the willows rest home limited. current status: 05-feb-13 ... · the last audit with the exception...

The Willows Rest Home Limited.

CURRENT STATUS: 05-Feb-13.

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

GENERAL OVERVIEW

The Willows Home and Hospital is located in Otahuhu, South Auckland. At the time of audit there are 22 residents receiving care. Seventeen are receiving hospital level care and five are rest home level care. There are two residents who are aged less than 65 years of age. The clinical manager advises there have been no changes to the services or facility since the last audit with the exception of some bathroom renovations. The clinical manager was present at audit. She has worked in this facility for 12 years and been the clinical manager since 2007. The owner/manager is overseas at the time of the unannounced surveillance audit. The majority of human resources and quality and risk documentation is currently held by the owner/manager so was not on site or retrievable at audit. While staff and the clinical manager interviewed could describe systems and practices, where implementation of systems /processes could not be fully verified without these records, the criteria are noted to be partially attained and require improvement. At the last audit there were five areas identified as requiring improvement. Four of these areas have been addressed. At this audit there are 18 areas identified as requiring improvement in each of the following: ensuring privacy locks on communal bathroom facilities; the complaints register and associated documents was not available; ensuring documentation is made each shift by health care assistants; documenting the timeframes for residents' routine general practitioner reviews; ensuring care plans are sufficiently detailed; and ensuring care plans are evaluated in a timely manner. Two areas requiring improvement are identified for each of the following: human resources; medication management; and food and nutrition services. Six areas requiring improvement are identified in relation to implementing the quality and risk programme.

AUDIT SUMMARY AS AT 05-FEB-13

Standards have been assessed and summarised below:

Key

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

Indicator Description Definition

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

A number of shortfalls that require specific action to address

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

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

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

Consumer Rights Day of

Audit 05-Feb-13

Assessment

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


Organisational Management Day of

Audit 05-Feb-13

Assessment

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


Continuum of Service Delivery Day of

Audit 05-Feb-13

Assessment

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


Safe and Appropriate Environment Day of Audit

05-Feb-13

Assessment

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


Restraint Minimisation and Safe Practice Day of

Audit 05-Feb-13

Assessment

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

Standards applicable to this service fully attained

Infection Prevention and Control Day of

Audit 05-Feb-13

Assessment

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


The Willows Home and Hospital

The Willows Rest Home Ltd

Surveillance audit - Audit Report Audit Date: 05-Feb-13

Audit Report To: HealthCERT, Ministry of Health

Provider Name The Willows Rest Home Ltd

Premise Name Street Address Suburb City


16 Princess St Otahahu Auckland

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

Type of Audit Surveillance audit and (if applicable)

Date(s) of Audit Start Date: 05-Feb-13 End Date: 05-Feb-13

Designated Auditing Agency

The DAA Group Limited

Audit Team

Audit Team Name Qualification Auditor Hours on site

Auditor Hours off site

Auditor Dates on site

Lead Auditor XXXXXXXX RN, NZ 8086, Infection preventionist

8.00 4.00 05-Feb-13 to 05-Feb-13

Auditor 1 XXXXXXXX RCN,BA, Lead Auditor 8086 8.00 4.00 05-Feb-13 to 05-Feb-13

Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor

Peer Review Auditor XXXXXXXX

RN,BA,MBA NZQA 8086

2.00

Total Audit Hours on site 16.00 Total Audit Hours off site

(system generated) 10.00 Total Audit Hours 26.00

Staff Records Reviewed 1 of 13 Client Records Reviewed (numeric)

3 of 22 Number of Client Records Reviewed

using Tracer Methodology

2 of 3

Staff Interviewed 7 of 13 Management Interviewed (numeric)

1 of 2 Relatives Interviewed (numeric)

2

Consumers Interviewed 5 of 22 Number of Medication Records Reviewed

7 of 22 GP’s Interviewed (aged residential care and residential disability) (numeric)

1

Declaration

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

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

Dated this 25 day of February 2013

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

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

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

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

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

Services and Capacity Kinds of services certified

Hospital Care Rest Home Care

Residential Disability Care

Premise Name Total Number of Beds

Number of Beds Occupied on Day of Audit

Number of Swing Beds for Aged Residen-tial Care


28 22 7

Executive Summary of Audit

General Overview The Willows Home and Hospital is located in Otahuhu, South Auckland. At the time of audit there are 22 residents receiving care. Seventeen are receiving hospital level care and five are rest home level care. There are two residents who are aged less than 65 years of age. The clinical manager advises there have been no changes to the services or facility since the last audit with the exception of some bathroom renovations. The clinical manager was present at audit. She has worked in this facility for 12 years and been the clinical manager since 2007. The owner/manager is overseas at the time of the unannounced surveillance audit. The majority of human resources and quality and risk documentation is currently held by the owner/manager so was not on site or retrievable at audit. While staff and the clinical manager interviewed could describe systems and practices, where implementation of systems /processes could not be fully verified without these records, the criteria are noted to be partially attained and require improvement. At the last audit there were five areas identified as requiring improvement. Four of these areas have been addressed. At this audit there are 18 areas identified as requiring improvement in each of the following: ensuring privacy locks on communal bathroom facilities; the complaints register and associated documents was not available; ensuring documentation is made each shift by health care assistants; documenting the timeframes for residents' routine general practitioner reviews; ensuring care plans are sufficiently detailed; and ensuring care plans are evaluated in a timely manner. Two areas requiring improvement are identified for each of the following: human resources; medication management; and food and nutrition services. Six areas requiring improvement are identified in relation to implementing the quality and risk programme.

