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Peter and Jacqui de Ruiter - Northanjer Rest Home

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: Peter and Jacqui de Ruiter

Premises audited: Northanjer Rest Home

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 11 May 2016 End date: 12 May 2016

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: 14

Peter and Jacqui de Ruiter - Northanjer Rest Home Date of Audit: 11 May 2016 of 27

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

Northanjer Rest Home is certified to provide rest home level care for up to 15 residents. On the day of this certification audit there were 14 residents.

The facility is in Oamaru North Otago and is owned by a company and operated by a couple who are directors of the company. The nurse manager/owner oversees the day to day management of the facility and is supported by a registered nurse (RN) and the co-owner business manager.

This audit against the Health and Disability Services Standards and the provider’s contract with the district health board, included observation of the environment, interviews with the management team and staff, review of documentation and interviews with residents and their families. There are no required improvements identified during this audit.

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.


The admission process for residents into the facility is planned and timely. The information portfolio is provided prior to admission to ensure residents and families have time to consult with others and are fully informed. Time and privacy for discussion to occur is provided.

Completed incident/accident reports show that open disclosure is occurring and this is confirmed by relatives and residents who talk of being fully informed and say the manager and staff maintain open dialogue with them at all times. An interpreter policy with contact details is in place, however there has not been any requirement for such services.

During the audit staff were observed to respect residents’ rights during service delivery, allowing for personal choices, acknowledging and supporting cultural, spiritual, emotional, individual rights and beliefs and encouraging independence.

Residents and family members interviewed reported that staff are very respectful of their needs, that communication is consistent and appropriate and they are given time for discussions to take place with staff and family/whanau. They have a clear understanding of their rights and the facility’s processes if these are not met.

Information about the Health and Disability Commissioner’s Code of Health and Disability Services Consumer Rights (the Code), including the facility’s complaints process and the Nationwide Health and Disability Advocacy Service, was on display at the entrance to the facility and is available in admission packs and on request. A current complaints register is maintained by the nurse manager.

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.


The organisation’s quality plan is current and documents the facility’s purpose, values, scope, direction and goals. There is evidence that the nurse manager, business manager and the registered nurse (RN) have the relevant experience and skill to manage the facility. In a temporary absence of the nurse manager, the RN takes over day to day management of the facility.


A detailed quality and risk management plan is specific to the facility covers all aspects of service delivery. There is a defined document control system in place. A suite of policies and procedures are current and reviewed regularly. Accidents and incidents are being reported and analysed and an internal audit programme is maintained to ensure that required standards are being upheld. Corrective action plans are in place for system shortfalls.

There are appropriate systems for the recruitment, appointment and management of all employees including a comprehensive induction and orientation programme and the related documentation is completed. Employment practices meet best practice guidelines. A planned training programme guides professional development which is well supported by the nurse manager. The roster indicates that staffing levels are safe and that there is either the RN or the nurse manager on call.

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.


Services are being delivered according to service delivery plans that are developed and reviewed by a RN. Assessment tools are used and residents and relatives are consulted. This facility has commenced using the interRAI assessment programme. The RN completes the assessment from which an individualised, detailed care plan is developed. Regular review occurs to reflect the residents’ assessed needs. There has been a comprehensive review and implementation of care planning and evaluation process with input from residents, families/whanau, allied health professionals and the wider community.

Short term care plans are developed when issues arise within the review time frame. Staff were observed to provide services that reflected the care plan content. This was also confirmed in resident and family/whanau interviews. Planned activities occur that are meaningful to the resident as part of the service delivery plan and are appropriate to their needs, age, culture and the setting of the service.


Medicines are being managed according to policies and procedures and guidelines for safe practice. Those administering medicines have been assessed as competent to do so. One general practitioner (GP) was interviewed during the audit and confirmed the facility provides a high level of care; that is, assessments and service delivery are appropriate, timely and in line with treatment recommendations.

Whole foods and home prepared cooking contribute to ensuring the nutritional needs of residents are met. A rotating menu has been reviewed by a dietitian and any resident with special dietary needs has these accommodated. Food is stored safely with daily temperature monitoring and stock rotation occurring in the fridges, freezer and pantry.

