althorp private hospital limited current status: 21-aug-13 on … · 2015. 3. 20. · althorp...

Althorp Private Hospital Limited

CURRENT STATUS: 21-Aug-13

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Verification 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

Althorp Private Hospital is currently certified to provide care for up to 90 residents across four service levels (hospital, medical, psychogeriatric, dementia and rest home level care). The facility is divided into six smaller units/houses.

This verification is for the newly purpose-built Reuben Home (27 hospital beds and two serviced apartments), and the transition of one existing hospital unit (15 beds) to provide psychogeriatric level care.

Althorp Private Hospital proposed staged changes means that the service is to increase the number of hospital beds from 46 to 58, and an increase of Psychogeriatric beds from 30 to 45. Overall a total of 29 new beds increasing with the overall capacity from 90 beds to 119 beds (inclusive of 14 dementia beds).

The service has developed a very comprehensive transition plan, staff training process, and staff, resident, community and relative information process.

Improvements required are related to the building still in the process of being completed (Reuben Home) and refurbishment of Best Home and include; provision of a certificate of public use, a fire evacuation plan approved by the New Zealand fire service, installation of the kitchenette in Reuben Home and ensuring entry into the Kitchenette in Best Home which is to become a psychogeriatric unit is to be made secure. The outdoor area to Best Home is to be made secure and a lock is required to be in place on the sluice room door.

Althorp Private Hospital

Althorp Private Hospital Ltd

Verification audit - Audit Report

Audit Date: 21-Aug-13

Audit Report To: HealthCERT, Ministry of Health

Provider Name Althorp Private Hospital Ltd

Premise Name Street Address Suburb City

Althorp Private Hospital Ltd 9 Grantston Drive Tauranga

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

This verification is for the new building, Reuben Home, (27 hospital beds and two rest home serviced apartments), and the transition of one existing hospital unit (15 beds) to provide psychogeriatric level care.

Type of Audit Verification audit and (if applicable)

Date(s) of Audit Start Date: 21-Aug-13 End Date: 21-Aug-13

Designated Auditing Agency

Health and Disability Auditing New Zealand Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXX RN, Auditor certificate 5.00 3.00 21-Aug-13

Auditor 1

Auditor 2

Auditor 3

Auditor 4

Auditor 5

Auditor 6

Clinical Expert

Technical Expert

Consumer Auditor

Peer Review Auditor XXXXXX 1.00

Total Audit Hours on site 5.00 Total Audit Hours off site

(system generated) 4.00 Total Audit Hours 9.00

Staff Records Reviewed of Client Records Reviewed (numeric)

of Number of Client Records Reviewed

using Tracer Methodology

of

Staff Interviewed 4 of Management Interviewed

(numeric) 3 of 3 Relatives Interviewed

(numeric)

Consumers Interviewed of Number of Medication Records Reviewed

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

Declaration

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

I confirm that Health and Disability Auditing New Zealand Limitedhas in place effective arrangements to avoid or manage any conflicts of interest that may arise.

Dated this 18 day of September 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

Althorp Private Hospital Ltd

119 88

Executive Summary of Audit

General Overview

Althorp Private Hospital is currently certified to provide care for up to 90 residents across four service levels (hospital, medical, psychogeriatric, dementia and rest home level care). The facility is divided into six smaller units/houses. This verification is for the newly purpose-built Reuben Home (27 hospital beds and two serviced apartments), and the transition of one existing hospital unit (15 beds) to provide psychogeriatric level care. Althorp Private Hospital proposed staged changes means that the service is to increase the number of hospital beds from 46 to 58, and an increase of Psychogeriatric beds from 30 to 45. Overall a total of 29 new beds increasing with the overall capacity from 90 beds to 119 beds (inclusive of 14 dementia beds). The service has developed a very comprehensive transition plan, staff training process, and staff, resident, community and relative information process. Improvements required are related to the building still in the process of being completed (Reuben Home) and refurbishment of Best Home and include; provision of a certificate of public use, a fire evacuation plan approved by the New Zealand fire service, installation of the kitchenette in Reuben Home and ensuring entry into the Kitchenette in Best Home which is to become a psychogeriatric unit is to be made secure. The outdoor area to Best Home is to be made secure and a lock is required to be in place on the sluice room door.

