coldstream rest home and hospital web viewcoldstream rest home and hospital limited. introduction....

Coldstream Rest Home and Hospital Limited

Introduction

This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted by The DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

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

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity: Coldstream Rest Home and Hospital Limited

Premises audited: Coldstream Rest Home and Hospital

Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit: Start date: 9 December 2015 End date: 9 December 2015

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 57

Coldstream Rest Home and Hospital Limited Date of Audit: 9 December 2015 of 22

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

consumer rights organisational management continuum of service delivery (the provision of services) safe and appropriate environment restraint minimisation and safe practice infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short falls Standards applicable to this service fully attained

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

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


Indicator Description Definition

A number of shortfalls that require specific action to address

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

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

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

General overview of the audit

Coldstream Rest Home and Hospital is a 57 bed hospital and rest home, which on the day of the spot surveillance audit was fully occupied. There are 21 rest home beds and 36 hospital level beds. The facility is in the Mid-Canterbury town of Ashburton. A clinical nurse manager provides day to day oversight with support from the organisation’s regional manager.

The audit process included sampling files, interviewing residents, family and staff, and observing the environment. Information gathered was used to determine the effectiveness of care services and the systems.

Four areas for improvement identified at the previous audit have been addressed; however one remains open, relating to evaluations of care. A further six areas have been identified as requiring improvement relating to: documenting open disclosure; an up-to-date complaints register; medication reconciliation; nutritional assessments; kitchen storage and safe food handling certificates.


Consumer rights

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

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

Open disclosure, translation and interpreter processes are in place for any situation that may arise. There is some evidence of family communication following a resident incident, however this is not always documented on the incident form and this needs addressing.

There is a detailed complaints register as part of the facility's complaints process. Those reviewed were documented with actions to resolve. All those reviewed had been resolved. Three recent complaints have not been included on the register and this requires improvement.

Organisational management

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.

A current business, quality, risk and management plan includes nursing and organisational goals and objectives. The clinical nurse manager provides the residents’ care meeting, and the organisation’s management committee, with a report that includes quality and organisational management data and information. Staff receive this information at the monthly meetings and in notices.

Quality systems include monitoring and corrective action processes, surveys, incident report data and analyses, policy and procedure updates and health and safety monitoring.


Human resources are primarily overseen by the clinical nurse manager with support from the regional manager. Annual practising certificates are recorded, a comprehensive orientation programme is in place and being used, and there are ongoing opportunities for training for staff at all levels and in all roles. Good employment processes, such as initial interviews, referee checks and the three monthly and annual performance appraisals, are in place and up to date.

A staffing level and skill mix policy, on which the roster is based, is available. Staffing levels meet requirements and are adjusted according to acuity levels of residents’ needs.

Issues related to a previously raised required improvement around resident identification details in personal files, and recording of the name and designation of staff, have been addressed.

Continuum of service delivery

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

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

Assessments were being undertaken and used to assist with the development and/or review of personal care plans. The use of interRAI as an assessment tool has commenced but is not able to be routinely used until sufficient staff have been trained.

Care plans described the required interventions and reflect information obtained from the assessment processes. Residents’ files reviewed, showed both prevention and management strategies were documented for each identified problem and progress notes reflected the interventions. Positive feedback about the high level of care at Coldstream was provided.

Monthly reviews of residents’ goals are occurring, although evaluations of the degree of achievement of goals in short and long term care plans require attention. Comprehensive evaluations of residents’ activities goals were documented and a varied activities programme was in place.


Medicines were being managed according to policies and procedures, legislation and guidelines; however, the absence of one for the reconciliation of medicines is compromising the integrity of this process and requires corrective action.

A summer and a winter menu have been reviewed by a dietitian, nutritional assessments and dietary profiles have been completed on admission and residents were satisfied with their meals. There is a need for information from the nutritional assessments to be more accessible to kitchen staff and for staff to be updated in food safety to ensure requirements meet expectations.

Safe and appropriate environment

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.


There is a current warrant of fitness for the building and there have been no building or configuration changes since the last audit.

Restraint minimisation and safe practice

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


Coldstream Rest Home and Hospital makes all efforts to minimise the use of restraints, and on the day of the audit three restraints and eight enablers were in place. Policies and procedures that describe enablers and the different types of restraint use are followed and reflect the standard. These include assessment, review, and evaluation processes, meeting three previous required improvements.


Infection prevention and control

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.


An infection control nurse coordinates the surveillance of infections on a monthly basis, which is occurring according to the policy and procedures. The incidence of infections is being graphed, the percentages calculated and meeting minutes show that the analysis of the data is being presented at monthly staff meetings and to management every two months. Suggestions for the prevention of recurring infections are documented.


Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating

Continuous Improvement

(CI)

Fully Attained(FA)

Partially Attained

Negligible Risk(PA Negligible)

Partially Attained Low

Risk(PA Low)

Partially Attained

Moderate Risk(PA Moderate)

Partially Attained High

Risk(PA High)

Partially Attained Critical

Risk(PA Critical)

Standards 0 15 0 5 0 0 0

Criteria 0 37 0 4 2 0 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome

Attainment Rating

Audit Evidence

Standard 1.1.13: Complaints Management

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

PA Low The facility’s complaints policy, which meets the requirements of Right 10 of the Code of Health and Disability Services Consumers’ Rights (the Code), is in place. Staff interviewed were aware of how to assist residents and family if they wished to make a complaint. Complaints are on the monthly resident care meeting agenda, with complaints identified and the resolution or on-going process included. This was confirmed in the complaints log. Three complaints have been documented on the complaints register for 2015, and all have been closed out. However it was noted that three other complaints for the year have not been included.

Residents and family interviewed confirmed that the complaints process is easily accessible.

Standard 1.1.9: Communication

Service providers communicate effectively with consumers and provide an

PA Low Documented guidelines are in place for communicating with residents and visitors. These were observed during the audit with staff heard addressing people in a respectful manner and residents being given time to answer. Residents and family members interviewed reported that staff ensured that they are understood and communication is always respectful.

Open disclosure occurs according to the organisation’s policy, and this is verified in family and resident interviews and in some incident reports sighted. There is a section on the incident form for family notification; however this is


http://www.health.govt.nz/your-health/services-and-support/health-care-services/services-older-people/rest-home-certification-and-audits

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

environment conducive to effective communication.

not always completed.

Interpreter services are available for any residents who require it. There has not been any resident requiring an interpreter since the previous audit.

Standard 1.2.1: Governance

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

FA The organisation’s mission statement includes the purpose of the service and strategic links to deliver an overall vision. The links listed include: stable and well trained staff; highly regarded facilities; family’s first choice; resident centred care. Actions and how this is demonstrated are included in the visionary plan. There have been recent management changes that are reflected in the business plan.

The Clinical Nurse Manager (CNM) is one day from retirement. The new CNM has been orientating to the role for two months, is a registered nurse with a current practising certificate, and during interview confirmed her extensive experience relevant for the role. She is being provided with guidance by the regional manager during this transitional phase. All are supported by the owner who is also the business manager of the umbrella organisation of Greenvale Investments Limited.

There is a business, quality, risk and management plan last reviewed May 2014. Nursing and organisational goals and objectives are in place with the latter coming under the quality and risk plan. The CNM reports to the regional manager and to the governing body at meetings three times a year. The last meeting was November 30 2015. The minutes sighted included reports from each CNM.

The regional manager has been in her current role for two years and prior to that was a Nurse Manager for the facility for 12 years.

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

FA An organisation wide quality management and risk management policy (May 2014) states that quality care is primarily achieved through leadership, commitment and example set by the management team, and that this is reflected in the care delivery and actions of the staff and is evident in all that they do. The quality programme clearly documents the expectations of the organisation linking to the quality and risk management system, and is consistent with the organisation’s overall vision. The strategic plan for the organisation measures achievement against the facility’s goals each year, and is signed off by the owner.

Documents are reviewed annually, as sighted in a staggered document control process, and all sighted were current.

The CNM is the quality coordinator, and chairs the resident care meeting. The group meets monthly and includes a representative from all areas of the facility, and any others that wish to attend. Minutes of meetings from the past three months were sighted. Feedback from the meetings is passed onto staff via a staff communication book and on


principles. displayed notices. The agenda and documented minutes are comprehensive and cover all areas required.

Risks are identified and documented, with a corrective action plan implemented for those areas that do not meet pre-determined criteria. At the time of the audit all corrective actions have been closed out.

There is an internal audit programme collating numbers of incidents, complaints, survey responses and overall results collected. Results are reported monthly at the resident care meeting.

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.

FA Incidents are being reported on a form intended for the purpose. Staff interviewed demonstrated awareness of the reporting requirements for adverse events and confirm they use the form and process when appropriate. The information on the forms is used to address the issues as they arise and the forms show the CNM or regional manager is signing them off following review of the incident and taking appropriate action. Incidents are an agenda item at the resident care meeting where they are discussed. Incident data is being collated and documented. The CNM and regional manager interviewed were aware of their statutory obligations in relation to essential notification. An example was provided of a recent case when the service had some recruitment issues, even though these were resolved quickly.

