orewa beachview retirement home limited - orewa web view · 2015-12-19one resident who...

Orewa Beachview Retirement Home Limited - Orewa Secure Care

Introduction

This report records the results of a Certification 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: Orewa Beachview Retirement Home Limited

Premises audited: Orewa Secure Care

Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Dementia care

Dates of audit: Start date: 24 November 2015 End date: 25 November 2015

Proposed changes to current services (if any): The service plans to convert one single occupancy room in the rest home/hospital section to double occupancy room. This will increase capacity to 30 residents (15 in the rest home hospital and 15 in the dementia unit).

Total beds occupied across all premises included in the audit on the first day of the audit: 27

Orewa Beachview Retirement Home Limited - Orewa Secure Care Date of Audit: 24 November 2015 of 32

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

Orewa Beachview Retirement Home (trading as Orewa Secure Care) can provide rest home, hospital and secure dementia care services for up to 29 residents. At the time of audit there were residents receiving hospital and secure dementia rest home level of care. At the time of audit, all rooms were single occupancy, with the service wanting to convert one of the single rooms in the rest home/hospital wing to a double occupancy room, which will increase the capacity of the service to 30 residents.

This certification audit was conducted against the Health and Disability Services Standards and the service’s contract with the district health board. The audit process included the review of documentation, observations and interviews. The audit report is an evaluation of the combined evidence on how the service meets each of the standards.

There are three areas requiring improvement identified at this audit. These relate to ensuring appropriate call and privacy systems are implemented prior to use of the current single room as a double room, recording the staff member’s name in progress notes and the detail in the evaluation of care.

Positive feedback was received from the families and residents regarding the quality of the care provided under the new management.


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.

Standards applicable to this service fully attained.

Staff demonstrated good practice related to respecting residents’ rights in their day to day interactions and this was confirmed during interviews with residents and family/whānau members. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). The staff interviewed were able to verbalise their knowledge and understanding of residents’ rights.

Policies and procedures describe how residents from a range of cultures, including Māori, have their individual cultural values and beliefs identified and respected by the service. Currently there are no residents who identify as Māori. The service provider reports there are no known barriers to Māori residents accessing the service.

Written consent to receive services is obtained from the residents or their appointed guardians or enduring power of attorney (EPOA). Information on informed consent is provided in the residents' admission pack and is fully explained as part of the admission process to reflect policy requirements.

Orewa Secure Care provides services that reflect current accepted good practice. Evidence-based practice was observed, promoting and encouraging good practice.

Resident and family/whānau members confirmed during interview that visitors are welcomed and that communication is open and honest and that they are kept informed if staff have any concerns or if there is a change in their relative’s condition.

The complaints process is documented and all complaints, including external complaints, were effectively closed out.


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.

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

Organisational structures and processes are monitored at organisational level. Service performance is aligned with the organisation`s philosophy and goals identified in the quality and risk plan.

The service has a documented quality and risk management system that supports the provision of clinical care and support. Policies are reviewed by the management team annually and quality and risk performance is reported through meetings at the facility and monitored by the management team. Review of service delivery includes incidents/accidents, infections, complaints and reports from the internal audit programme.

The adverse event reporting system is planned and coordinated with staff documenting and reporting adverse, unplanned or untoward events.

Policies and procedures are documented to guide staff on all aspects of service delivery. The manager is suitably qualified and is supported by a clinical manager. Resident and staff records reviewed were well documented and maintained by the clinical nurse manager and the manager. There has been a change in the management team in the past two months.

Systems for human resources management are established and implemented. The education programme for all staff is available and planned for the year. The required training for staff who work in the dementia unit is provided.

Resident information is uniquely identifiable, accurately recorded, kept up to date and privacy is protected. Stored records are secure. Staff do not use their full name when signing what they have written in residents’ progress notes. This is an area identified for improvement.


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.


Entry criteria for the services are communicated to family/whānau or the resident’s nominated EPOA and referring agencies. Management confirmed that if entry to the service was to be declined, a record would be maintained and the potential resident’s family/whānau would be referred to a more appropriate service.

Residents receive timely, competent, and appropriate services in order to meet their assessed need. The processes for assessment, planning, provision, evaluation, review and exit are provided within required time frames to meet contractual requirements using both interRAI and paper based assessments. The service is coordinated in a manner that promotes continuity in service delivery and a team approach to care delivery.

The care plans reviewed described the required support and interventions consistent with residents’ assessed needs. Care plans are evaluated at least six monthly, or sooner if there is a change in the resident’s needs. Not all evaluations identify if the resident’s goals are being met and this requires improvement. Where progress is different from expected, the service responds by initiating changes to the care plan or with the use of short term care plans.

Support for residents to access or be referred to other health and/or disability service providers is appropriately facilitated to meet their needs. The processes in place related to transition, discharge or transfer identify known risks to ensure this is managed safely.

An activities programme is managed and implemented by providing a variety of group and individual activities to meet the interests of residents.


Medicine systems implemented reflect safe medicine management processes. Staff responsible undertake annual assessments to show they are competent to perform the role safely.