1.1 Consumer Rights (not applicable) 1.2 Organisational Management

The overall service is managed by the General Manager a registered nurse with extensive experience in managing within the health and disability sector. There are four Nurse Team Leaders and a quality coordinator who support the General Manager.

This verification is for the new building, Reuben Home. The new home is made up of 27 hospital level care beds and two rest home apartments. The verification also includes the transition of the existing 'Best unit' (hospital) to provide psychogeriatric level care.

The service plans to move 15 of current hospital residents that are in 'Best unit' (hospital wing) into the new building, Reuben Home, when it is completed. The Best unit will then be converted to a 15 bed psychogeriatric unit the week after the residents have moved into Reuben Home. The service has developed a very comprehensive transition plan, staff training process, and staff, resident, community and relative information process.

1.3 Continuum of Service Delivery

The food services are contracted out to Alliance Catering under the Spotless umbrella. Staff have been trained in safe food handling and two yearly renewal of food handling certificates could be described by the food service manager.

The service has a large workable kitchen with a walk in chiller and freezer. The main kitchen is situated in the service area and supplies meals for each of the units (Homes) that are transferred to kitchenettes via insulated hot boxes. There is evidence of modified diets being provided e.g. diabetic menu and further nutritional supplements. The national menus have been audited and approved by an external Dietitian.

The new Reuben Home has a kitchenette which is not fully installed. Best Home has a kitchenette which at present is not secure from residents. The gate to secure the kitchenette in Best Home will be installed during the refurbishment which will take place when the current hospital residents move into the newly built Reuben Home. Daily cleaning schedules are completed, daily temperatures are recorded for fridge/freezer and food temps. Internal audits in the kitchen are completed by spotless.

1.4 Safe and Appropriate Environment

The new building being verified "Reuben Home" includes a lounge, kitchenette and dining area. A storage area for equipment such as wheelchairs and hoists is available. There is a nurse's office/treatment room. There are communal toilets available near the lounge and dining area. The existing laundry area in the main building will service the whole facility and has industrial equipment i.e. washing machines and dryers already in place. A new sluice room is available in the new facility. Visual inspection evidences toilet, shower and bathing facilities are of appropriate design and number to meet the needs of the residents noting that some furniture purchased is still to be installed. The fixtures, fittings, floors and wall surfaces are constructed from materials that can be easily cleaned.

There are emergency lighting, torches, extra food supplies, blankets and cell phones. There is a gas barbeque should the mains gas supply fail and a generator on site. There are water storage tanks in the grounds. The new building has call bells installed in all resident areas, including the communal areas and toilets. The service has emergency equipment including food and blankets to support a full complement of residents if required.

Best Home in the older building has 15 ensuited rooms. There is a separate lounge and dining area. There is a kitchenette. Best home has a key pad entry/exit system in place which can be activated as it is currently not in use. The following improvements are required prior to occupancy: approval of the evacuation plan by the New Zealand Fire Service, the Certificate of Public Use to be provided, the kitchenette in the new building is to be fully installed. In Best Home, the outdoor area is to be made secure, a lock is to be fitted to the sluice room door.

2 Restraint Minimisation and Safe Practice (not applicable)

3. Infection Prevention and Control

There is an infection control policy and procedures manual which is comprehensive and includes policies and procedures appropriate to this service. This includes an infection control policy which states purpose outlining the intent of the policy and implementation of the purpose, roles of the infection control committee. There has been input from the Quality Coordinator, the IC nurse and the DHB IC nurse who have been consulted with regard to the refurbished building. The transition plan includes and infection control walk around and all transitions plans reference the infection control issues have been considered.