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.


The facility is a converted house and is well maintained. Residents’ rooms are kept clean, tidy, well ventilated and at a comfortable temperature. There is a main communal area which provides sufficient space for residents to use. A separate porch provides an additional area for residents to relax. There are a sufficient number of toilets and bathrooms for the number of residents.

Easily accessed, safe outside areas are provided for use for residents. The building has a current building warrant of fitness. There are systems in place for the management of waste and hazardous substances by staff who have been trained in this area.

Emergency procedures are well documented, with sufficient stock and resources in place in case of an emergency. Regular fire drills are held and staff are well trained to respond in any emergency. Appropriate security arrangements are in place.


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 facility has a philosophy of not using restraints and there were no enablers in use at the time of the audit. There are policies and procedures in place, which meet the requirements of these standards, should they be needed. All staff receive training in the facility’s procedures.

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 control RN is the nurse manager who has a specific role to manage the environment and minimise the risk of infection to residents, staff and visitors. The service has a clearly defined and documented infection control programme that is reviewed at least annually.

Staff files, observation and interviews verify initial and ongoing infection control education occurs. Surveillance for infection is conducted monthly and transferred to an annual data sheet. There are minimal infections at the facility, and those identified have been analysed to identify any patterns or trends.


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 45 0 0 0 0 0

Criteria 0 93 0 0 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 Interviews with residents, family/whanau members and a review of rest home care records and observation during the audit verified that staff have knowledge and understanding of consumer rights and integrate them into every day practice. Records reviewed confirmed staff training occurs initially, during orientation and annually. A detailed Code of Rights policy was sighted and inclusive of consumer rights as stated in the Code of Health and Disability Services Consumers’ Rights (the Code).

Standard 1.1.10: Informed Consent

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

FA There are appropriate informed consent policy and procedures. These were reflected in documentation reviewed. These included signed admission agreements and advance directives, written consents for transport, influenza vaccination, outings, photographs, names on doors and care provisions. Where applicable, power of attorney documentation was provided and accompanying signatures.

Staff during interview demonstrated knowledge of informed consent


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

practices. Residents and family/whanau confirmed and provided examples that staff gain consent on a daily basis.

Standard 1.1.11: Advocacy And Support

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

FA There are policies that include the right of residents to have an advocate or support person of their choice. Residents and family/whanau interviewed confirmed that family/whanau and support persons are included in discussions relating to care provision. Staff interviewed were aware of the residents’ rights to have a support person of their choice at any time.

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 All residents and family/whanau interviewed verified that family and visitors of their choice are able to visit at any time and there are no restrictions.

External community links are encouraged and enabled to continue, with examples of this provided.

Care plans, activity plans and progress notes reviewed confirmed regular outings, activities and appointments where transport can be organised to enable attendance.

Standard 1.1.13: Complaints Management

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

FA Northanjer’s complaints policy meets the requirements of Right 10 of the Code. This is provided to all new residents on entry to the service, and included at induction for all new staff. There is an annual staff training session that includes complaints management.

The complaints register is maintained by the nurse manager and three residents’ complaint have been registered in the past year. The required timeframes have been met. The issues raised were managed appropriately. Staff interviewed demonstrated a clear understanding of their responsibilities for reporting any concerns raised by residents and family.

Standard 1.1.2: Consumer Rights During Service Delivery

Consumers are informed of their rights.

FA Residents and family/whanau in the facility confirmed that they are provided with information regarding the Code and the Nationwide Health and Disability Advocacy Service. They verified that explanations regarding their rights occur initially and on an ongoing basis if they have any concerns. They were aware an advocate can be appointed if required. None of those interviewed had required the


service.

Consumer rights posters, consumer rights brochures and information on the Advocacy Service were available at the entrance to the facility and include information on providing feedback, complaints and compliments.

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 Care plan documents reviewed include preserving independence, values, beliefs and cultural, social, and/or ethnic needs of residents, with further examples observed and provided during interviews with staff.