The menu has been reviewed by a registered dietitian as suitable for the older person living in long term care. Snacks are available 24 hours a day. There were no negative comments made during interviews related to food.

Residents and family/whānau confirmed the delivery of services meets their needs and wants.

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.


All building and plant complies with legislation with a current building warrant of fitness displayed. Ongoing maintenance ensures the building is maintained to a high standard. Fixtures, fittings, floor and wall surfaces are suitable for this environment. All rooms have access to ensuite toilet and hand basin facilities. There are adequate toilets, showers, and bathing facilities located throughout the facility that provides privacy.

The environment is appropriate for rest home/hospital and specialist dementia level of care services. All areas ensure physical privacy is maintained and have adequate space and amenities to facilitate independence. There are processes in place to protect residents, visitors, and staff from exposure to waste and infectious or hazardous substances.

The laundry service for the linen is provided by an external contractor and conducted offsite. There is some resident’s personal laundry done onsite. There are processes in place to provide safe and hygienic cleaning services.


The facility had an appropriate call system installed. There is access to external gardens and verandas off most rooms. The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the residents. The secure dementia unit is separated from the rest home/hospital section.

Routine safety checks and internal audits are performed by maintenance personnel and management. Emergency preparedness was evident with adequate resources being available in the event of an emergency. Staff are trained appropriately in all aspects of health and safety in the work place.

There will be some changes required to the room that is proposed to be a shared room, before this room can be used for two residents.

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.


The service has a commitment to minimising and appropriate use of restraints and enablers. Restraint and enablers are only used as a last resort to maintain the resident’s safety and comfort. Clear definitions in the policies reviewed ensured staff understood the implication of restraint and enabler use. There were seven residents using restraint (bed rail or lap belt) and one resident with an enabler (bed rail) in use.

There are appropriate processes in place to ensure that when restraints and enablers are used a sound assessment, review and evaluation process is occurring. The restraint minimisation committee monitors and approves all restraint use. As part of the internal auditing programme the service conducts six monthly quality reviews of their use of restraint.


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.


The infection prevention and control programme is implemented by the service. This process is overseen by the infection prevention and control coordinator. Policies and procedures describe all aspects of infection control good practice which are suitable for the level of care provided at the service. There are adequate resources to allow for a managed environment which minimises the risk of infection to residents, staff and visitors. The infection control programme is reviewed annually.

Surveillance for infections is conducted monthly with agreed objectives, priorities, and methods that have been specified in the infection control programme. Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated and reported to staff and management in a timely manner. Data is trended monthly on-site and benchmarked quarterly by an off-site provider to show any variance in infection rates. Follow up corrective actions would be undertaken as required. Documentation identifies that the service managed an influenza outbreak using good practice standards, including reporting requirements.


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 47 0 3 0 0 0

Criteria 0 98 0 3 0 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 1.1.1: Consumer Rights During Service Delivery

Consumers receive services in accordance with consumer rights legislation.

FA Policies and procedures are implemented by staff to ensure residents’ rights are met. The Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code) was displayed in English and an easy read version is displayed near the nurses’ station. Family/whānau members are provided with copies of the Code as part of the admission process.

Staff files evidenced regular education is presented in relation to the Code. This was last presented in January 2015 by a Health and Disability Services advocate. The clinical staff interviewed demonstrated knowledge on the Code and its implementation in their day to day practice. Staff were observed respecting the residents’ rights.

Resident and family/whānau interviews confirmed staff respect the rights of users of the service.

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

FA Policy covers written and oral informed consent and directs staff to ensure informed consent is undertaken as part of everyday practice. Policy identifies how each section of resident rights is met via the informed consent process.

The residents' files reviewed had signed admission agreements which clearly set out what was being consenting to. Residents and family/whānau confirmed all parts of the admission agreement are


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

give informed consent. discussed prior to signing and explanations of the informed consent processes are given. Residents reported that they are not made to do anything they do not want to do.

As observed residents are informed of what staff intend to do and staff respected the resident’s right to refuse. Staff acknowledged the resident's right to make choices based on information presented to them. Staff acknowledge the resident’s right to withdraw consent or refuse treatment at any time. Residents who have an advance directive have them activated by the service where they are valid. For residents in the dementia care unit the GP has stated if resuscitation is clinically indicated and family/whānau wishes are shown. Staff understand this is a guide only.

Standard 1.1.11: Advocacy And Support

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

FA It is highlighted in policy that the service recognises the resident and family/whānau right to advocacy services. The family/whānau members interviewed reported that they were provided with information regarding access to advocacy services and were also encouraged to involve themselves as advocates. Contact details for the Nationwide Health and Disability Advocacy Service was listed in the resident’s information booklet, with the brochure available at the entrances to the service. One family/whānau member discussed their use of the advocacy service for an issue that they had and stated the service was very supportive.

Staff education is conducted as part of the in-service education programme. The Health and Disability service advocate presented education in January 2015 which included how to seek advocacy and support services. Senior staff understand their responsibility to assist family/whānau and residents to gain an enduring power of attorney when required.

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.