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.

FA There is clear evidence in employment practice that the organisation offers equal employment opportunities, and follows best practice employment processes. Recent files reviewed confirmed this.

Records of annual practising certificates were sighted for the two CNMs, three registered nurses, an enrolled nurse, two GPs and the pharmacist.

An orientation programme that covers key information and safety topics is documented within human resource policies and procedures. Orientation records were on file for all of the seven staff files viewed.

A staff training schedule was sighted. Monthly education sessions are held covering all essential topics required. Staff interviewed reported they are provided with training on topical issues, with an example being managing residents for end of life care. External training such as interRAI is provided for RNs. (Refer standard 1.3.3).

All RNs have a current first aid certificate and other key staff such as activities persons. Caregivers are at different


levels of attainment of certificates through Aged Care Education.

Standard 1.2.8: Service Provider Availability

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

FA There is a staffing and skill mix policy that reflects the mix of staff as documented on the facility’s roster. A RN is always on call as specified in the roster. The regional manager may extend hours and staff numbers to respond to specific requirements, such as resident acuity or special events. New staff reported that they always work with a senior staff member until deemed competent, but that all care staff work in teams, with a team leader who is an experienced staff member. Staff files verify that senior staff have the necessary competencies.

A roster framework was sighted and four weeks of rosters were consistent with this and with the minimum requirements. The regional manager works Monday to Friday and is exclusive to the roster.

Residents, family members and staff interview report that there are sufficient staff on duty to meet the needs of residents.

Standard 1.2.9: Consumer Information Management Systems

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

FA All pages within the residents’ records that were sighted had identification stickers on them that included the resident’s details. Likewise, the evaluation/review records all include the full name and designation of the person reviewing the residents’ goals and all entries in progress notes include the signature and designation of the person making the entry. These observations demonstrate that the standard is being met and addresses the corrective action raised at the last audit.

Standard 1.3.12: Medicine Management

Consumers receive medicines in a safe and timely manner that complies with current legislative

PA Low Medicine management policies and procedures describe the requirements for managing medicines. All medicines are stored in a locked room and a lockable mobile trolley is used during the administration of medicines. Each type is stored and checked according to legislative requirements and guidelines. Registered nurses, enrolled nurses and care co-ordinators administer medicines and all have a current medicine administration competency. Although the pharmacy is not local and medicines are couriered from Christchurch, which staff inform has not posed a problem, there is evidence of pharmacy involvement and relevant checks are being made by them. Unused and discontinued medicines are returned to the pharmacy for disposal.

Medicine records reviewed showed that prescribing requirements are being met, reviews are occurring every three


requirements and safe practice guidelines.

months and as required, dates and physician signatures is evident when medicines have been discontinued, the pharmacy is involved, a record of sample signatures is maintained (the master is currently being completely renewed) and allergies, or a note of ‘nil known’, are being recorded. There are not currently any residents in this facility who self-medicate.

During observation of the mid-day medicine round there was evidence of confusion over the correct medicines for a resident. Further investigation confirmed the lack of integrity in the process around the reconciliation of medicines when a person has been temporarily away from the facility and when medicines arrive at the facility.

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.

PA Low There is both a winter and summer menu that was reviewed by a dietitian in August 2015 when some recommendations were made. This is reportedly followed on a daily basis, with an explanation provided as to how menu items may be swapped around if an item is not available. A nutritional assessment and personal food profile that includes likes and dislikes and any special dietary requirements is completed on admission. This is only reviewed when indicated, such as when there is a change in the health status of a resident and examples of this were sighted. Although the staff interviewed were familiar with residents’ additional or modified nutritional needs, access to this information in the kitchen was limited.

Efforts to comply with requirements to ensure food safety are being made with temperature checks being made for fridges, the freezer and hot food, stock rotation occurring and correct disposal processes. However, kitchen staff have not completed updates in food safety training and there are some gaps in compliance with current guidelines for the food safety chain, for which a corrective action has been raised.

Standard 1.3.6: Service Delivery/Interventions

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

FA Services are being delivered according to information in residents’ individualised care plans. Short term care plans are being developed for short term problems such as skin tears and sudden shortness of breath. Progress notes reviewed demonstrated that care and support was consistent with the identified problems, personal goals and interventions, as in the care plans. Carers informed they report any concerns about a resident, such as a change in their condition, both in the progress records and to registered nurses, and this was confirmed. Any untoward issues that arise are managed through the short term care planning process, which includes detailed interventions. Residents spoke highly of the level of care and support provided and consistently stated that all of their needs are being met.

