medication reviews and states that she is contacted about any concerns in a timely and proficient manner. The GP advises she has been providing care at Rosedale Village since January 2013. The GP visits for four hours in the morning two days a week and is otherwise on call at all times. On very infrequent occasions staff may be requested to bring a resident to the GP rooms for care (e.g. removal of a skin lesion). The GP and physiotherapists time on site occurs at the same time to enable collaborative discussion on residents needs if applicable.Continuity of care is maintained. Residents' files sampled evidence multidisciplinary involvement. For example, GP entries and visits from other health providers are sighted (including wound care nurse, physiotherapist, and podiatrist). Residents' files are integrated. Verbal and written handovers between shifts also ensure continuity. Responsibilities for the provision of daily care is identified during the handover reports. The CM advises she reviews the handover sheets on a daily basis.The relevant ARC requirements are predominantly met excluding time frames in 2011 for one resident.

Rest Home resident audited using tracer methodology: XXXXXX This information has been deleted as it is specific to the health care of a resident.

Hospital level care resident audited using tracer methodology: XXXXXX This information has been deleted as it is specific to the health care of a resident.

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


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


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


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STANDARD 1.3.4 Assessment

Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

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



Stage one: Policy, procedures and assessment tools sighted for continence, skin care, wound care, challenging behaviour, falls management and falls prevention and pain management. These assessments are performed at admission in five resident files sampled and six days following admission for one resident. The assessments have been repeated prior to the last care plan review. Medical assessments are sighted regularly occurring in all six residents' files reviewed during audit. Pain assessments (using the Abbey tool) are undertaken (where applicable). The detail of assessments and plan of care are clearly documented in the sampled files. Assessments in relation to challenging behaviour are undertaken as applicable and sighted in the hospital resident's file who is being audited. Base line observations are also recorded as part of the admission process, and there after monthly (or more frequently if required). The six residents whose records reviewed are being weighed monthly. The resident’s weights are stable or interventions undertaken to manage fluid retention. One resident who is on digoxin has their heart rate checked and recorded daily prior to the administration of this medication and records sighted. Blood glucose levels (BGL) are checked at the frequency required for the residents whose records are reviewed. Where requested daily weights of one resident occurred until these were discontinued.The results of the assessments are used to inform the care plan with outcomes and goals documented. Short term care plans are developed as required. A review of the assessments are undertaken by the RN's six monthly as a component of the care review process. All assessments sighted in the six sampled files are current. ARRC contract requirements are met.

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


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STANDARD 1.3.5 Planning

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

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


How is achievement of this standard met or not met? Attainment: FAAn initial care plan is developed on admission and a long term care plan developed within three weeks (except as noted in 1.3.3). The long term care plan is developed by a RN and includes goals and interventions for personal hygiene needs, oral hygiene needs, mobilisation needs, skin integrity, pain, nutritional needs, sleeping needs, individual spiritual/cultural needs, communication, behaviour and cognition and any other identified needs. Interventions sighted are consistent with assessed need and good practice. The required level of dependence/assistance required is documented for each component. Current long term care plans are sighted in all six residents' files sampled.Short term care plans are developed when required. A number of short term care plans are sighted within the six residents' files sampled. For example, for the management of a urinary tract infection, respiratory infection, mouth abscess, tooth extraction, falls and wounds. Short term care plans are reviewed regularly and closed out when no longer required or the requirements transferred to the long term care plan.

Residents' files sampled evidence integration. Assessments (including the needs assessment), care plans, progress notes, GP notes, physiotherapist records (where applicable), podiatrist notes, adverse events, consents, advanced directives, laboratory/radiology results, DHB letters and medical specialists records/discharge records.The RN and two HCAs staff interviewed confirm they have access to residents' records and are sighted completing their progress notes or daily care monitoring record (HCAs) during audit. Medical plans are of care are clearly documented within the commentary of the GP notes (sighted). The WCNS recommendations are recorded by the GM or CM in the residents' notes and also noted in a dictated letter.Initial assessments are completed on admission and six of six residents and three family members interviewed in more detail on this topic confirm input in the development of health care plans and reviews. Family are invited to attend the six month multidisciplinary review meeting. If they are unable to attend feedback is sought and noted. The ARRC requirements are met.

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


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Criterion 1.3.5.3 Service delivery plans demonstrate service integration.


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STANDARD 1.3.6 Service Delivery/Interventions

Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

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


How is achievement of this standard met or not met? Attainment: FAInterventions are documented within each domain of the care plan for the six (three hospital and three rest home) residents' care plans sampled. Interventions sighted are commensurate with the completed assessments and residents' desired goals. Interventions are detailed and documented clearly to guide staff. Residents are encouraged to be involved in developing realistic and optimal levels of functioning to meet their own everyday living needs/goals and to maintain independence. This is verified during interview with six of six resident's (three hospital and three rest home level care resident's) and three family members (two rest home and one hospital level care). The residents and family members interviewed confirm that the residents are receiving timely care to meet their identified needs. Where applicable changes are made and communicated to/with them.The CM discusses recent changes that have occurred for the rest home level care resident who has a deteriorating chronic wound. The nursing staff have been documenting regular observations of the wound, its presentation and wound care provided. The GM is now using photographs to assist monitoring the wounds (sighted).Short term care plans (STCPs) are being developed when a specific new problems are identified or following an reportable event. The required interventions are documented. One resident's file sampled required daily weights due to weight gain/fluid retention. Daily weights are documented as occurring and the plan discontinued when deemed appropriate by the RN. Another resident has a short term care plan for the daily monitoring of lying and standing blood pressure following a fall and changes in the residents medications. This has now been discontinued by the GP. Several residents have a short term care plan related to a urinary tract infection or respiratory infection. Another resident developed a tooth abscess, was seen promptly by the GP and commenced on antibiotics and an appointment made for the resident to see a dentist. The tooth was removed and a new STCP developed to identify the care required for the tooth socket. Records of fully implemented and monitored interventions are sighted to have occurred. Two residents have short term care plans related to wound care. The rest home resident auditing has a large wound on the leg (refer to 1.3.3). This resident also is provided with PRN pain relief as required (Refer to 1.3.3). This is verified by the resident and the family member during interview. An air rotating mattress has been placed on the resident’s bed since early signs of a pressure area identified.

The relevant ARRC requirements are met.

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


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STANDARD 1.3.7 Planned Activities

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

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


How is achievement of this standard met or not met? Attainment: FAThe activities programme is appropriate and reflects that independence is encouraged and choices are offered. An activities assessment and plan is documented for all six residents whose records are reviewed. This identifies personal interests and hobbies. Activities are then planned to help maintain skills and interests. The programme is sighted displayed in communal areas. Residents interviewed also had a personal copy of the plan. Three activities assistants are involved with the provision of the activities programme which is provided weekdays between 9.00 am and 3.00 pm. The activities programme includes: games, newspaper reading, cooking, tai chi, walking, games, sing-a-long/entertainment, quiz’s, television/movies, church services, celebrating residents birthdays and outings. Happy hours are also scheduled. All six residents interviewed and three family members interviewed speak highly regarding the variety of activities and outings that are provided. Preferences are considered and interests maintained. Family members are encouraged to keep social interactions with residents ongoing. Residents are observed participating in activities including happy hour, newspaper reading, games and the entertainment. The resident audited confirms being able to attend activities of choice and find them enjoyable. The activities coordinator has been in her room the morning of audit to assist with applying make-up. The resident confirms this is common. All residents have a television in their room with Sky TV channels. Another resident who does not speak English watches programmes in Russian. The activities coordinator advises she also downloads clips from you tube for this resident to watch. On the weekends the HCA read to residents, put movies or music on as time permits.Records of attendance are kept for the activities. The activities coordinator participates in the MDT reviews as evidenced in the six residents' files reviewed during audit.

The relevant ARRC requirements are met

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


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STANDARD 1.3.8 Evaluation

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

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


How is achievement of this standard met or not met? Attainment: FAStage two: Policy identifies that resident care outcomes are evaluated to ensure the required response has occurred. If a resident's progress is different from expected the service initiates changes to the care plan or a short term care plan is completed for specific problems that require a different intervention. At least six monthly reviews of the residents' progress towards meeting the care plan goals is being undertaken. Progress notes are completed by the RN at least daily or sooner when required in the six residents' files sampled. Any changes or support interventions are documented to enable the resident to attain their goals or to work towards goals if not already attained. The monthly/three monthly GP reviews and three monthly medication reviews are evident in all six residents' files sampled. There is evidence of the follow-up of laboratory results and the residents response to changes in medications. Short term care plans are utilised and care plan updates are made as required (refer 1.3.5 and 1.3.6). There is evidence of regular evaluation until the care plan is closed or the care requirements transferred to the long term care plan. The RN's are responsible for the review of care

plans and maintain a schedule of when these are due. Residents and family member participation is encouraged including at the MDT meetings as sighted in the six resident files sampled. The six residents and three family members interviewed confirm that changes are made to care provision in response to the residents' needs.

The relevant ARRC requirements are met.

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


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


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

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

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


How is achievement of this standard met or not met? Attainment: FAThe GP interviewed states that resident support for access or referral to another health and disability provider is facilitated in a timely and safe manner. The GP confirms her involvement in the referral process. The RN states that the resident and family are consulted prior. This includes prior to transferring residents to the DHB hospital for care. This is verified during interview with the rest home resident audited and her family member. The rest home resident audited has been referred to and seen by the DHB WCNS. The resident and family member confirm this was discussed and consented prior to the referral being made. This resident was also referred to the Salvation Army visitor services as agreed with the resident and family member prior. Evidence of a recent referral to the dentist is noted in one of the six resident files sampled. The CM advises if residents have increasing care needs and are no longer rest home or hospital level care, discussions occur with the resident and family and GP and the resident is referred to the Needs Assessment Service for assessment.The ARRC requirements are met. Six of six residents and three family member interviewed state they have access to the community and allied health services of their choice.

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


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STANDARD 1.3.10 Transition, Exit, Discharge, Or Transfer

Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


How is achievement of this standard met or not met? Attainment: FAPlanned discharges or transfers are required to be conducted in collaboration with the resident/family. There are documented policies and procedures to ensure exit, discharge or transfer of residents is undertaken in a safe manner. Rosedale Village is using the 'yellow envelope' to send information to the DHB when a resident is transferred to document the needs and requirements of residents during this process to ensure continuity of care. An example sighted during audit when St John’s ambulance service returned the yellow envelope which was inadvertently not given to the emergency department staff earlier in the week when a resident was transferred. A copy of key documents including care plan, advanced directive, enduring power of attorney and medication records are also copied and provided. The GM and CM advises there is open communication between staff and family relating to all aspects of care including transfer and this is evidenced in applicable residents' records sighted.The GP interviewed confirms she will be involvement in the discharge/transfer process as applicable to individual residents. The GP and CM advise there have been no transfers to other facility since they have started working at Rosedale Village.