Summary of Attainment

1.1 Consumer Rights

Attainment CI FA PA UA NA of Standard 1.1.1 Consumer rights during service delivery Not Applicable 0 0 0 0 0 1

Standard 1.1.2 Consumer rights during service delivery Not Applicable 0 0 0 0 0 4

Standard 1.1.3 Independence, personal privacy, dignity and respect Not Applicable 0 0 0 0 0 7

Standard 1.1.4 Recognition of Māori values and beliefs Not Applicable 0 0 0 0 0 7

Standard 1.1.6 Recognition and respect of the individual’s culture, values, and beliefs Not Applicable 0 0 0 0 0 2

Standard 1.1.7 Discrimination Not Applicable 0 0 0 0 0 5

Standard 1.1.8 Good practice Not Applicable 0 0 0 0 0 1

Standard 1.1.9 Communication Not Applicable 0 0 0 0 0 4

Standard 1.1.10 Informed consent Not Applicable 0 0 0 0 0 9

Standard 1.1.11 Advocacy and support Not Applicable 0 0 0 0 0 3

Standard 1.1.12 Links with family/whānau and other community resources Not Applicable 0 0 0 0 0 2

Standard 1.1.13 Complaints management Not Applicable 0 0 0 0 0 3

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

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

1.2 Organisational Management

Attainment CI FA PA UA NA of Standard 1.2.1 Governance FA 0 2 0 0 0 3

Standard 1.2.2 Service Management Not Applicable 0 0 0 0 0 2

Standard 1.2.3 Quality and Risk Management Systems Not Applicable 0 0 0 0 0 9

Standard 1.2.4 Adverse event reporting Not Applicable 0 0 0 0 0 4

Standard 1.2.7 Human resource management Not Applicable 0 0 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 Not Applicable 0 0 0 0 0 10

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


1.3 Continuum of Service Delivery

Attainment CI FA PA UA NA of Standard 1.3.1 Entry to services Not Applicable 0 0 0 0 0 5

Standard 1.3.2 Declining referral/entry to services Not Applicable 0 0 0 0 0 2

Standard 1.3.3 Service provision requirements Not Applicable 0 0 0 0 0 6

Standard 1.3.4 Assessment Not Applicable 0 0 0 0 0 5

Standard 1.3.5 Planning Not Applicable 0 0 0 0 0 5

Standard 1.3.6 Service delivery / interventions Not Applicable 0 0 0 0 0 5

Standard 1.3.7 Planned activities Not Applicable 0 0 0 0 0 3

Standard 1.3.8 Evaluation Not Applicable 0 0 0 0 0 4

Standard 1.3.9 Referral to other health and disability services (internal and external) Not Applicable 0 0 0 0 0 2

Standard 1.3.10 Transition, exit, discharge, or transfer Not Applicable 0 0 0 0 0 2

Standard 1.3.12 Medicine management Not Applicable 0 0 0 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:11 CI:0 FA: 0 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0 PA 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 of Standard 1.4.1 Management of waste and hazardous substances FA 0 2 0 0 0 6

Standard 1.4.2 Facility specifications PA Low 0 1 2 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 PA Low 0 1 1 0 0 3

Standard 1.4.7 Essential, emergency, and security systems PA Low 0 4 1 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: 5 PA Neg: 0 PA Low: 3 PA Mod: 0 PA 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 of Standard 2.1.1 Restraint minimisation Not Applicable 0 0 0 0 0 6

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

Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2

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

Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3

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

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


3 Infection Prevention and Control

Attainment CI FA PA UA NA of Standard 3.1 Infection control management Not Applicable 0 0 0 0 0 9

Standard 3.2 Implementing the infection control programme Not Applicable 0 0 0 0 0 4