1.1 Consumer Rights Complaints are managed to meet policy requirements. At the time of audit there is one outstanding complaint which is not shown in the complaints register. This is an area requiring an improvement. Advanced directives sighted in three hospital and one rest home file review meet legislative requirements. This was an area identified for improvement in the previous audit and is now fully attained.

1.2 Organisational Management Clinical records are sighted to be dated, timed and the name and designation of the person making the entry noted. The area identified as requiring improvement at the last audit now meets the criterion. A new area requiring improvement is raised at this audit. The daily care review summary which is required to be completed by health care assistants each shift for every resident is not consistently being completed. The facility has an owner/manager with many years experience in aged care. She has owned the facility since 1999 and is supported by a nurse manager (registered nurse) who has overall responsibility for clinical care services. All incidents, accidents and untoward events are reported, recorded and evaluated. Residents' files reviewed and resident and family/whanau interviews confirm open disclosure is maintained. Corrective actions are shown on the monthly incident and accident evaluation forms. Policy identifies the process undertaken to monitor, analyse and report quality and risk. However, many processes could not be validated on the day of audit as the documentation was not on site. This has generated five areas for improvement related to implementation of quality processes, including the undertaking of audits, satisfaction surveys, the use of collected data to generate corrective actions, and the evaluation and reporting processes of data collected.

Aged related residential care (ARRC) requirements for D17.7b, D17.7e, D19.1b could not be verified on the day of audit and D19.4 could only be partially verified. Staffing levels and skill mixes are implemented to ensure residents' needs are met. Every shift is covered by a registered nurse. Human resources management processes identified in policy meet good practice standards and meet legislative requirements. Not all staff qualifications could be validated on the day of audit. There is very limited evidence of staff education; generating two required improvements. ARRC requirements D17.6, D17.7 and D17.8 could not be verified on the day of audit.

1.3 Continuum of Service Delivery Assessment tools are used by registered nurses to identify residents' care needs and these assessments are linked to individualised care plans. Care plans are not sufficiently detailed to identify residents' care needs. However, despite this care is being provided to meet individual resident's needs as these needs are being communicated via other methods, including shift handover. Evaluations of residents' progress in meeting the care plans is not occurring in the timeframes required to meet the provider's contract with Counties Manukau District Health Board (CMDHB) and is an area requiring improvement. One general practitioner (GP) provides services for all long term residents. The GP routinely visits one day a week and is otherwise on call. Currently the GP does not document that residents have been assessed as stable and suitable for routine three monthly reviews and this requires an improvement. An assessment is undertaken to identify each resident's interest, hobbies and preferred recreation activities. A range of activities are planned and provided for residents to meet these needs. Individual residents' dietary needs and food preferences are identified, communicated and met. Records are not available to verify the menu has been reviewed by a dietitian to ensure residents' nutritional needs are being met and kitchen policies and procedures and temperature monitoring records are also not available for review at audit. These are areas require improvement. There are policies and procedures related to medication management readily available for staff. Required improvements relate to ensuring medication standing orders are sufficiently documented, and records are available to verify appropriate monitoring of medication storage. While the clinical manager reports there are processes in place to assess staff competency in relation to medication management, the facility is unable to demonstrate that all staff who administer medications have been assessed as competent in the last twelve months and this is also an area requiring improvement.

1.4 Safe and Appropriate Environment The service has a current building warrant of fitness. Toilet and shower facilities sighted are in good condition but not all communal facilities have privacy locks or any form of identification to show they are in use. This is a required improvement. One area identified for improvement from the previous audit is fully attained. ARRC requirements are met for the criteria reviewed.

2 Restraint Minimisation and Safe Practice The service currently has no restraint in use. Policies and procedure clearly identify that enablers are voluntary and the least restrictive method to allow residents' independence. Staff interviews identify their knowledge and understanding of policy.ARRC requirements are met for these criteria.

3. Infection Prevention and Control There is an infection prevention and control programme which is appropriate to the service setting. The area identified as requiring improvement at the last audit now meets the criterion. Surveillance for residents who develop infections is occurring. Residents with infections are noted to be reported to the clinical manager. Health care assistants interviewed confirm they are advised in a timely manner of residents who develop infections. The process for analysing and monitoring overall infection rates and trends cannot be fully verified as records for 2012 and priorarecurrently held off site and are not accessible at audit. This is an area identified as requiring improvement.