FA There are no set visiting hours and family/whānau are encouraged to visit at any time. The family/whānau members interviewed report there are no restrictions to visiting hours and that they are always made to feel welcome. Residents are assisted to maintain family/whānau contact and the service is actively working with community groups and services to encourage interaction. The residents’ activity programme includes outings into the local community. The monthly resident meeting is advertised and open to all family/whānau members if they wish to attend.

Standard 1.1.13: Complaints Management

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

FA The complaints process sighted identified the required procedures. Complaints are dealt with in a professional manner with consideration to any cultural or other values. Complaints are actively managed in a timely manner and in accordance with the complaints policy, and any other statutory requirements relevant to the specific situation.


and upheld. Complaints management information is included in resident information packs given on admission, and as confirmed by the nurse manager, the process was discussed with family/whānau and residents as part of the admission process. Complaints forms are accessible to staff, residents and family/whānau as required.

Staff interviewed confirmed their understanding of the complaints process.

The complaints register records the complaints, dates and actions taken. The service has implemented a review of subsidised and non-subsidised medication, antiviral treatment for an influenza outbreak and ambulance charges after a number of complaints were received about these issues.

There have been three external complaints received (one through the HDC and two through the DHB), since the previous audit. The service has appropriate systems in place for communication, complaints management, adverse event reporting, staffing levels, care planning and continence management, which addresses the concerns raised in the HDC complaint.

Standard 1.1.2: Consumer Rights During Service Delivery

Consumers are informed of their rights.

FA Family/whānau and most residents interviewed stated that the Code was explained to them as part of the admission process. Some residents with memory loss could not remember. Nationwide Health and Disability Services Advocacy information is available at the facility and included in the welcome pack given upon admission.

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.

FA Policy identifies that residents will be treated with respect and dignity that residents will not be subjected to discrimination, coercion, harassment, sexual, financial, or other exploitation or abuse. Staff interviewed verbalised the actions they take as part of everyday practice to ensure residents are treated with respect and privacy whilst encouraging independence. This is supported by resident and family/whānau members interviewed. All responses were positive and a high level of satisfaction with the manner in which services are provided was reported with two family/whānau members stating the care was excellent. All family/whānau members interviewed stated they were impressed by the new ownership and management in place. Residents confirmed all their needs, wants and likes are met.

Privacy is maintained as all bedrooms were single occupancy at the time of audit. No concerns were expressed from any person interviewed related to any form of abuse and neglect. Residents’ values, beliefs, religious and cultural needs are met by the service. This is identified in the care planning sighted and confirmed during staff and family/whānau interviews. One example given related to putting weekly communion in place for a recently admitted resident who identified as catholic.


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.

FA Policy contains guidelines for staff to follow to ensure cultural responsiveness is appropriate to meet residents’ needs. Orewa Secure Care has procedures in place which cover Māori health and there is a specific assessment available for any resident who identifies as Māori. Staff education covers cultural safety and is booked for one week following the audit. The service acknowledges the importance of family/whānau in all aspects of care.

At the time of audit there were no residents who identify as Māori. Staff interviewed demonstrated knowledge of cultural appropriateness of care for Māori residents. The facility manager confirms there are no known barriers to entry to the service for Māori.

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.

FA The six residents’ files reviewed demonstrated consultation with family/whānau and residents on individual values and beliefs. Residents and family/whānau reported they were consulted with the assessment and care plan development. Care plans are signed off by either the resident or family/whānau and their input is clearly identified.

Clinical staff interviewed demonstrated good knowledge on respecting resident’s individual culture, values and beliefs. The service assists residents to meet their spiritual needs by providing appropriate church services to residents who identify this as a need. This is clearly recorded on the care plans sighted.

Standard 1.1.7: Discrimination

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

FA Staff are made aware of professional boundaries upon employment in job descriptions and documented guidelines. This is confirmed during staff interviews. Residents and family/whānau interviewed did not express any concerns related to staff breaching any professional boundaries.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

FA The nursing practice observed was current good practice for the level of care being offered. Policies and procedures are linked to evidence-based practice, regular visits by the GP, and links with the local services, such as speech language therapist, audiology, psychogeriatric services, the wound care nurse specialist and other health services are shown in residents’ files reviewed. The service utilises DHB specialist services as required.

There are regular in-service education sessions and staff access external education that is focused on aged care and best practice. The family/whānau and residents interviewed were very satisfied with


the care delivered.

Standard 1.1.9: Communication

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

FA The service has policy related to the use of interpreter services, as required. Staff education related to appropriate communication methods has been conducted. Staff reported that they understand the process for accessing interpreter services. One resident who has English as a second language has key word sheets, one staff member speaks the same language and family/whānau assist as required. Staff confirmed there are no issues with communicating with the resident.

The family/whānau members interviewed confirmed they are kept informed of the resident's status, including any events adversely affecting the resident. Evidence of open disclosure was documented in each resident’s file via the family communication sheet, on the accident/incident forms and in the residents' progress notes.

Staff report that information is shared among all staff during handover, at staff meetings and during education sessions. The GP reports there is good communication between all health care providers.