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

Standard 3.4 Education Not Applicable 0 0 0 0 0 5

Standard 3.5 Surveillance Not Applicable 0 0 0 0 0 8

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


Total Standards (of 50) N/A: 38 CI: 0 FA: 8 PA Neg: 0 PA Low: 4 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 0 FA: 19 PA: 5 UA: 0 N/A: 0

Corrective Action Requests (CAR) Report

Provider Name: Althorp Private Hospital Ltd Type of Audit: Verification audit Date(s) of Audit Report: Start Date:21-Aug-13 End Date: 21-Aug-13 DAA: Health and Disability Auditing New Zealand Limited Lead Auditor: XXXXXX Std Criteria Rating Evidence Timeframe 1.3.13 1.3.13.1 PA

Low Finding: (i)Best Home has a kitchenette area which is not secure from resident access. Advised by the General Manager that a gate is to be installed. (ii) the kitchenette area in Reuben Home is currently being installed. Action: Ensure the kitchenette area in Best Home is secure from resident access unless residents are supervised. Ensure the kitchenette is fully installed prior to occupancy.

prior to occupancy.

1.4.2 1.4.2.1 PA Low

Finding: The new building has yet to have a sign off as part of the current Certificate of Public Use Action: Ensure the new area has been signed out as part of the current Certificate of Public Use

Prior to occupancy.

1.4.2 1.4.2.6 PA Low

Finding: The outside area in Best Home (to be a PG unit ) is not secure. Action: Ensure there is a safe and secure outside area in Best Home.

prior to occupancy

1.4.6 1.4.6.3 PA

Low Finding: The sluice in Best Home which will become a psychogeriatric unit at present is not able to be locked. Action: Ensure that the sluice room in Best Home can be locked.

Prior to Occupancy

1.4.7 1.4.7.3 PA Low

Finding: The fire service has yet to approve a fire evacuation plan for the new building. Action: A fire evacuation plan should be approved by the NZ Fire Service.

Prior to occupancy

Continuous Improvement (CI) Report

Provider Name: Althorp Private Hospital Ltd Type of Audit: Verification audit Date(s) of Audit Report: Start Date:21-Aug-13 End Date: 21-Aug-13 DAA: Health and Disability Auditing New Zealand Limited Lead Auditor: XXXXXX

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS OUTCOME 1.2 ORGANISATIONAL MANAGEMENT Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. STANDARD 1.2.1 Governance 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

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

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

This verification is for the newly purpose-built building, Reuben Home, (27 hospital beds and two rest home apartments), and the transition of one existing hospital unit (15 beds) to provide psychogeriatric level care. Althorp Private Hospital proposed staged changes means that the service is to increase the number of hospital beds from 46 to 58, and an increase of Psychogeriatric beds from 30 to 45. Overall a total of 29 new beds increasing with the overall capacity from 90 beds to 119 beds (inclusive of 14 dementia beds). It is intended that 15 hospital residents that are currently in Best unit (hospital wing) will move into the new building,(Reuben Home), when it is completed. The Best wing will then be converted to a 15 bed psychogeriatric unit the week after the residents have moved into Reuben Home. It is planned that some refurbishment of Best wing will be completed prior to proposed reopening. The service has developed a very comprehensive transition plan, staff training process, and staff, resident, community and relative information process. Althorp is managed by a CEO (RN). The CEO has previously owned an aged care service and has significant experience in the strategic management of Aged Residential Services. General Manager (RN), who reports to the CEO, manages Althorp with the support of four nurse team leaders who manage the specialised services - hospital (medical), psychogeriatric and dementia. A considerable investment has been made in this care home - developing specialised buildings, refurbishing existing ones and most importantly in training and educating staff so they can give the best care possible.

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

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

Finding Statement

Corrective Action Required:

Timeframe:

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.


Finding Statement Corrective Action Required:

Timeframe:

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



There are staffing policies in place that aligns with contractual requirements and includes skill mixes. There will be a Nurse Team Leader in Reuben Home and another in Best Home. There will be an RN on duty on each shift in Best Home and in Reuben Home. The service transition plan has specific staffing rosters, training and staff support for the time leading up to the moving of residents and services to the new building. The service should be commended on the in-depth and comprehensive planning in place for this process to ensure resident safety and care. The service will base staffing on the current staffing roster, plus additional staff on a day to day basis.