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


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STANDARD 1.3.12 Medicine Management

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

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


How is achievement of this standard met or not met? Attainment: PA LowPolicies and procedure describe all aspects of safe medicines management. It states "all medication is administered by the registered nurse in the hospital and by an enrolled nurse or supervisor in the rest home - all whom have been competency tested". Records sighted verify all RNs and the CM have been assessed as competent to administer oral medications, warfarin, insulin and other injectable medications. All ENs and one HCA have been assessed as competent for the administration of oral medications only. There are clearly described reconciliation processes which are sighted to be implemented at audit. Areas for improvement are identified at audit in relation to medication administration and associated documentation.The service has no standing orders. Policy describes that residents may self-administer medicines is they are deemed competent to do so by a RN assessment. The clinical manager advises there is one resident who are currently self-administering their eye medication. This resident has been regularly assessed as competent to do so (sighted).Six of six residents interviewed and the three family members interviewed confirm they (or another family member) are kept informed of all changes to medications.

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

Audit Evidence Attainment: PA Risk level for PA/UA: LowTwelve of twelve medications records reviewed have the resident's photograph present and the medication record is legible. Each entry is signed by the prescriber and the date and signature noted for all discontinued medications. Allergies are documented as being assessed on all records. Medications have been noted as reviewed by the GP in the last three months in all 12 resident records sighted. Where residents' medications are to be crushed this is clearly noted on the medication records sighted. The verbal orders have been signed by a RN and another staff member. These have been signed off by the GP for the two applicable residents who had verbal orders in their files.

Medication packs are delivered monthly from the pharmacy. All packs are checked by two RNs against the current medication records before being released for use. Where changes are made by prescribers after a new blister pack has been issued, details of the changes are faxed to the pharmacy and a new pack issued. Medications are delivered each evening by the pharmacy. Where there are additional medications prescribed (including short course) these are dispensed in supplementary blister packs. A register is maintained of all medications returned to the pharmacy for disposal (sighted).

There are summaries in all 12 residents' files (whose medication records reviewed) attached to the MDT meeting of the intended purpose for each medication and potential side effects/interactions.

Medications are safely stored in a locked medication cabinet in the staff office. Staff are sighted carrying the keys on their person. There are several residents requiring controlled drugs. The pharmacy delivers a supply each week. These are entered into the controlled drug (CD) books and placed in the designated safe. The CD register is maintained when medications are administered and this is reviewed at least six monthly by the pharmacist. Regular checks of the balance are noted and the six monthly quantity stock count has been done.

Non-packaged medications (creams, inhalers and eye drops) are also stored safely in the medication cabinet.

A lunch time medication round is observed and confirms administration is safely maintained, explanations provided to the residents of medications given and the administration record is documented after the resident has been observed to swallow the medications. The RN is wearing a blue apron that states medication is in the process of being administered.

Medication errors are reported and investigated and discussed with the pharmacists/ GP as applicable. Incident forms sighted detail a comprehensive investigation and corrective action plan to address issues.

At audit a number of areas are identified as requiring improvement. Three of twelve residents have non-blister pack medications (Chlorvescent and panadol elixir) included in the blister pack signing sheet. These are currently signed as administered with the blister pack medications and not separately. Not all non-blister pack (Laxatives and panadol elixir) medications have been administered as prescribed. The time and dose of pro re nata (PRN) medications is not consistently detailed in records sighted. An internal audit undertaken in July have identified these issues and communications made with applicable staff on the 30 July 2013 and records sighted. A number of additional issues identified in the internal audit have already been addressed. As the organisation has identified and is already actively working to address these issues it has been rated as a low risk.

ARRC requirements are predominantly met. Residents' medication is reviewed on entry to the facility. This includes a medication reconciliation (sighted in GP records of the most recently admitted resident) and the resident following transfer back from WDHB.

Finding Statement

1) Three of twelve residents whose records reviewed have non-blister pack medications (e.g. oral Chlorvescent tablets (for dissolving in water) and panadol elixir) signed for with the blister pack medications administered. These are non-blister pack medications and a separate signing sheet is not currently being maintained. 2) The time and dose of PRN medication administration is not consistently documented. 3) Routine administration of non-blister pack medications including laxatives and panadol elixir cannot be consistently evidenced.


Ensure medication management practices meets current accepted practice and legislative requirements.