Residents and their family/whanau members interviewed have not been subject to, or witnessed, any signs of abuse or neglect. Those interviewed maintained that all staff show respect at all times; by knocking before entering rooms, ensuring conversations are private, respecting and understanding the individual resident’s values and beliefs and maintaining independence. These practices were observed during the audit and confirmed in the review of residents’ files.

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 Currently there are no Maori residents in the facility. The Maori Health Plan includes definition of and inclusion of cultural safety for all residents, and encompasses specific needs for Maori clients when developing a plan of care.

At initial assessment an appropriate care plan is developed in consultation with the resident and whanau and regularly re-evaluated to ensure it meets the resident’s required goals and outcomes. It includes: food and fluids; sleep and rest; spiritual/cultural needs; communication; hygiene; grooming; oral hygiene; elimination; medical requirements; activities; visiting; and death and dying. All are specific and appropriate for Maori.

Policies on cultural safety and Maori health provide guidelines for the provision of culturally safe services for Maori residents. There is ongoing education in line with the Treaty of Waitangi expectations for staff.

Staff combine the Maori health care plan reflecting spiritual,


traditional Maori healing practices, mental, physical and extended family in assessment, ongoing care planning and re-evaluations. Interviews with staff confirmed this occurs when a Maori resident is in the facility. A whanau room is available with unlimited whanau access.

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 Alongside the policies and procedures to address the needs of Maori residents, in the cultural safety policy, there is a section on cultural needs of all persons within the facility. Cultural safety is included in the Maori Health Plan. Residents and family/whanau interviewed verified that the facility ensures their individual values and beliefs are met. Examples were provided that staff ensure residents receive services that respect their individual values and beliefs. This was also observed during the audit.

Standard 1.1.7: Discrimination

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

FA Policy documents reviewed, including the elderly abuse and neglect prevention policy, include guidelines to ensure residents are free from any discrimination, coercion, and harassment, sexual, financial, or other exploitation. Staff interviewed demonstrated an awareness of the residents’ rights in relation to these areas. Residents and family/whanau interviewed verified there have been no issues relating to coercion or exploitation.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

FA Induction and orientation for staff aligns to best practice processes. Records reviewed and interventions with staff verified that in-service education and ongoing professional development is provided and supported by the organisation. Policies and procedures are current and reflect best practice guidelines. The facility has completed the interRAI assessment for every resident and every new resident will be interRAI assessed.

The New Zealand on line learning resource has been implemented for all staff, can be accessed from home and supports the Health Education Trust NZ learning for staff.

A diversional therapist from another facility attends monthly meetings with the activity co-ordinators. Together they plan for the next month and the plan is presented to the residents at the monthly


residents meeting for approval.

Standard 1.1.9: Communication

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

FA The facility’s open disclosure policy describes key principles and explains expectations for this service. Residents and family/whanau members interviewed confirmed that communication is appropriate and delivered in a manner the resident and family/whanau can understand. Staff were observed taking time to ensure when communicating with residents that they are understood and residents have time to answer.

The facility’s nurse manager (NM) has verified the facility has not needed to access interpreter services, although she could explain the processes in place should these be required.

Standard 1.2.1: Governance

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

FA Northanjer Rest Home is owned by a company. The directors of the company are two couples; one couple manages Northanjer rest home and live on-site in adjoining accommodation and the other couple operates another facility in south Oamaru. The couples have owned the facility for over 20 years, and one of the managers is a RN. She is supported by another RN to provide clinical guidance and on call and leave cover.

The mission, vision and values of the organisation are documented in both the business and quality plans. These are reviewed annually against the organisation’s objectives.

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 RN assumes the nurse manager’s role during any temporary absences. The RN has been in this role for over 10 years.

Staff during interview reported that the managers and the RN are a supportive and stable team. Staff report that they are approachable and responsive to any queries they may have.

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 There is a documented and implemented quality and risk management plan that includes key components of service delivery. Policies and procedures in place are current, regularly reviewed and reflect evidence based practices.

The nurse manager attends the six monthly committee (staff) meetings which includes all aspects of quality and risk. Minutes


sighted confirmed that most other staff also attend. The minutes include reports and discussion on residents’ wellbeing, staff, education, hazards/risks, incidents and complaints, infection control, analysis of data and maintenance. The meeting includes a summary of amended policies for implementation.