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.



Timeframe:

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 1.3.13 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 Low

The food services are contracted out to Alliance Catering under the Spotless umbrella. D19.2 staff have been trained in safe food handling and two yearly renewal of food handling certificates could be described by the food service manager. The service has a large workable kitchen with a walk in chiller and freezer. The main kitchen is situated in the service area and supplies meals for each of the units (Homes) that are transferred to kitchenettes via insulated hot boxes. There is evidence of modified diets being provided e.g. diabetic menu and further nutritional supplements. The national menus have been audited and approved by an external Dietitian. The new Reuben Home has a Kitchenette which is not fully installed. Best Home has a Kitchenette which at present is not secure from residents. The gate to secure the kitchenette in Best Home will be installed during the refurbishment which will take place the week beginning 02-Sept-13 when the current hospital residents move into the newly built Reuben Home. Therefore there are improvements required. Daily cleaning schedules are completed, daily temperatures are recorded for fridge/freezer and food temps. Internal audits in the kitchen are completed by spotless

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.

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

The food services are contracted out to Alliance Catering under the Spotless umbrella. D19.2 staff have been trained in safe food handling and two yearly renewal of food handling certs could be described by the food service manager. The service has a large workable kitchen with a walk in chiller and freezer. There is evidence of modified diets being provided e.g. diabetic menu and further nutritional supplements. The national menus have been audited and approved by an external Dietitian. The main kitchen is situated in the service area and supplies meals for each of the units that are transferred to kitchenettes via insulated hot boxes. The new Reuben Home has a Kitchenette and Best Home has a Kitchenette which is to be made secure. The gate to secure the kitchenette in Best Home will be installed during the refurbishment which will take place the week beginning 02-Sept-13 when the current hospital residents move into the newly built Reuben Home. Daily cleaning schedules are completed, daily temperatures are recorded for fridge/freezer and food temps. Internal audits in the kitchen are completed by spotless.

Finding Statement (i)Best Home has a kitchenette area which is not secure from resident access. Advised by the General Manager that a gate is to be installed. (ii) the kitchenette area in Reuben Home is currently being installed. Corrective Action Required: Ensure the kitchenette area in Best Home is secure from resident access unless residents are supervised. Ensure the kitchenette is fully installed prior to occupancy.

Timeframe: prior to occupancy.

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



Timeframe:

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



Timeframe:

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



Documented processes for the management of waste and hazardous substances are in place and incidents are reported on in a timely manner. Policies and procedures specify labelling requirements in line with legislation including the requirement for labels to be clear, accessible to read and are free from damage. Material Safety Data sheets are available throughout the facilities and accessible for staff. This will continue in the new building. The hazard register is current for the main building. There is a scheduled health and safety 'walk through' of the new building to ensure that all hazards are documented. Staff training is planned to ensure that all staff are orientated to the new service and any hazards. PPE is available in the main facility and will continue to be available in the 'new' facility. All toilets and sluice have glove storage containers. There is a secure store for chemicals and chemicals (such as cleaning) have a designated secure storage area. The current process for management of chemicals will continue. There is a documented process for the storage of all chemicals to the new facility.

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.



Timeframe:

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.