Timeframe:Six months

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


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


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


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STANDARD 1.3.13 Nutrition, Safe Food, And Fluid Management

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

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


How is achievement of this standard met or not met? Attainment: PA LowStage one: Cater Plus Services New Zealand Limited provides catering services on site and commenced in April 2013. The service is reported to operate a food safety programme using a New Zealand Food Safety Authority and HACCP (Hazard Analysis of Critical Control Points) based system to maintain the highest possible levels of food safety and quality. The site manager must complete the monthly food safety Inspection to ensure that the food safety programme is implemented and effective. Corrective actions are implemented immediately using the opportunity for improvement.Onsite: The winter menu is for a four week period and rotates. This has been recently reviewed (May 2013) by the dietitian and records sighted verify this. The dietitian feedback is very positive and recommended changes have been made. There are home baked morning and afternoon teas. The main meal is provided in the evening when dessert is also served. The lunch meal comprises a soup, savoury dish, fresh fruit and cake/slice.Nutritional assessments are completed on entry to the rest home. Special dietary needs are identified by the RN and communicated to the kitchen. A copy of the resident's dietary profile is present in the kitchen and a whiteboard also details individual resident's dietary needs, allergies, and likes and

dislikes. Six residents' records sampled included a resident who requires minced moist meals and the resthome resident audited who dislikes chicken and fish cooked in any way other than as 'fish and chips'. These needs are also clearly documented in the residents' care plans. Five of six residents weights are being monitored monthly and are stable. One resident refuses to be regularly weighed although agrees from time to time and is noted to be gaining weight.Seven of seven residents interviewed are very satisfied with the food and confirms adequate amounts of food are served. This is verified by the three family members interviewed. There are currently several residents who require a diabetic meals and several residents who require a specific textured meal. Several residents are on nutritional supplements and supplies sighted. Staff members are sighted assisting resident's to eat during the lunchtime meal and offering more food/soup if they want it. Several residents are having cranberry juice daily as part of the care plan aimed at reducing urinary tract infections.Not all food in the refrigerator is dated, recipes are only used for baked items, two staff involved with food preparation have not undertaken relevant food hygiene training and the temperature of chilled and frozen food is not being monitored on delivery. These are areas requiring improvement. Most ARRC requirements are met.

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


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


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

Audit Evidence Attainment: PA Risk level for PA/UA: ModerateThe temperature of the refrigerator and freezers are checked and documented on a daily basis. The temperature of all dishes are checked and documented as within the required parameters when the food is ready to leave the kitchen. Monitoring of the temperature of chilled or frozen food on delivery is not currently occurring. Not all food in the refrigerator is dated as when opened or refrigerated. This include a packet of open fresh salmon, tinned fish, whipped cream, cheese and other food items. Recipes are currently only available and used for baked items and dessert. Recipes are not being used for soups or main meal dishes. Two staff who are involved with food preparation have not undertaken relevant food hygiene training. These are areas requiring improvement. Certificates verifying three other staff members have completed food hygiene training are sighted.

Finding Statement

1) Food currently stored in the refrigerator is undated. This includes open fresh salmon, tinned fish, whipped cream and assorted cheeses. 2) Two staff involved with food preparation have not undertaken food hygiene training. 3) Currently recipes are only available for baked items /desserts. 4) The temperature of chilled and frozen food stuffs is not being monitored on delivery.

Corrective Action Required:Ensure all aspects of food management are undertaken to meet legislation, guidelines and current accepted practice.

Timeframe:Three months

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

These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3.

STANDARD 1.4.1 Management Of Waste And Hazardous Substances

Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

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


How is achievement of this standard met or not met? Attainment: FAStage one: There is a clearly documented policy and procedures for the safe and appropriate storage and disposal of waste. They meet infection control requirements. There are no specific territorial authority requirements. Sharps are disposed of in specific sharps bins located on medicine trolleys and in the medication room. Part two: Chemicals are supplied by Ecolab. Safety data sheets are visible in all areas where chemicals are stored. Personal protective equipment/clothing (PPE) sighted includes disposable gloves and aprons, goggles and masks. Interviews with 14 of 14 staff from across the organisation (HCAs, RNs, ENs, cleaning, maintenance, laundry and management) confirm they can access PPE at any time and they can verbalise appropriate use. Staff are observed wearing disposal gloves and aprons as required. Approved yellow sharp bins sighted are used for the safe disposal of sharps. Sharps bins located on medicine trolleys and in the medication room.The service undertakes appropriate storage and disposal of waste, infectious and/or hazardous substances to comply with current legislation. The GM confirms there are no territorial authority requirements for waste disposal. Waste is collected by a contracted company (JJ Richards).

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


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


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STANDARD 1.4.2 Facility Specifications

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

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



Stage one: Documentation identifies outside areas are easily accessible and meets the needs of people with disabilities. The seating offers enough privacy for residents who wish to sit by themselves or with their relatives/visitors. Umbrellas are placed over each outside table to offer adequate shading. The service encourages residents to wear a hat in the sun and offers sun block to prevent burning.Stage two: All processes are undertaken as required to maintain the service building warrant of fitness. The current warrant of fitness expires on 12 October 2013. An exterior and interior maintenance schedule is sighted for 2013. Electrical testing occurred in February 2013.All biomedical and medical equipment which includes beds, hoists, otoscope, oxygen connectors and regulators, sphygmomanometers, stethoscopes, syringe drivers and chair scales had safety checks carried out by an approved provider on 4 July 2013. The only item which failed the test was a blood sugar monitor which was disposed of and replace with a new one. This is well documented.