Standard 1.3.7: Planned Activities

FA A range of activities are planned for each month and copies of the monthly activity schedules showed that options are varied and creative. Options included entertainers coming in, cognitive activities with crosswords and word games, van outings, crafts, themed activities and presentations and events, such as barbecues. The 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.

coordinator described the preparation and delivery of some of the options, which include a physical component involving movement whenever possible. Residents have a copy of the activity schedule and staff reportedly discuss the options for the day when attending to their morning cares. Those interviewed are comfortable with the options available, say they like the variety and confirmed there is no compulsion to attend, or they are permitted to watch if they do not want to participate. Residents who are unable to participate in the wider activities programmes are assisted to undertake activities on a one to one basis as time allows. The activities coordinator will do tasks in the local township for residents who do not have family members to assist them.

A personal profile is completed on the admission of each resident. The activities coordinator records the level of participation for each person for the different types of activities and she writes up monthly evaluations that show the overall level of achievement of the goal. These records are comprehensive.

Standard 1.3.8: Evaluation

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

PA Low Evaluation of both short and long term care plans is occurring with monthly reviews of long term goals and interventions being completed consistently and outcome evaluation statements being made for short term problems when they have resolved. Families are consulted both formally and informally according to their preferred method of communication and are informed when changes are identified. There is, however, a need for the evaluations of long term care plans to more specifically detail the progress towards achievement of the desired outcomes. Information is being included in progress note updates and changes are being made to interventions when indicated. Staff informed that the recently introduced documented handover system is useful in assisting them to know about any changes for residents and the revised interventions, as applicable. The corrective action from the previous audit remains open.

Standard 1.4.2: Facility Specifications

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

FA The building warrant of fitness is on display and expires 1 May 2016. Electrical checks have been completed within the required timeframe and tagged equipment and records are sighted. There have been no alterations or reconfiguration to the building, or to rooms used since the previous audit.

Standard 3.5: Surveillance

FA Processes for the surveillance for infection are described in the organisational policy and procedure infection control manual. These include descriptions of the infections to be included. The surveillance for infections is undertaken by the infection control nurse, who collates the data, calculates the incidence against bed numbers, graphs it on a


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

monthly basis and compares the data with previous months and years.

Results of surveillance for infections and suggestions of methods to reduce the incidence of infections were evident in the minutes of registered nurse and carer staff meetings each month. The wider management team are also provided with a report on the surveillance for infections and information on any outbreak at their meetings every four months and in the monthly reports to the owner/manager. There was evidence that staff had been provided with additional information on hand-washing and reminded of its importance following a rise in the number of infections overall. The hygienic disposal of continence products had also been covered in a staff meeting.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The restraint minimisation and safe practice policy and procedures include definitions of enablers, and the need for their use to be voluntary, as well as for the different types of restraint. These outline the organisation’s philosophy, which notes their commitment to a restraint minimised environment and to provide the staff with guidelines to enable them to prevent the need for restraint. The restraint policy documentation notes the circumstances under which restraint may be used, the ways in which the service will assess and monitor its use, relevant authorities and responsibilities around restraint, definitions of associated terminology including enablers, how the staff knowledge will be updated annually, considerations to be made prior to its use, guidelines for their use, and risk and quality management aspects.

Staff during interview demonstrate knowledge of the restraint and enabler processes at the facility. This reflects documents sighted.

At the time of the audit three residents required restraints and eight had enablers in use. All were fully documented according to policy.

Standard 2.2.2: Assessment

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

FA A fully documented assessment as per the requirements of the standard, and consistent with the facility’s policies, was sighted for all persons requiring a restraint. This meets a previous required improvement.

Standard 2.2.3: Safe Restraint Use

FA Three residents’ files of those with restraint in use were reviewed. Restraint use was comprehensively documented according to the requirements of the standard, addressing a previous required improvement. Staff interviewed were


Services use restraint safely

able to identify residents requiring restraints and enablers.

Standard 2.2.4: Evaluation

Services evaluate all episodes of restraint.

FA In three files reviewed each episode of restraint was evaluated according to the standard and the organisation’s policy, meeting a previous required improvement. Staff interviewed and documents sighted verified the evaluation process is followed according to policy and procedure.


Specific results for criterion where corrective actions are required

Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded.

Criterion can be linked to the relevant standard by looking at the code. For example, a 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 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights.

If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit.

Criterion with desired outcome

Attainment Rating

Audit Evidence Audit Finding Corrective action required and timeframe for completion (days)

Criterion 1.1.13.3

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

PA Low Three complaints have been documented on the complaints register for 2015, and all have been closed out. However it was noted that three other complaints for the year have not been included.