Staff during interview demonstrated an understanding of reporting processes.

Two monthly resident meetings occur; any issues identified here are carried over to the committee meeting. These are well attended by residents and family. Residents during interview reported these meetings are an excellent forum to get and provide feedback.

The detailed quality and risk management plan includes analyses and system improvements for all reported risks. A corrective action process is implemented for areas of non-compliance.

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 There is an incident and accident reporting policy which includes the essential notifications and statutory and regulatory reporting. The requirement to report pressure injuries of category 3 under section 31 of the Health and Disability Services (Safety) Act has been added to the policy.

Adverse events are reported and recorded on an incident reporting form. The service is small which is reflected in the small number of incidents reported over the past 12 months. All have been analysed on an individual basis with no patterns or trends identified. Staff confirmed that they would report events using the reporting forms. They understand the importance of reporting events as soon as possible.

The general practitioner (GP) reported that he is notified of events in a timely manner. Residents and family reported that they are also notified of events if they occur.

There have been no pressure injuries in the rest home; however, the manager and RN are aware of their responsibilities regarding these.

Standard 1.2.7: Human Resource Management FA The nurse manager is responsible for human resources


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

management. Professional registration is sighted and recorded in the RNs’ files. General practitioner (GP) and podiatrist registrations are reviewed and current.

A comprehensive induction, orientation and appraisal programme is in place, including documented interviews, reference checks, police vetting and ongoing performance reviews. During interview the nurse manager reports that staff turnover is low with no new staff employed in recent months.

The 2015 and 2016 training programmes includes monthly in-service education sessions. Content reflects service needs and standard requirements. Staff during interview reported that in-service is relevant and reflective of the service. There is a staff member on each shift who has completed first aid training.

Standard 1.2.8: Service Provider Availability

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

FA The roster was reviewed and reflects the facility’s skill mix policy. A care staff of eight are rostered to cover shifts over 24 hours. These staff exclude the registered nurse (RN) and nurse manager.

There is one staff member on from 11 pm to 7 am, with a RN on call – either the nurse manager or the RN. During interview care staff reported that there are sufficient staff to cover all shifts. This is confirmed in resident and family interviews.

Standard 1.2.9: Consumer Information Management Systems

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

FA A review of records, interview with the nurse manager (NM), RN and documentation reviewed confirmed that information was entered into each resident’s integrated file in a timely manner. Records reviewed were current, accurately recorded, legible, and stored in a locked room. Residents’ records no longer in use were observed stored in a separate locked cupboard. The consumer records policy included in the documentation and report writing policy identifies privacy needs and meets the standards requirements. Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable and easily accessible when required. The consumer information management system is appropriate to the service type and setting.

Standard 1.3.1: Entry To Services FA Residents’ entry to service documentation details all requirements


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

for both parties on admission to the facility. Records reviewed showed a needs assessment and service coordination (NASC) assessment occurs prior to all admissions to ensure admission is appropriate. The facility’s service agreement requirements have all been met in the files reviewed. Residents and family/whanau interviewed verified the facility ensured the admission was timely and carried out with dignity and respect, taking into account the resident’s and family/whanau’s identified needs.

Standard 1.3.10: Transition, Exit, Discharge, Or Transfer

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

FA One file of a transferred resident was reviewed. The NM confirmed all transfers included the involvement of the NM, resident, family/whanau and GP. The file reviewed was completed with evidence of the family/whanau and GP involvement prior to the transfer occurring. Policy reflects the process.

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 A medicines management system is well documented in the policies and procedures and details, which meet legislative requirements and recommended guidelines. Medicine management is overseen by the RN, who is responsible for the reconciliation of medicines into the facility and for the return of unused medicines to the pharmacist who uplifts the medicines from the rest home. The rest home uses a four weekly medico blister pack system whereby the pharmacist delivers the medication to the RN and medications are locked away in a cupboard. There is a medication check sheet completed by the RN for all residents when checking medication in from pharmacy as evidenced. All medicines and the folder holding the medicine record sheets are locked in a mobile trolley.