The physical environment minimises the risk of harm and safe mobility by ensuring the flooring is in good condition, the correct use of mobility aids and walking areas not being cluttered. Wide corridors with safety handrails assist residents to mobilise safely. Residents who have mobility difficulties are assessed by a physiotherapist and appropriate walking aids are obtained to assist with safe mobilisation. Regular environmental audits are undertaken and follow up corrective actions are documented for areas that have a deficit identified. For example if any area requires maintenance it is written in the reactive maintenance book for repair. The maintenance book and interviews with staff including the maintenance person and residents confirm repairs are undertaken as soon as possible. There is a monthly maintenance checklist completed by the maintenance person to identify regular planned maintenance is undertaken.Residents have access to outdoor areas with seating and shaded areas. All rest home area bedrooms have doors which lead directly onto a balcony or into the garden area. Hospital residents can access outdoor areas from the many exterior exits to the gardens. Interviews with seven of seven residents (four hospital and three rest home) and three of three family/whanau members confirm the environment is suitable to meet their needs. One resident who has poor memory stated she is very happy with everything. Residents were observed walking around inside and outside the facility both independently and with the use of walking aids.

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


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


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


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STANDARD 1.4.3 Toilet, Shower, And Bathing Facilities

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

ARC E3.3d ARHSS D15.3c


How is achievement of this standard met or not met? Attainment: FAStage one: Documentation identifies hot water is provided at an acceptable temperature, determined by the Building Regulations 1992, to minimise risk of burning. Water temperatures are checked regularly ensuring safe temperature of 45 degrees Celsius is maintained.Stage two: All rest home level care bedrooms have full ensuite facilities. The hospital level care area has a toilet and hand washing area between two rooms. (One room has single use as there are 13 rooms). There are adequate numbers of centrally located showers in the hospital area. Sanitising hand gel is available throughout the facility. Hot water temperatures are monitored and recorded. It was noted in June that water temperatures went to 48oC in three bedrooms. A plumber was called and this has resulted in five tempering values being replaced. Water monitoring was checked and is now below the required 45oC safety temperature. There are separate staff and visitor toilets.

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


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STANDARD 1.4.4 Personal Space/Bed Areas

Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

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


How is achievement of this standard met or not met? Attainment: FAStage one: There are 13 hospital level bedrooms. All bedrooms are single occupancy. Stage two: All bedrooms are single occupancy. They are personalised to meet residents' wants and needs and are large enough to enough to allow residents with or without mobility aids to move around safety. Interviews with residents and family/whanau confirm they are happy with their bedrooms and they appreciate that they are all personalised to make residents feel at home.

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


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STANDARD 1.4.5 Communal Areas For Entertainment, Recreation, And Dining

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

ARC E3.4b ARHSS D15.3d


How is achievement of this standard met or not met? Attainment: FAStage two: The physical environment provides safe, age appropriate and accessible areas to meet resident’s needs. Residents are free to move around the facility as they wish. There are two lounges and two dining areas. One lounge/dining area is for village and rest home level residents and the one a separate lounge/dining area for hospital residents. The lounge and dining areas are separated by the placement of furniture and a change in flooring. They do not impinge on each other. There is a library, hairdressing salon for resident use. There are small, appropriately furnished seating areas throughout the facility. All areas are furnished to a very high standard. Both lounge areas and a separate room are used for recreation as appropriate. Seven of seven resident (four hospital and three rest home) and three of three family/whanau interviews confirm their high level of satisfaction with the facilities provided.

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


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STANDARD 1.4.6 Cleaning And Laundry Services

Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

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


How is achievement of this standard met or not met? Attainment: FAStage one: Cleaning and laundry policies and procedures. Staff education is undertaken specific to cleaning and laundry and includes safe chemical handling (14 October2012).Stage two: Cleaning and laundry processes are undertaken as described in policy and according to the job description sighted. This covers required daily tasks and the laundry and cleaning staff interviews confirms they have the appropriate equipment and time to complete all tasks. There are dedicated cleaning and laundry staff, seven days a week. Interviews with cleaning and laundry staff confirm they have adequate supplies of personal protective equipment and they verbalised their knowledge related to when to wear gloves and aprons. PPE is sighted in all areas. Staff verbalise their understanding of isolation techniques and knowledge of documented laundry and cleaning process related to outbreak management. Ecolab supply the chemicals used in the facility and they ensure all products are being use for the job they are intended and they monitor the effectiveness of the product. Up to date safety data sheets are available to staff in all areas chemicals are stored. Staff education is confirmed during interview and in the staff file reviews undertaken for the laundry and cleaning staff members. All chemicals sighted are appropriately labelled. The laundry has a clean/dirty flow, with adequate equipment for the size of the facility. No negative comments have been received related to either laundry or cleaning during the audit or in the results of the resident satisfaction surveys sighted. Cleaning trolleys are securely stored when not in use. Interviews with residents and family/whanau confirm they are satisfied with laundry and cleaning services.

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


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


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STANDARD 1.4.7 Essential, Emergency, And Security Systems

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

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


How is achievement of this standard met or not met? Attainment: FAStage one: Documentation identifies that each resident room, bathroom, toilet and shower is fitted with a call bell to ensure that residents can summon help when needed. These are tested at least annually. Staff receive training regarding the importance of answering the call bells as soon as possible.

Policies related to fire are comprehensive and identify that all fire equipment is tested regularly. The activation of the sprinkler and manual fire alarm systems initiates an automatic call to the Fire Service. The smoke detector system is not connected to the Fire Service by automatic call but show up on a mimic panel. Fire evacuation drills are carried out at least six monthly. It is compulsory for staff to attend one fire drill annually. All staff must complete a fire safety questionnaire.