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 service can provide rest home, hospital and secure dementia level of care for up to 29 residents. At the time of audit there were 13 hospital and 14 dementia level of care residents. The service plans to convert one of the rest home/hospital rooms to double occupancy rooms, to increase capacity to 30 residents (maximum 15 in the rest home/hospital unit and 15 in the secure dementia unit). Services are provided to meet the individual needs of the each of the residents.

The Business Plan for 2015-2016 contains the organisation’s mission, values and goals. There are long term and short term goals within the plan. The plan is reviewed on an annual basis.

The facility manager is a registered nurse (RN) with doctorate level of professional qualifications in geriatric nursing. The facility manager’s job description describes their responsibilities, accountabilities and authorities. The facility manager has managed the service since 6 October 2015 and has a background in aged care nursing and nursing education in Australia and New Zealand. The facility is a member of an aged care association, and regular updates and education is received on current legislation and issues related to management of aged care services. The facility manager has attended over 8 hours of education in the past 12 months related to leadership and management in the aged care sector.

The facility manager is also supported by a clinical manager, who is a RN and has been employed for just one week. The owner is also onsite most days and has the responsibility for the ongoing maintenance and up keep of the facility.


The family/whānau and residents confirmed they were satisfied with the services provided and that their needs were met and they feel listened to. Families comment that both the owner and facility manager are approachable and listen and act on any concerns.

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.

FA The organisational chart identified the facility manager and the clinical manager fills in for each other during temporary absences. The facility manager reports confidence in the clinical manager’s ability to fill in during their temporary absence and the clinical manager is currently undergoing orientation and induction to their role. The facility manager reports the clinical manager will receive ongoing support and education related to the management side of their role.

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.

FA The quality and risk plan details the risks, current controls and ongoing actions required to provide safe and appropriate care. The quality and risk systems are monitored through the clinical governance. Each of the quality goals identified cover all aspects of care and service delivery. Staff are actively involved in the quality programme and demonstrated an understanding of what the organisation aims to achieve. The outcomes of the internal auditing and quality management systems are discussed at the monthly staff meetings. Staff confirmed they understood and implement the quality and risk management systems.

The policies are developed by an external aged care consultant. All policies and procedures sighted were up to date, reflected current good practice and met legislative requirements. The organisation currently reviews all documents in a two yearly cycle, or more frequently if there is best practice or legislative changes. All documents have a version control footer that includes the date when the policy was last reviewed. The document control system ensures that obsolete documents were removed from use. The review of policies or any updates are distributed to staff to read and they sign that they have understood any changes. Recent policy updates include the implementation of the interRAI assessment and care planning.

The organisation had a documented quality and risk management plan which identified risks and showed the strategies in place to manage risks. All potential and actual risks are reported at board level and reviewed regularly. Clinical risks are discussed monthly at staff meetings as confirmed in meeting minutes sighted and confirmed by staff.

Quality data collection and analysis is maintained by the service and evaluation of results shared with staff and management. Quality improvements are put in place where indicated. The internal audit


form records the identified issue, actions needed, who is to implement the actions and the review of when the actions have been implemented. Staff confirmed that all follow up actions were discussed during handover and at regular staff meetings. Data is collected, trended, reviewed and evaluated for all key components of service (complaints, incidents and accidents, health and safety, hazards, restraint and infection control). The graphs and analysis of the quality data is displayed in the staff room.

The risk, hazard and emergency response plan identifies potential and actual hazards. The plan includes what the hazard is, risk level, preventative actions and ways to minimise risk.

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 The facility manager understands their obligations for reporting serious harm and essential notifications. There have been no incidents or accidents that have required essential notification since the last audit. Though there was an increase in influenza in July 2015, which was reported to the DHB, with the Ministry of Health guidelines on influenza being implemented at that time.

Staff demonstrated knowledge of when they are required to complete an incident/accident form. There is a monthly analysis of the incident and accident reports. The analysis of the incidents and accidents are used to implement improvements as indicated. The analysis includes the numbers of falls and the times that falls are occurring for residents who have had increased falls, with strategies implemented to reduce the number of falls.

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 Professional qualifications and annual practising certificates (APCs) are validated on employment and annually. The service maintains a folder of current APCs which was sighted for all staff and contractors who require them.

The staff files evidence that good employment processes are implemented, such as recruitment, interview and reference checking. After the orientation period there is a performance review conducted at 11 weeks then annually, as confirmed in the staff files reviewed.

The orientation and induction programme is conducted over a six week period. There is an initial two day orientation that all new staff complete, then role specific orientation for the different roles within the services. The initial general orientation includes the essential and emergency systems, handling concerns and complaints, cultural best practice, infection control, incidents/accident reporting, managing challenging behaviours and restraint minimisation. Each staff file reviewed evidenced an orientation and induction into their role. Staff reported that the orientation and induction gave them a good understanding of their role and responsibilities.


The in-service education programme covers the essential components of service delivery for rest home and dementia level of care. The service also accesses ongoing education support from the DHB aged residential care programme, gerontology nurse specialists and palliative care services. The care staffing in the dementia unit meets contractual requirements for the required education related to the national unit standards for dementia care. Attendance records are kept for the education that staff have attended, as sighted in each of the staff member’s personnel files.