There is currently one controlled medicine in use. The controlled drug register was sighted as was the locked metal safe used for storage of the medicine. Recordings and checks of controlled medicines have been undertaken according to requirements. A medicine round undertaken by the carer, wearing a blue vest indicating giving out medication and not to be disturbed, was observed and administration protocols are upheld with safe practices in use. The NM informed that medicine related errors are managed through the adverse event reporting system and there is evidence of this in these reports.


There is a master list of staff who are competent to administer medicines and these staff have evidence of a current medicine competency in place which aligns to the master list.

There are not currently any residents who self-administer their medicines, although there are related policies and documentation required if a resident chooses to self-administer.

Medicine records were reviewed. All medicines are signed individually by the GP, all records have an allergy status recorded and a photograph of the resident. All medicines are being signed when administered and staff have sample signatures at the front of the medicines file. Pro re nata medicines and short term medicines are being administered as prescribed and their uses are monitored.

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 A copy of the report on the review of the four week rotational menu by a registered dietitian is in place. Food and nutritional assessments are completed for new residents when they are admitted. An additional dietary check list is completed to ensure any feeding aid and preferences about nutrition and fluids, or where a resident may prefer to eat, are covered.

There are currently residents who have diabetes, gluten intolerances and their dietary needs are met. Residents are regularly weighed and where necessary, high protein drinks and food supplements are introduced in conjunction with relevant health checks being undertaken. Re-evaluation occurs on a regular basis as viewed in documentation provided.

The kitchen works with an external provider in maintaining kitchen hygiene and infection control prevention. It was observed that both staff members who participate in food preparation have completed their certificates in food hygiene. Areas inspected were clean and in good repair. Food stores inspected were all current, dated and stock rotation is undertaken and a hard copy of this process was sighted. Prepared food is sealed and dated. Fridges and freezer are temperature monitored daily and hot food temperatures were checked and recorded as per schedule. Staff are aware of the expected temperatures and know to report any deviation from these.


The senior cook informed that every effort is made to use natural and whole foods which is confirmed by a senior caregiver, who also does a number of kitchen duty shifts. Homemade preserves and jams are available, baking of biscuits and slices are undertaken on site and vegetables are frozen in season and used to supplement foods that are ordered and purchased externally. Items are uplifted by the senior cook and stored on arrival appropriately as evidenced on audit.

Residents are surveyed as to dietary preferences and copies of notes and meal adjustments were sighted as part of the routine practice in the kitchen.

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 Interview with the NM and RN and a review of records confirmed the facility follows current policy in admitting residents into rest home care. The NM maintains a record of prospective residents and a NASC assessment from the Care Coordination Centre occurs prior to admission for the appropriate placement. When a potential resident is unsuitable for the facility, or there are no beds available, or the residents needs change to the point they are no longer suitable for the facility, a NASC assessment identifies this. The Care Coordination centre then organises an appropriate service alternative.

Standard 1.3.4: Assessment

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

FA The NM confirmed during interview that prior to admission, a NASC assessment is under taken to ensure the placement is appropriate, and the NM makes the final decision based on the assessment. The RN completes an appropriate assessment on admission to the facility. The assessment includes a pressure area risk assessment, falls risk assessment, continence assessment, nutritional assessment and, if required, a wound assessment.

An interRAI assessment is being completed on new admissions as verified in records reviewed and an updated care plan is completed based on the completed assessment. Resident, family/whanau input and appropriate allied health and community feedback is incorporated into the assessment. Reviews occur in a timely manner by the RN. If an issue arises within the evaluation period, an appropriate assessment tool is completed prior to the development


of a short term care plan. Examples reviewed show a consistent assessment and care planning process.

Standard 1.3.5: Planning

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

FA The facility RN develops the initial care plan following the interRAI assessment within time frames to safely meet the resident’s needs. Residents files reviewed verified the long term plan is completed within three weeks of admission. During interview the RN explained that when progress alters the RN will develop a short term care plan using appropriate assessment tools. Care staff during interview demonstrated knowledge of the care plan content.