Stage two: The approved emergency evacuation plan signed off by the New Zealand Fire Service is dated 09 November 2005. There have been no changes to the facility foot print since this time. Six monthly trial fire evacuations are conducted. Last undertaken on 16 April 2013. The GM monitors staff attendance to ensure policy requirements are met related to staff education.Fire equipment was checked by an approved provider in February 2013. Records are sighted for regular sprinkler, fire doors, emergency lighting and sign checks by Fire Systems Maintenance company. Civil defence and emergency supplies are checked regularly. There are lists of emergency phone numbers for staff and community services in staff areas. Observation and interviews with the GM confirms there are emergency food and water supplies for up to five days if required. All clinical staff hold current first aid certificates to ensure there is always a staff member on duty in case of an emergency. Staff are required to ensure doors and windows are securely closed at night. This is confirmed by a HCA who works afternoon and night duty. The external electronic gates and external doors automatically lock at 6pm. To gain entry after this time visitors need to use the intercom at the gate. which activates the staff pager to ensure all calls are responded to quickly. Matrix Security company undertake twice nightly rounds to check the grounds and doors and windows are secure. Call bells are sighted in all resident areas. When the bell is activated a buzzer rings and a light shows up outside the room it has been activated from. The room number also goes onto staff pagers. A visual ceiling LED display in each corridor identifies the room number the bell has been activated from. Interviews with seven of seven residents (four hospital and three rest home) confirm staff respond in an appropriate timeframe if the call bell is activated. The GM can electronically monitor the time it takes for staff to respond to a call bell. A monthly call bell log book sighted to show every room is tested to ensure call bells are operating.

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


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

Audit Evidence Attainment: FA Risk level for PA/UA: Fire service approved 9 November 2005.

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


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


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


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STANDARD 1.4.8 Natural Light, Ventilation, And Heating

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

ARC D15.2f ARHSS D15.2g


How is achievement of this standard met or not met? Attainment: FAStage one: Documentation identifies heating in every living room, dining room, recreational room, bedroom and bathroom is fitted with a safe and approved heating system.Stage two: All resident areas have at least one opening window and/or door which provides natural light and ventilation. The facility is heated by use of both electric and gas fired heating. Interviews with staff, residents and family/whanau confirm the facility is kept at an even temperature throughout the year. The facility was warm on the days of audit. The buildings are smoke free and there are dedicated outdoor smoking areas.

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


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


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

OUTCOME 2.1 RESTRAINT MINIMISATION

STANDARD 2.1.1 Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


How is achievement of this standard met or not met? Attainment: FAStage one: Policy states "The voluntary use of enablers by residents with the intent of promoting independence, comfort and/or safety is not considered a form of restraint under the meaning of this policy. Separate guidance are provided within the protocol on the use of restraint".Stage two: At the time of the audit two bedside rails are being used as a restraint and one bedside rail as an enabler. The hospital area has a key pad lock on the door. The number is clearly advertised at the door but seven residents have approved restraint sighed for keypad restraint. This is documented in the resident's file and approved by family/whanau as a measure to ensure staff undertake regular monitoring of these residents as they have varying degrees of memory loss and are prone to wander. The GM has discussed the level of care for the residents with the gerontology nurse specialist and they do not need reassessment at this stage as the monitoring in place is adequate to ensure their safety. A restraint assessment is completed by the registered nurse to ensure that restraint is the least restrictive option. A consent form is signed by the general practitioner, the resident (or their representative) and the restraint coordinator prior to any restraint being put in place.Policy identifies that enablers shall be voluntary and the least restrictive option and that restraint is used for safety reasons only. Policy clearly states that restraint type will be decided by the approval group following assessment to ensure it is the least restrictive option to meet residents' needs. The restraint coordinator (RN) and GM confirm that the only types of restraint considered are bedside rails and chair lap belts and environmental restraint owing to the locked door in the hospital area. This door is not kept locked at night as the exterior doors are on automatic lock after 6pm.

Three non-restraint hospital level care resident interviewed confirm they can exit the unit via the keypad at any time. This is confirmed by one family/whanau member interview.

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


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OUTCOME 2.2 SAFE RESTRAINT PRACTICEConsumers receive services in a safe manner.

STANDARD 2.2.1 Restraint approval and processes

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy identifies that the decision to commence restraint must be agreed by the approval group. Approved restraints are chair lap belts, environmental (keypad locked door in hospital area) and bedside rails.

The restraint approval group is the same people as the quality group, CM, GM, director, and the GP. The GP also is involved in the three monthly assessment and approval for ongoing restraint. She signs to say she agrees that restraint is required. Family/whanau are involved in the restraint approval process. Stage two: The restraint approval group monitors all restraint use on at least a three monthly basis or sooner if required. All restraints in use at the time of audit have been approved, monitored and updated by the approval group. The review process is clearly documented. The only restraint in use at the time of audit are clearly described in policy. All restraints used are for safety reasons only. All RNs are competent to undertake restraint assessment and once completed it must go to the approval committee to be signed off as appropriate. Restraint education was conducted on 14 March 2013 and 19 staff attended. On the 28 March 2013 challenging behaviour and de-escalation education occurred and 7 staff attended.During interviews with eight HCAs, one RN, one EN the GM and CM identify their knowledge and understanding of safe restraint requirements as described in policy and procedures. They understand the lines of accountability for restraint use.