The facility manager has completed their interRAI competency training. Another RN is currently undergoing their interRAI training and the clinical manager is enrolled in interRAI training. Although the facility manager has completed the interRAI training, they have yet to gain access to the interRAI records at this service.

Staff reported that they are supported and encouraged with maintaining their knowledge and skills.

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 clearly documented policy on staffing levels and skill mix to meet the needs of residents requiring rest home/hospital and secure dementia level of care. There is at least one RN on duty in the hospital at all times. There are two caregivers on duty on morning and afternoon shifts in both the rest home/hospital and dementia units. There is at least two caregivers and one RN on duty for night shift, this allows for one staff member to always be in the rest home/hospital and dementia unit sections at all times.

There is at least one staff member on duty each shift who has current first aid qualifications. There are appropriate staffing level for activities, cooking, cleaning and laundry. Staff confirmed they have adequate time to do their required work and all staff assist in implementing meaningful activities for the residents throughout their shifts.

Standard 1.2.9: Consumer Information Management Systems

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

PA Low Information is entered into the resident information management system in an accurate and timely manner. Records were securely stored. Archived records are stored onsite. When required, records are appropriately destroyed.

There are at least, daily progress note entries. These records do not identify the name of the staff member, only initials are used and this is an area identified for improvement. Staff show their designation.

All records pertaining to individual residents are integrated. Bowel charts and weight information is kept in a separate chart for each resident but this is filed in the main chart when the page is full. Information of a private or personal nature is maintained in a secure manner and was not publicly


accessible or observable at the time of audit.

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.

FA Policies and procedures are in place and accessible to assist staff to ensure timely, safe service delivery occurs.

The service implements policy related to service enquires and admission and information packages for potential residents. Before a resident can be accepted into the service they must have an approved assessment for either secure dementia care or hospital level care. The entry criteria, assessment and entry process is clearly documented and communicated to the potential resident and family/whānau. The service reports their bed status daily and this can be viewed on the internet.

Standard 1.3.10: Transition, Exit, Discharge, Or Transfer

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

FA All residents’ exit, discharge or transfer is documented using specific forms. The service utilises the transfer forms approved by the DHB and this is confirmed in files reviewed. Known risks are identified to the place of transfer in order to manage the resident safely. Expressed concerns of the resident and family/whānau are clearly documented including advanced directives and EPOA documentation. This is confirmed during residents’ file reviews.

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.

FA Policies and procedures describing safe medication management are implemented by the service. This covers the storage, administration and recording of medicines. There is policy in place which describes the process to follow for residents who are deemed competent to self-administer medicines. At the time of audit there are no residents who self-medicate.

With the exception of liquid medicines and stock medications, such as antibiotics, medicines are supplied by the pharmacy in a pre-packed robotics administration system for individual residents. Medications are checked for accuracy by the RN when delivered. The pre-packed medicines and the signing sheets are compared against the medicine prescription. Regular medicine reconciliation processes are documented. Safe medicine administration was observed at the time of audit.

The medicines, controlled drugs and medicine trolley were securely stored. The management of the controlled drugs meets legislation and best practice guidelines. Two staff sign the controlled drug register when medication is given and a physical check is undertaken weekly.

All the medication files sampled had prescriptions that complied with legislation and aged care best practice guidelines. The GP has conducted medication reviews for all residents within the last three months.


Medication competencies were sighted for all staff who assist with medicine management, this included the RNs and senior caregivers.

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.

FA Policies and procedures implemented cover all aspects of food preparation. Documentation identifies that safe food hygiene management practices are followed.

The menus were reviewed by a registered dietitian in May 2015 as being suitable for the residents at Orewa Secure Care facility. The cook stated that food is produced in accordance with the menus. There is a documented cleaning programme implemented.

The kitchen has the dietary information for all residents and their likes and dislikes are catered for. Residents are routinely weighed at least monthly, and more frequently when indicated. Residents with additional or modified nutritional needs or specific diets have these needs met. The residents and family/whānau reported being satisfied with the meals and fluids provided and confirm snacks are available 24 hours a day.

Food, fridge and freezer recordings are undertaken daily and meet requirements. Evidence was seen of all kitchen staff having completed safe food handling certificates.

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.

FA A record is kept of any request for service that is declined. If entry to the service was to be declined the referrer, potential resident and where appropriate their family/whānau would be informed of the reason for this and of other options or alternative services. Management confirm potential residents who have an appropriate needs assessment are accepted to the service if a bed is available.

The admission agreement contained information on the termination of the agreement and if the service can no longer provide a safe level of care to meet the needs of the resident they would be reassessed for the appropriate level of care. One resident’s file reviewed contained a recent needs assessment for a change of care level from secure dementia care to hospital level care.

Standard 1.3.4: Assessment

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

FA The service uses interRAI assessments. However, three residents have had a review undertaken using paper assessments owing to a change in staff and the newly appointed facility manager is awaiting her interRAI access to be transferred from her previous place of employment. (One other newly appointed RN has almost completed their interRAI training). Additional paper tools are used for some issues such as behaviour management. There is specific assessment related to continence management. Information for assessment is used to inform each resident’s care plan. Assessments


cover physical, spiritual, cultural and psycho-social needs of the residents. Initial assessments commence upon admission and are updated at least six monthly or if there is any change to the resident’s condition. The goals set are resident focused.