Challenging behaviour reference includes specifics for challenging behaviours that are not restraint related and guidelines for staff to manage behaviours were in line with best practice.

Each care plan was complete, comprehensive and included interventions that reflected the resident’s goals and desired outcomes following the interRAI assessment. Residents and family/whanau confirmed their involvement in care planning and the review process. There was evidence of allied health interventions and this was confirmed during GP interview.

Standard 1.3.6: Service Delivery/Interventions

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

FA Policies are in place for continence management, management of challenging behaviours, pain management, pressure injury prevention management, personal cares, skin management, wound care, death of a resident and falls prevention. Links with other services were demonstrated through policies and assessment processes.

The facility’s RN documents appropriate interventions on the resident’s short term or long term care plan, based on completed prior assessments and the interRAI assessment tool. Clinical detail recorded in the residents individual progress notes and those sighted confirmed residents’ needs were met and service delivery was provided in a timely manner. This was verified during interviews with residents, family/whanau and staff.

GP assessments sighted were detailed on the medical clinical forms in the integrated resident’s files and the subsequent intervention included on the resident’s short term care plans. GP interview


confirmed interventions were timely and always completed by the facility staff.

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 A social activity profile including the resident’s personal history and interests were developed by the two activity coordinators in the rest home following admission to the facility in files reviewed. An activity plan was developed following completion of the resident’s long term care plan in the rest home.

Progress notes were observed to be completed weekly and report on progress relevant to the resident’s individual activity programme and social interactions. A daily activities attendance is recorded. The general activity programme includes the local shopping run, church services, newspaper reading, arts and crafts, outings, singing group visits, entertainers, sing a longs, exercises, word games and individual birthday celebrations as observed at audit.

Residents and family/whanau interviewed were happy with the content and variety of activities provided. The two activity co-ordinators meet monthly with a diversional therapist to discuss prior to the next month planned activities.

Encouragement has been given from the NM for the activities coordinators to undertake the diversional therapy course.

Standard 1.3.8: Evaluation

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

FA Care plan reviews are the responsibility of the RN. During interview the RN reported when progress is less than expected a short term care plan is developed and implemented. Evidence in files confirmed this occurs, including re-evaluation and if required transferring the issue to the long term care plan. Examples were sighted where this had occurred. Files reviewed verified care plans were completed at least six monthly and more often if progress alters.

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 A review of integrated files, resident, family/whanau interviews and GP interview provided evidence of referral to other health and disability services. During interview with the NM, examples were discussed and documentation reviewed of referrals to allied health services.


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 There are guidelines for the management of waste and hazardous substances, which are followed by staff. These include directions for housekeeping and laundry. Laundry is managed onsite and cleaning products are provided by an external contractor. This provider has material safety data sheets for all their products and these were current and matched all products used on site.

All cleaning and laundry chemicals, and those used by the maintenance person, are stored in locked storage areas. Staff have access to cleaning chemicals in labelled containers with instructions for use.

Staff have regular training in the use of the chemical products and in the management of waste and hazardous substances. This was evident in the review of personnel files and at interview with staff.

Personal protective equipment (PPE) is available to all staff in utility rooms, the laundry and on the cleaner’s trolley. Staff confirmed that they have ready access to adequate supplies of PPE at all times.

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 current building warrant of fitness expires 24 July 2016. Residents and family members interviewed during this audit reported that they find the environment is maintained to a good standard at all times and it is well presented. The facility has no additional rooms or alterations since the previous audit.

There is a regular system for the relevant testing, maintenance and calibration of electrical equipment and medical devices. This is maintained and current.

All outside areas were easily accessed from the facility. All are well maintained and provide an outside area for residents and visiting families to use.

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

FA The facility has all single rooms. There are no ensuites in bedrooms but sufficient bathroom and toilet rooms for all residents. There is a separate staff and a separate visitors’ toilet.


hygiene requirements. The ratio of toilets and bathing facilities are adequate given the guidelines for safe care which are utilised within the sector.

Standard 1.4.4: Personal Space/Bed Areas

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

FA There are fifteen single rooms. The smallest rooms meet the size requirements for the provision of rest home level care. Residents are able to move independently, or with the use of aids in their rooms. Residents have personal items and furniture in their rooms as they choose.