Criterion 2.2.1.1 The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.


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STANDARD 2.2.2 Assessment

Services shall ensure rigorous assessment of consumers is undertaken, where indicated, in relation to use of restraint.



How is achievement of this standard met or not met? Attainment: FAStage one: Policy identifies assessment for the use of restraint is undertaken by a RN. It covers all aspects of this standard. Rosedale Village’s Quality and Risk Management Team are responsible for approving any form or type of restraint practice or device that can be used at the facility. The approval process for each practice or device approved shall include documentation of:1. Indications for use 2. Identified associated potential risks3. Written instructions on safe use of practice /device4. Minimum observation and monitoring requirements5. Required documentation6. Evaluation and review frequency7. Maintenance of equipment frequency

Stage two: Restraint and enabler assessment forms sighted in restraint resident file reviews are completed to meet policy requirements. They describe behaviour, duration of use, assessed potential effects, consumer input into the decision making process, restraint authorisation and plan, observation/monitoring frequency according to risk, acknowledgement and explanation and review dates.Alternative strategies, such as lowering the bed, are listed on the assessment form. Family/whanau are included in any restraint decisions as appropriate. This includes discussion around past history to identify any risks with the use of restraint. Assessment findings inform resident care planning. The RN can clearly verbalise correct assessment process required to ensure appropriate use of restraint.

Criterion 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.


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STANDARD 2.2.3 Safe Restraint Use

Services use restraint safely



How is achievement of this standard met or not met? Attainment: FAStage one: Policy identifies the restraint coordinator shall maintain a restraint register that records sufficient information to provide an auditable record of restraint use. Approved restraint is only applied as a last resort for safety reasons after alternative interventions have been considered such as the use of a lowered bed. The restraint coordinator determines the outcome of the restraint episode and identifies any injury to any person occurring as a result of the use of restraint. Policy identifies that staff education is undertaken during orientation and annually thereafter. This includes staff completion of a competency related to safe restraint use and monitoring. Stage two: Monitoring is decided according to identified risk and ranges from 30 minutes to two hours. Currently all residents with bedside rails are on two hourly monitoring and environmental restraint required the residents to be sighted at least every 30 minutes. The GM confirms there have been no injuries related to restraint use.

All restraint is documented in the restraint register (sighted) by resident name, the date of the introduction of the restraint, and review date. Each monitored observation is recorded with the date and signature of the observer. The use of restraint and monitoring frequency is documented on the resident's care plan. The restraint register identifies that restraint is ceased as appropriate. The restraint register identifies that if a resident becomes less mobile and does not move around the bed, bedside rails are discontinued as the risk of falls is no longer present.

Criterion 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.


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Criterion 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.


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Criterion 2.2.3.5 A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.


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STANDARD 2.2.4 Evaluation

Services evaluate all episodes of restraint.



How is achievement of this standard met or not met? Attainment: FAStage one: The use of restraint at Rosedale Village is reviewed on an ongoing basis to ensure compliance with the relevant standards and Rosedale’s policy. The approval group is responsible for ensuring an ongoing process of quality review and at least an annual comprehensive quality review of the Restraint Minimisation and Safe Practice Programme is undertaken. This includes the monthly measuring of relevant clinical key performance indicators.Stage two: Three monthly reviews sighted in restraint file reviews show the review is undertaken by the restraint approval group. Reviews evaluate the need for continued restraint and considers all aspects of restraint use to ensure resident safety. Resident care plans are updated to reflect any changes required. Following review modifications are made or the restraint is discontinued as appropriate. Restraint use is discussed with the resident and/or their family/whanau at the six monthly resident care plans review. Family/whanau involvement is identified in all reviews sighted. Six monthly restraint use audits are maintained. They cover:- documentation related to type and duration of restraint use- ensure policy is followed- identify if alternatives to restraint have been tried and if they are successful- that the resident been offered support- that three monthly review and evaluations have occurred- ensures monitoring documentation is completed correctly- that staff competencies are up to date- the appropriateness of education - evidence of reduction in restraint useThe June 2013 monthly review gained a 100% pass rate on all of the above mentioned areas.

All documentation is checked by the restraint coordinator every month to ensure policy is being implemented. If a resident's acuity level changes between reviews the restraint coordinator will review the need for continued restraint use at any time.

Criterion 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.


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Criterion 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.


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STANDARD 2.2.5 Restraint Monitoring and Quality Review

Services demonstrate the monitoring and quality review of their use of restraint.

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


How is achievement of this standard met or not met? Attainment: FAStage one: Policy identifies that the annual quality review includes: • The extent of restraint use and any trends• Rosedale’s progress in reducing restraint usage• Adverse outcomes from restraint intervention• Staff compliance with Programme, Policies and Protocols• Whether the approved restraint is necessary, safe, of an appropriate duration and appropriate in light of consumer and staff feedback and current accepted practice. Stage two: An annual quality restraint use review sighted undertaken in 28 January 2013 includes manual and policy reviews. The review identifies that in January 2013 there were 11 restraints in use and that all 13 hospital level residents had key pad restraints. Currently the service has reduced this number to 3 restraints and 7 environmental (keypad) hospital level resident restraints. This report is presented at board level.