Standard 1.3.5: Planning

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

FA The service uses assessment information to inform their care planning process. All the care plans reviewed evidenced individualised care planning processes that reflected the resident's individual needs. The care plans reviewed demonstrated service integration. Residents’ records are integrated. There is a separate file for bowel recordings and weight recordings but this information is put into the resident’s file when each page is completed. This was discussed on the days of audit and the clinical manager intends to integrate these records into the main current file.

The residents and family/whānau interviewed reported that the staff have excellent knowledge and care skills. They acknowledge and verbalised examples where their involvement has changed some aspects of the care planning process upon request. The GP interviewed expressed satisfaction with the care provided.

Standard 1.3.6: Service Delivery/Interventions

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

FA The care plans reviewed were individualised to show interventions put in place to contribute to meeting resident goals. Information sighted on care plans is congruent with assessment findings. Residents and family/whānau interviewed reported a high level of satisfaction with the services they receive.

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.

FA The diversional therapist plans activities to meet the resident’s abilities. Information gained by an activities assessment and resident’s history assessment is used when developing the activity plan. The diversional therapist stated that their role was to focus on giving the residents back some independence by focusing on activities that are meaningful. For example one resident in the dementia care unit had a love of photography and now the resident is assisted to take photos of activities and outings.

There are planned activities that covered physical, social, recreational and emotional needs of the residents. Under the new management structure a greater emphasis has been placed on community involvement and more outings are being undertaken. Additional church services, pet therapy and library services have been put in place. The activities programme is a revolving plan to match weather conditions and residents abilities. Feedback received from the residents and family/whānau


is taken into account when planning activities.

Standard 1.3.8: Evaluation

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

PA Low Evaluations are documented at least every six months. However they did not all indicate the degree of achievement or response to the support and/or interventions put in place towards the resident meeting their desired goals.

Where progress was different from expected, the service responded by initiating changes to the care plan or by use of short term care plans for temporary changes. Short term care plans were sighted in the files reviewed.

The residents and family/whānau interviewed reported high satisfaction with the care provided at the service.

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.

FA Residents may use the GP of their choice. Referrals to other health providers is supported by the organisation and facilitated by the GP and RNs. This is confirmed in resident file reviews and during resident and family/whānau interviews.

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.

FA The cleaning, laundry and sluice room have safe, secure and appropriate storage of waste, chemicals and hazardous substances. Personal protective equipment (PPE), such as gloves, disposable gowns, and eye protection is available in the laundry/chemical storage area. The cleaning and laundry staff demonstrated knowledge on the safe use of the chemicals and PPE. Staff have ongoing education on infection prevention and control and the use of chemicals.

Standard 1.4.2: Facility Specifications

Consumers are provided with an appropriate, accessible physical

FA The service has a current building warrant of fitness displayed.

Hot water temperatures are monitored monthly, these are within safe guidelines. Medical equipment has annual calibration, last conducted within the last year. The electrical equipment is tested and tagged; this was last conducted in May 2015. The annual service of the wheelchairs and hoist was


environment and facilities that are fit for their purpose.

sighted. There is some wear and tear of some of the equipment (such as rusting surfaces), this is on the maintenance list to be repaired or replaced. The facility manager conducts a monthly compliance check of the environment.

The environment promotes safe mobility, with secure hand rails in the hallways and floor surfaces that are intact and do not present a trip hazard. Each wing has access to the external areas. The dementia unit external area is separated from the rest home section of the service, though there is limited access to the external area from the dementia unit. There is external access from each resident’s room in the dementia unit, though these doors were locked and the residents could only access the external area when the staff take them outside. This was addressed at the time of audit and residents in the dementia unit now have freedom of movement to go outside.

The residents and families reported satisfaction with the environment.

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.

FA There is one room in the rest home/hospital and one room in the dementia unit that have access to ensuite toilet facilities. Both the rest home/hospital and dementia units have access to centrally located toilet and shower facilities. There are three toilets and three showers in each wing. All of these facilities have privacy locks and signage. The residents and families reported satisfaction with the facilities at the service.

Standard 1.4.4: Personal Space/Bed Areas

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

PA Low All rooms are single occupancy and suited to the needs of residents at rest home level of care. The rest home and dementia units are separated. Each resident’s room has their personal items and provide enough space for the resident and staff to mobilise. The residents and families reported satisfaction with the personal space.

The service wishes to convert room number 13 in the rest home/hospital wing to a double occupancy room. The room would be of a suitable size for two rest home level of care residents, though would not be of adequate size for two hospital level of care residents as there would not be enough space to manoeuvre mobility aids, such as hoists, for two residents. The room would also be suitable for two related residents, who would not desire privacy screening.

Standard 1.4.5: Communal Areas FA Each wing has lounge and dining areas. The dementia unit is separated from the rest home/hospital


For Entertainment, Recreation, And Dining

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

unit. Resident rooms also provide areas for residents to relax or entertain in privacy. The residents and families report satisfaction with the access to dining and lounge facilities.