Three recent complaints reviewed, two from staff and one from a family member, have not been fully documented and included in the facility’s complaints register.

An up-to-date complaints register is maintained.

180 days

Criterion 1.1.9.1

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

PA Low Open disclosure occurs according to the organisation’s policy, and this is verified in family and resident interviews and in some incident reports sighted. There is a specific section on the incident form to indicate that family are notified and documentation of any comments. This is not always being

Nineteen of thirty incident forms reviewed did not have the section for family notification completed, although staff interviewed said that this is often documented in the resident’s progress notes, this could not be verified on the day of the audit.

Open disclosure communication with family is documented on the resident’s incident form.


completed.

180 days

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.

PA Moderate

Medicine management policies and procedures are in place but do not include the reconciliation of medicines. Staff report that medicines are checked when they arrive by courier from the pharmacy. As a result of such a check there was evidence of a pharmacy error in an incident report; however records of this process were not available during the audit. During a medicine round staff were observed to be reviewing the medicines of a person who had returned from hospital and had had a change in their usual prescription. The confusion evident could have been avoided had a robust medicine reconciliation process been in place.

There is no policy and procedure for the reconciliation of medicines and there is no documented evidence to demonstrate that reconciliation of medicines is occurring in an accountable and timely manner.

Medicine management policies and procedures include the reconciliation of medicines. There is documented evidence that the reconciliation of medicines occurs when required, for example when a person enters the facility, is temporarily absent or when medicines arrive at the facility from the pharmacy.

30 days

Criterion 1.3.13.2

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

PA Low Mini nutritional assessments are completed on admission as is a dietary profile; however there is no consistent process in place for ongoing reviews of nutritional requirements unless indicated in the monthly weight monitoring process. Copies of the assessments and profiles were not found in the kitchen, although a list that was difficult to follow was on a whiteboard and a 2013 list was in a drawer. Preferences regarding fluids are on the walls of both dining areas. Although staff report that they know what all

There is no certainty that residents who have additional or modified nutritional requirements are having these met: copies of the nutritional assessments were not available in the kitchen; these are not being regularly reviewed; and a communal list of specific dietary needs and food preferences was difficult to follow.

Residents have their dietary requirements reviewed at least six monthly/as indicated and records of nutritional assessments, specific dietary needs and preferences of residents is readily accessible to staff


of the residents need or prefer, there was no back up information for new or temporary staff.

involved in meal preparation and serving.

180 days

Criterion 1.3.13.5

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

PA Low There is an overall awareness of safe practices around managing food procurement, preparation, storage, delivery and disposal. Foods are delivered to the facility and stock rotation is practised. Basic temperature monitoring of fridges, freezers and of the main hot meals prior to serving is occurring on a daily basis. Food in fridges is being covered and staff reported it is only kept for a maximum of 24 hours before disposal. Food is disposed of into an ‘insinkerator’ or into rubbish receptacles that are removed from the facility three times a week.

Aspects of food management do not meet accepted good practise: opened frozen foods were not re-sealed; some foods in the refrigerator were not covered and dated; not all decanted dry goods are being dated in a legible manner, and the year of opening is not being recorded. The temperature of meat and poultry is not being recorded on arrival at the facility; although staff informed that the delivery person does this and retains the records. Two of the kitchen staff have not undertaken a refresher in food safety handling since 2011, two others not since 2012. One other person has only recently been employed and has not yet completed any such training.

Kitchen staff update their food safety training and ensure all aspects of food procurement, preparation and storage comply with current legislation and guidelines.

180 days

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.

PA Moderate

A system is in place in which the goals in the long term care plans of each resident are reviewed on a monthly basis. The reviews are dated and recorded on a care plan evaluation form. A box is ticked to indicate that the goals and intervention remain relevant, or otherwise, for the respective resident.

For short term care plans, there are outcome based evaluation statements made for each problem following the resolution of the different identified short term issue(s). A corrective action has been raised as there is a lack of evidence that the goals of short or long

The monthly reviews of residents’ care plan goals do not evaluate the progress towards meeting the desired outcome, nor do they report on the degree at which the goals have been achieved.

Ongoing evaluation of progress towards the resolution of goals in short term care plans is not consistently occurring.

Evaluations of long and short term care plans indicate the degree of achievement, or response to the support and/or intervention and progress towards meeting the desired outcome.


term care plans reflect the residents’ progress with their goals.

90 days


Specific results for criterion where a continuous improvement has been recorded

As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded.

As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights

If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit.

No data to display

End of the report.