All rooms are appropriate for the needs of the residents.

Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining

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

FA There is one lounge and an adjoining dining room. The lounge and dining room are sufficiently spacious to accommodate residents and their family in private conversation as needed. There is a separate large spacious porch. Residents and families confirmed there are sufficient spaces for private conversations to occur and reported their satisfaction with the environment at the facility.

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 laundry is managed onsite. A staff member during interview demonstrated processes that reflect the facility’s policies and guidelines. Monitoring occurs through regular internal audits conducted by the nurse manager. The external cleaning and laundry products provider undertakes regular audits of the effectiveness of their products. Review of both confirms that the services are undertaken to an acceptable standard.

Residents and families interviewed during the audit stated that they were satisfied with cleaning and laundry services. During the two days on site the environment was observed to be well maintained, clean and odour free. Chemicals and cleaning products were stored securely when not in use. All products were named with original labels.

Standard 1.4.7: Essential, Emergency, And Security Systems

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

FA Staff members interviewed confirmed that they receive training in fire, emergency and security procedures. Records reviewed confirmed this occurs at orientation and annually.

There is a documented emergency plan, which covers processes for all emergencies. The managers were interviewed in relation to the


emergency response preparedness for the facility. Appropriate resources and equipment are in place in case of an emergency.

There are security procedures in place to lock external doors and this occurs at nightfall and are checked again during the night. According to the NZ Fire Service the approved evacuation plan for the facility remains current. The call bell system functions throughout the facility and was observed to be responded to in a timely manner.

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 rooms, including residents’ bedrooms, have large windows, which allow natural light in. There are windows in every room, which can be opened to provide ventilation. On the days of audit it was warm and the facility was comfortable inside. The rooms are maintained with good window coverings and thermostatically controlled heaters. Residents and family interviewed verify the facility is kept at a comfortable temperature all year round.

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 The infection control (IC) RN is the nurse manager and was interviewed. The job description for the infection control coordinator role is clearly defined. There are clear lines of accountability for infection control matters at the service through the committee and business meetings. The nurse manager attends these meetings, and provides a report on IC.

The annual review of the infection control programme has been conducted within the past 12 months.

The service has clear policies about staff, residents and visitors suffering from, or exposed to and susceptible to, infectious diseases. Staff reported that they do not come to work if they are unwell.

Notices are placed at entrances to ask visitors not to visit if they are unwell, or have been exposed to others who are unwell. There was sanitising hand gel throughout the service for residents, visitors and staff.

Standard 3.2: Implementing the infection control programme FA The IC nurse manager attends ongoing education. The nurse manager reported that the facility can access external advice from


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

the hospital IC consultant, the GP, DHB and Ministry of Health services as required. Infection control is discussed at the committee meetings and staff education occurs randomly as part of the audit process.

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 Northanjer Rest Home uses policies and procedures that were developed by a specialist infection prevention and control advisory service. Staff demonstrated good infection prevention and control practices reflective of policy. These have been designed to be fit for purpose for the small rest home environment.

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 provided by the nurse manager or the RN who has maintained her knowledge of current practice. The in-service education programme contained education and attendance sheets for lC education sessions. The service also utilises a NZ based online learning programme for staff. These sessions were referenced to current accepted good practice. Infection control practices are included in induction and orientation for all new staff.

Informal education is provided as required to residents. The RN gave examples of encouraging residents with fluids during the warmer months to prevent urinary infections.

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 The facility has clear lines of accountability for infection control matters through the committee meetings, and relevant information is provided by the nurse manager at these meetings. There have been five infections at the facility in the past three months, they have all been included in the monthly surveillance data and an analysis of trends is included. All have been isolated infections, with no trends identified, have been treated and resolved within accepted timeframes.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA A documented restraint and enabler use policy is in place and meets the standard requirements. At present there are no residents with either enablers or restraints in use at the facility. Staff interviewed demonstrated knowledge in enabler and restraints and


confirmed their training in relation to this.


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.

No data to display


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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