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.

FA The cleaning is conducted by specific cleaning staff, with the care staff assisting with the laundry duties. The linen is conducted by an offsite laundry service. The residents’ personal clothing is conducted by the care staff. Though there is a steriliser/macerator in the hospital wing, the staff hand clean the bed pans/urinal in the laundry area. There are adequate processes in place for ensuring the cleanliness and sanitising of the reusable equipment (such as bed pans).

The service conducts a monthly inspection of the housekeeping areas, such as carpets, floors and toilets, with all these evidencing a good housekeeping rating. There is secure storage of the bulk chemical supply in the laundry area. Staff demonstrated knowledge on the use of chemicals. The residents and family/whānau report satisfaction with the cleaning and laundry services.

Standard 1.4.7: Essential, Emergency, And Security Systems

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

FA The approved evacuation scheme is dated 23 January 2014. The fire and emergency equipment has a monthly inspection as well as an annual certification by an external contractor. Emergency and security training is provided as part of staff orientation and ongoing in-service education. Evacuation drills are conducted six monthly, with the last conducted on 16 November 2015 and next scheduled for May 2016. Staff demonstrated knowledge on how to respond in emergency or civil defence situations.

The service has bottled gas for cooking and emergency lighting in the event of mains failure. There is a water tank and bottled drinking water that is accessible in emergency situations.

Each room, toilet and bathing facility has access to a call bell. The call bell system has a light and audible alert when activated. Staff responded promptly when the call bell was tested. The residents and families reported satisfaction with the time frames in which call bells are answered. The owner states they are currently looking into updating the call system in December 2015, which is also to include adding the additional call bell to room 13 to make this room suitable for two residents (also refer to 1.4.4.1).

The layout of the dementia unit allows for residents with cognitive impairment to wander freely inside and into the secured external area. A night staff member has a checklist to ensure the entrances,


doors and windows are secure. After hours visitors are required to use the doorbell to gain access to the facility through the security gate in the driveway. This gate in the driveway has free access during the day. Staff, residents and families report satisfaction with the security arrangements.

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.

FA All areas used by residents and families are ventilated and heated. The lounge and dining areas in the dementia unit have sky lights that provide natural lighting during the day time. Each resident’s room and hallway have wall mounted radiators and at least one window or sliding door for light and ventilation. Most room have external access through ranch type sliding doors. The residents and family/whānau report satisfaction with the heating, light and ventilation.

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.

FA Policy outlines the lines of accountability for infection control matters. The infection control coordinator is a registered nurse with a specific job description which identifies their responsibilities and accountabilities for the role. The current infection control coordinator has only been in the role for one week prior to audit when the previous coordinator left the role. Infection control data information is shared at all staff meetings which are attended by the owner. New infections are reported at handovers and if there are any concerns management are notified immediately.

The objectives of the documented infection control programme are audited at least annually. This was last undertaken in January 2015.

Policies and procedures are implemented related to taking measures to keep staff, visitors and residents safe. During interview, staff verbalised their knowledge and understanding of infection control processes. As observed there are notices at the main entrance asking visitors not to visit if they are unwell. There are sanitising hand gels throughout the service for residents, visitors and staff use.

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.

FA The infection control coordinator has access to expertise from Waitemata District Health Board, the Ministry of Health and a private infection control specialist. Extra advice can be sought from the GP and product supplier as required. The infection control coordinator and staff have access to personal protective equipment and resources to allow the infection control programme to be fully implemented. All staff interviewed understood their accountability to report any issues related to infection control concerns.

Infections are reported and managed using short term care plans as evidenced in the residents’ files


reviewed.

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.

FA Documented policies and procedures reflect current accepted good practice and identify relevant legislative requirements. Policy and procedures are written and managed by an off-site provider and are personalised for Orewa Secure Care as necessary. They are accessible to all staff and appropriate for the type of service provided.

Staff interviewed verbalised correct infection control procedures when dealing with infections and were observed using good preventative practice, such as the use of person protective clothing and good hand washing techniques.

Standard 3.4: Education

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

FA Infection control education is included in staff orientation with ongoing annual updates. Staff in-service education related to infection control is appropriate to the services offered. Examples for 2015 include hand washing and standard precautions. Staff were observed using good infection control practices as part of their everyday service delivery.

Informal and formal education is provided for residents and family/whānau as required. This is confirmed in documentation sighted covering an influenza outbreak in July 2015 which is shown in residents’ files reviewed, a letter and information was sent to family/whānau and the gaining of consent for a ‘flu injection’ to be given.

Standard 3.5: Surveillance

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

FA Surveillance requirements are implemented to meet policy and standard requirements for the level of care offered at Orewa Secure Care. Monthly infection control surveillance data is collected, recorded, reviewed, analysed and trended at facility level. The data is sent off site for three monthly benchmarking against other like organisations. Standardised definitions of infections, which are appropriate to the long term care setting, are used. If an unexplained increase in infection rates is noted corrective actions are taken. The data sighted for November 2015 identifies a decrease in the overall number of infections on the previous month but especially related to urinary tract infections which have reduced from six to one. The facility manager and infection control coordinator confirm they actively undertake interventions to help reduce infection numbers. This is confirmed in


documentation sighted including meeting minutes. All data is shared with staff, management and the owner.