Restraint is used as a last resort and alternatives include the use of a mattress on floor, an increase in activities to assist in mental tiredness to decrease sun-downing, and additional fluids such as cranberry juice to lessen confusion due to urinary tract infections.

As confirmed in eight clinical staff file reviews education and competencies are undertaken for all new staff as appropriate during orientation and annually thereafter.

Criterion 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.


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

STANDARD 3.1 Infection control management

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

ARC D5.4e ARHSS D5.4e


How is achievement of this standard met or not met? Attainment: FAStage one: Policy and procedures reflect current accepted practice, which are implemented within Rosedale Village work practices minimising the potential risk for the spread of infection. The infection control programme covers all areas of service provision and is reviewed annually (each January) and a report is presented to the GM. The service has a nominated infection control officer (the CM) with clearly set out lines of accountability.The annual review of the infection control programme was undertaken for 2012 and records of this are sighted. All twelve staff interviewed comprising (one RN, one EN, the activities co-ordinator, eight HCAs, and one HCA supervisor) are able to describe what they would do if they suspected a resident has an infection. This is verified during audit during review of residents' files. Several residents are referred to the GP, seen and commenced on antibiotics for an infection including: urinary tract infections, a respiratory infection, a wound infection and a tooth abscess. The RN and CM advises there are currently seven residents with a multi-drug resistant organism (MDRO) and advises how they are caring for residents with a MDRO. The MDRO is noted in the applicable resident's care plan when reviewed.The CM (who is responsible for infection prevention and control activities) advises staff are offered an influenza vaccination by the owners free of charge each year. Residents are also provided with annual influenza vaccination following consent. Ten staff and 44 residents were vaccinated earlier in 2013. The CM advises when they are talking with family they request them not to visit if they are unwell.

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


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


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


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STANDARD 3.2 Implementing the infection control programme

There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



How is achievement of this standard met or not met? Attainment: FAStage one: Infection control data is presented at the CQI meeting monthly. Minutes sighted by the lead auditor verify discussion on relevant issues and quality improvement projects are occurring. There is a specific form for recording all infections. This is sighted to be completed as applicable on all occasions in the six residents' files reviewed who are diagnosed as having an infection.

The CM interviewed confirms she is responsible for facilitating the infection prevention and control programme. She participates in relevant ongoing education. This has included subcutaneous fluids management (23 February 2011), management of PEG devices and enteral feeding (7 April 2011 and 19 October 2012), Infection prevention and control/pandemic planning (12 July 2011), hand hygiene/standard precautions/ influenza and Norovirus in-service (22 July 2011), and wound care (20 September 2011 and 3 July 2012). The CM completed the18 hour vaccinator training programme (April 2013) as well as training on male catheterisation in June 2013.

The CM confirms there are sufficient supports in place and would speak to the GP as the first point of contact for infection control issues, followed by the gerontology nurse specialist or infection prevention and control nurse specialist at WDHB.

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


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STANDARD 3.3 Policies and procedures

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

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


How is achievement of this standard met or not met? Attainment: FAStage two: Policies and procedure reflect current accepted good practice and are reviewed annually. The policies are aligned with current accepted practice. The policy manual is accessible to staff as sighted and verified during interview with 12 of 12 clinical staff and the CM.

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


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STANDARD 3.4 Education

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



How is achievement of this standard met or not met? Attainment: FAStage one: The infection control nurse is required to undertake annual infection control specific education. Infection prevention and control education is provided for staff as a component of the orientation programme and ongoing education programme. Education was last provided in an in-service on 12 June 2013. This in-service was attended by 15 staff. Refer to 3.2 for details of relevant training attended by the CM. The 14 staff interviewed (one RN, one EN, the activities co-ordinator, two cleaners, eight HCAs, and one HCA supervisor) advise they have opportunities for ongoing education that is applicable to their roles. The company which provides the chemicals used throughout the facility is also involved with providing education to staff. Education provided to residents is primarily related to the treatment of infections and infection prevention strategies and is detailed in the applicable short term care plans sighted at audit.

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


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


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


How is achievement of this standard met or not met? Attainment: FAStage one: The infection control programme describes the need for all infections to be recorded and reported. These include lower respiratory tract, skin and soft tissue, influenza, urinary tract, ear, eyes, nose and mouth infections. Data is collated daily and analysed monthly and identified separately for rest home, hospital and village residents. Monthly reports are presented at the CQI meeting and to the GM and verified in minutes sighted. A template form is provided for the reporting of infections. Infection forms are sighted completed in all applicable residents' files sampled. The infections have been reported through the surveillance programme when checked. Twelve staff involved with service delivery are aware of their responsibilities in relation to the reporting and follow up of infections. Staff confirm they are advised of infections in a timely manner via handover processes and overall infection rates and trends are discussed at staff meetings. This is verified in staff meeting minutes sighted by the lead auditor.The GP interviewed confirms staff communicate in a timely manner when infections are suspected and detailed the process used by staff. It is documented in the sampled resident's files that the resident's family have been informed of the infection and treatment plan. The six (three rest home and three hospital level care) residents and three family members (two rest home and one hospital level care residents) interviewed confirm they or another family member are informed in a timely manner of suspected or diagnosed infections and the planned treatment.

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


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


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Certification audit summary - Ministry of Health€¦ · Web viewRosedale Village Care Limited...

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Transcript of Certification audit summary - Ministry of Health€¦ · Web viewRosedale Village Care Limited...