Timeframe:

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



The service completes environmental audits and building compliance audits. It is proposed to move 15 existing hospital residents from the Best Home (wing) into the purpose built 27 bedded hospital wing named Reuben Home once completed. There are also two serviced apartments in the new home that will be utilised for rest home level care. Advised that following the move of the hospital residents into Reuben Home, Best Home will then be painted and decorated to accommodate up to 15 psychogeriatric residents. The maintenance programme ensures all buildings, plant and equipment are maintained to an appropriate standard or specification

where a standard exists. For example; planned maintenance system, reactive maintenance System, list of equipment requiring calibration and current calibration reports, list of external Contractors and list of Preferred Suppliers. The facility has a current building warrant of fitness that expires 22-11-13. Best Home and Reuben Home has carpet to all communal areas with vinyl in residents rooms bathrooms, toilets, ensuites and dining area. The general manager, CEO and physiotherapist assists with ensuring appropriate purchase of equipment for example shower chairs, lounge and bedroom furniture and assists to coordinate input from relevant others. There has been equipment purchased. New shower chairs, a medication trolley a standing and full hoist were observed on the day of audit. New recliner chairs, and bedroom furniture were observed in Reuben Home. ARHSS D15.3d The lounge area in Best Home is designed so that space and seating arrangements provide for individual and group activities. The Reuben Home includes a large open plan lounge, small lounge and connected separate dining area with a kitchenette. The corridors in Best and Reuben homes are wide enough to allow residents to pass each other. There is sufficient space to allow the safe use of mobility equipment in all areas including resident rooms and en-suites. Safety rails are appropriately located in hallways and in bathrooms. There is storage area for mobility equipment. Equipment does not clutter passageways. There is designated storage area for hoists, wheelchairs and sit on scales. Floor surfaces/coverings are appropriate to the consumer group and setting. ARHSS D15.2e: There are quiet, low stimulus areas that provide privacy when required in Best Home. The residents have access to outside areas in Best and Reuben Homes. However there is an improvement required in Best Home to secure the outside area. The service employs a maintenance person who ensure regular checks of the buildings and equipment. Electrical equipment is checked annually and includes oxygen concentrators and nebuliser. Fire equipment is monitored and inspected monthly by an external contractor. There is an in-house maintenance request and record form and this will continue in the new building.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low Fire equipment is monitored and inspected monthly by an external contractor. The service employs a maintenance person who ensure regular checks of the buildings and equipment. There is an in-house maintenance request and record form and this will continue in the new building.

Finding Statement The new building has yet to have a sign off as part of the current Certificate of Public Use Corrective Action Required: Ensure the new area has been signed out as part of the current Certificate of Public Use

Timeframe: Prior to occupancy.

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.



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The residents have access to outside areas in Best and Reuben Homes. Residents in Reuben Home ( which is on the second storey) have access to the outside garden areas of McLeod wing.

Finding Statement The outside area in Best Home (to be a PG unit ) is not secure. Corrective Action Required: Ensure there is a safe and secure outside area in Best Home.

Timeframe: prior to occupancy

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: FA Best Home has 15 single rooms all with full ensuite facilities. Reuben Home has 27 single bedrooms plus two serviced apartments (rest home) all have full ensuite facilities. There are communal toilets located close to the lounge and dining areas in both Best and Reuben Homes. There is a spa bath and overhead track ceiling hoist in one bathroom in Reuben Home. Monthly hot water temperature checks are conducted by maintenance personnel. Records sighted evidence temperature is maintained at 44-45 degrees.

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.



Timeframe:

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: FA Resident’s rooms in both Best and Reuben Homes are spacious and allow cares including transferring and use of mobility equipment. There is also adequate space in communal bathrooms, living area and dining area to use mobility equipment and for residents to wander around.

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.



Timeframe:

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: FA There is a large dining and lounge area in both Best and Reuben Homes. Seating is adequate and positioned to allow staff access to residents as required. The lounge and dining area in both Best and Reuben Homes are spacious and would allow for activities. There are quiet lounge areas which residents can access. There is adequate space to allow maximum freedom of movement while promoting safety for those that wander

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



Timeframe:

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: PA Low It was noted on tour of the facility that all cleaning and laundry chemicals are safely and securely stored in locked cupboards, sluices and/or in laundry area away from residents. The main laundry in the service area in the main building will service the new Reuben Home and Best Home. The sluice room in Best Home does not have a lock therefore an improvement is required.