Staff interviewed confirmed they understand the data results presented.

There was on influenza outbreak in July 2015 (diagnostic verification sighted) with one resident being hospitalised. All outbreak measures were taken to meet policy and standard requirements. Eleven residents and no staff were affected by the outbreak. Notification to the District Health Board was undertaken in a timely manner. Communication with family/whānau is clearly documented. This includes written information about the strain of influenza identified.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The service currently has seven residents using restraints (bed rail and/or lap belt) and one resident using an enabler (bed rail). Policy clearly identified that enabler use is voluntary and the least restrictive option to maintain the resident’s independence and safety. The one enabler in use records that the resident requested it to make them feel safe when in bed.

One of the RNs is the delegated restraint coordinator with relevant authorities and responsibilities. There is a signed restraint coordinator job description. An approval group was established headed by the restraint coordinator. Restraint decisions are made in collaboration with the GP and families. The restraint coordinator was knowledgeable about the restraint process. Staff demonstrated good knowledge regarding restraint and use of de-escalation techniques. All staff were trained/educated regarding the restraint policy and procedures as well as managing challenging behaviours and restraint competency were sighted in all care staff files reviewed.

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.

FA The approved restraints and enablers at the service are the use of bed rails and lap harness. The restraint coordinator reports that the service has reduced the use of the types and number of restraints used, this includes one resident that previously required environmental restraint.

There is a restraint approval committee that meets at least six monthly. The restraint coordinator and restraint committee have approved all restraint use. The GP is part of the restraint committee meeting. Consent from family/whānau and an RN is required before restraint is approved. The consent form and approval process was sighted in the files reviewed of resident’s with restraint use.

Standard 2.2.2: Assessment FA The service has a restraint assessment form that includes the factors of this standard. The restraint


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

coordinator reported that restraint is only put in place following appropriate review of the risks and benefits of restraint or enabler use, such as considering the wellbeing of the resident or others, cultural safety, emotional trauma, physical safety, mobility, will it reduce risk of falls or harm, and is there a balance between independence and protection. The assessment process was sighted in the residents’ files. Care staff demonstrated, understood and implement alternatives to restraint, such as low beds and sensor mats, whenever possible.

Standard 2.2.3: Safe Restraint Use

Services use restraint safely

FA The restraint coordinator reported that restraint is only applied after consideration is given to all possible alternatives and that it will be used with the least amount of force. Restraint is monitored according to risk. Frequent falls from bed by individual residents will often generate commencement of reviewing the need for bed rails. The restraint documented all restraint and enablers in use. The restraint register records the type of restraint, when approved, review dates and if the restraint is still recommended for user. The register records that the service has reduced the numbers of residents with restraint use.

Standard 2.2.4: Evaluation

Services evaluate all episodes of restraint.

FA The evaluation process included all the points required in the standard. The restraint coordinator reported that all restraint and enabler use is evaluated at least six monthly as part of the resident review process. Within two days of when restraint is initially implemented, there has been a review and evaluation of its appropriateness and effectiveness. The evaluation process was sighted in the files of residents with restraint use. Restraint reviews are discussed at the restraint committee meetings. The resident and family/whānau consultation and evaluation was evidenced in the files of the residents with restraint use.

Standard 2.2.5: Restraint Monitoring and Quality Review

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

FA The six monthly restraint approval committee monitors and reviews the restraint and enabler use for the service. As part of the internal auditing system, an annual review of the restraint processes is conducted. Restraint use is closely linked to the falls reduction programme. All restraints are used for the safety and comfort of the resident. The service is further reviewing alternative options, such as an antiroll mattress to minimise the use of bedrails.


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 1.2.9.9

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

PA Low The content of what is written in residents’ files is legible, however staff do not use their full name only initial. Staff identify their designation.

In all six resident files reviewed staff only use their signature when signing what they have written in residents’ progress notes.

Provide evidence that staff sign progress notes using their name for ease of identification.

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 Low Evaluations are documented within required timeframes. They do not always identify the degree of achievement or response to the support interventions. This was the case in three of the six residents’ care plans reviewed. Three of the files reviewed had very well documented evaluations.

Three of six care plan evaluations did not identify the degree of achievement or response to the support and interventions put in place towards meeting resident’s stated goals.

Ensure all evaluations indicate the degree of achievement to the interventions in place so they describe the progress residents


They only had the interventions reworded.

are making towards meeting their set goals.

180 days

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.

PA Low There is one room that the service wishes to convert from single occupancy to double occupancy. The room currently has only one call bell and no privacy screening. The room would only be of a suitable size for two rest home level of care residents once the call bell system for each resident is installed. To use the room for two unrelated residents, privacy screening will need to be installed prior to occupancy as a shared room.

There is no privacy screening or call bell access in room 13 if this room is to be used as a shared room as the service has proposed.

Prior to using room 13 as a shared room, there will be adequate privacy and call bell access for each of the residents.

Prior to occupancy 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.


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