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



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low It was noted on tour of the facility that all cleaning and laundry chemicals are safely and securely stored in locked cupboards, sluices and/or in laundry area away from residents.

Finding Statement The sluice in Best Home which will become a psychogeriatric unit at present is not able to be locked. Corrective Action Required: Ensure that the sluice room in Best Home can be locked.

Timeframe: Prior to Occupancy

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



Documented systems are in place for essential, emergency and security services. Policy and procedures documenting service provider/contractor identification requirements appropriate to the resident group and setting along with policy/procedures for visitor identification. There are also policy/procedures for the safe and appropriate management of unwanted and/or restricted visitors. The New Zealand Fire Service has yet to approve an evacuation plan noting that there is a panel located in each Home and alert system in place already. There is an existing approved fire evacuation scheme in place with application underway to include the additional wing. Emergency and security situation education is provided to service providers during their orientation phase and at appropriate intervals. This includes fire safety training and emergency security situations. There are emergency lighting, torches, extra food supplies, blankets, and cell phones. There is a gas barbeque should the mains gas supply fail. There are water storage tanks in the grounds. The already verified building has call bells in at resident areas, including the communal areas and toilets. There are call bell indicator boards in the corridors and the call bells are also connected to the nurse’s area. There is a new call bell system installed in the new building "Reuben Home". D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included. An improvement is required prior to occupancy that there is a fire evacuation plan in place for the new building Reuben Home. D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included

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.



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included. Emergency readiness plan includes fire policy and instructions, emergency plans, bomb threat, earthquake, prowlers and intruders, and civil defence emergencies.

Finding Statement The fire service has yet to approve a fire evacuation plan for the new building.

Corrective Action Required: A fire evacuation plan should be approved by the NZ Fire Service.

Timeframe: Prior to occupancy

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



Timeframe:

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



Timeframe:

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


Finding Statement

Corrective Action Required:

Timeframe:

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: FA The new building is airy with plenty of natural light. All resident communal areas and rooms have at least one external window. The heating is by radiators and heat pumps and these are installed into all areas. Best Home in the older building and is light and airy with plenty of natural light and all bed rooms have an external window. Best Home has central heating which can be controlled by thermostats in individual resident’s rooms and in hallways and communal areas.

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



Timeframe:

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.



Timeframe:

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



D 19.2a: The infection control manual outlines a comprehensive range of policies, standards and guidelines and includes defining roles, responsibilities and oversight, the infection control team, training and education of staff. Other policies included (but not limited to) a) definition of infection for surveillance, b) infection control programme description, c) standards for infection control practice – cleaning, food service, linen service, waste management, d) policy and guidelines for antimicrobial usage, e) standard precautions, f) risk management of blood, g) hand hygiene, h) hand care procedures, i) UTI’s, j) clinical indicators of infection, k) Hep A & B & C, l) Inoculation/ contamination emergency response, m) risk assessment plan, n) accidental needle stick blood exposure, o) TB, p) MRSA, q) documentation of suspected and actual infections, r) isolation, s) disinfection, t) outbreak procedure, u) cleaning, disinfection and sterilisation guidelines, v) single use equipment, w) waste disposal policy, and x) notification of diseases. There is also a scope of the infection control programme, standards for infection control, infection control prep, responsibilities and job descriptions, waste disposal, and notification of diseases. Infection control procedures developed and include the kitchen, laundry and the housekeeping manuals, they incorporate the principles of infection control. These principles are documented in the service policies contained within the infection control manual. External expertise can be accessed as required, to assist in the development of policies and procedures. Policy development involves the infection control coordinator, the infection control committee and expertise from the governing body.

The IC nurse and the DHB IC nurse have been consulted with regard to the new building. The transition plan includes and infection control walk around and all transitions plans reference the infection control issues have been considered.

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.



Timeframe:

althorp private hospital limited current status: 21-aug-13 on … · 2015. 3. 20. · althorp...

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