Summary of Attainment

1.1 Consumer Rights

Attainment CI FA PA UA NA of Standard 1.1.1 Consumer rights during service delivery Not Applicable 0 0 0 0 0 1 Standard 1.1.2 Consumer rights during service delivery Not Applicable 0 0 0 0 0 4 Standard 1.1.3 Independence, personal privacy, dignity and respect Not Applicable 0 0 0 0 0 7 Standard 1.1.4 Recognition of Māori values and beliefs Not Applicable 0 0 0 0 0 7 Standard 1.1.6 Recognition and respect of the individual’s culture, values, and beliefs Not Applicable 0 0 0 0 0 2 Standard 1.1.7 Discrimination Not Applicable 0 0 0 0 0 5 Standard 1.1.8 Good practice Not Applicable 0 0 0 0 0 1 Standard 1.1.9 Communication FA 0 2 0 0 0 4 Standard 1.1.10 Informed consent FA 0 1 0 0 2 9 Standard 1.1.11 Advocacy and support Not Applicable 0 0 0 0 0 3 Standard 1.1.12 Links with family/whānau and other community resources Not Applicable 0 0 0 0 0 2 Standard 1.1.13 Complaints management PA Low 0 1 1 0 0 3

Consumer Rights Standards (of 12): N/A:9 CI:0 FA: 2 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Criteria (of 48): CI:0 FA:4 PA:1 UA:0 NA: 2

1.2 Organisational Management

Attainment CI FA PA UA NA of Standard 1.2.1 Governance FA 0 2 0 0 0 3 Standard 1.2.2 Service Management Not Applicable 0 0 0 0 0 2 Standard 1.2.3 Quality and Risk Management Systems PA Moderate 0 3 5 0 0 9 Standard 1.2.4 Adverse event reporting FA 0 2 0 0 0 4 Standard 1.2.7 Human resource management PA Low 0 2 2 0 0 5 Standard 1.2.8 Service provider availability FA 0 1 0 0 0 1 Standard 1.2.9 Consumer information management systems PA Low 0 0 1 0 0 10

Organisational Management Standards (of 7): N/A:1 CI:0 FA: 3 PA Neg: 0 PA Low: 2 PA Mod: 1 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.3 Continuum of Service Delivery

Attainment CI FA PA UA NA of Standard 1.3.1 Entry to services Not Applicable 0 0 0 0 0 5 Standard 1.3.2 Declining referral/entry to services Not Applicable 0 0 0 0 0 2 Standard 1.3.3 Service provision requirements PA Low 0 2 1 0 0 6 Standard 1.3.4 Assessment PA Moderate 0 0 1 0 0 5 Standard 1.3.5 Planning Not Applicable 0 0 0 0 0 5 Standard 1.3.6 Service delivery / interventions FA 0 1 0 0 0 5 Standard 1.3.7 Planned activities FA 0 1 0 0 0 3 Standard 1.3.8 Evaluation PA Moderate 0 1 1 0 0 4 Standard 1.3.9 Referral to other health and disability services (internal and external) Not Applicable 0 0 0 0 0 2 Standard 1.3.10 Transition, exit, discharge, or transfer Not Applicable 0 0 0 0 0 2 Standard 1.3.12 Medicine management PA Moderate 0 2 2 0 0 7 Standard 1.3.13 Nutrition, safe food, and fluid management PA Low 0 1 2 0 0 5

Continuum of Service Delivery Standards (of 12): N/A:5 CI:0 FA: 2 PA Neg: 0 PA Low: 2 PA Mod: 3 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


1.4 Safe and Appropriate Environment

Attainment CI FA PA UA NA of Standard 1.4.1 Management of waste and hazardous substances Not Applicable 0 0 0 0 0 6 Standard 1.4.2 Facility specifications FA 0 0 0 0 0 7 Standard 1.4.3 Toilet, shower, and bathing facilities PA Low 0 0 1 0 0 5 Standard 1.4.4 Personal space/bed areas Not Applicable 0 0 0 0 0 2 Standard 1.4.5 Communal areas for entertainment, recreation, and dining Not Applicable 0 0 0 0 0 3 Standard 1.4.6 Cleaning and laundry services Not Applicable 0 0 0 0 0 3 Standard 1.4.7 Essential, emergency, and security systems Not Applicable 0 0 0 0 0 7 Standard 1.4.8 Natural light, ventilation, and heating Not Applicable 0 0 0 0 0 3

Safe and Appropriate Environment Standards (of 8): N/A:6 CI:0 FA: 1 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


2 Restraint Minimisation and Safe Practice

Attainment CI FA PA UA NA of Standard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6 Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3 Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2 Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 0 6 Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3 Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 0 1

Restraint Minimisation and Safe Practice Standards (of 6): N/A: 5 CI:0 FA: 1 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


3 Infection Prevention and Control

Attainment CI FA PA UA NA of Standard 3.1 Infection control management FA 0 1 0 0 0 9 Standard 3.2 Implementing the infection control programme Not Applicable 0 0 0 0 0 4 Standard 3.3 Policies and procedures Not Applicable 0 0 0 0 0 3 Standard 3.4 Education Not Applicable 0 0 0 0 0 5 Standard 3.5 Surveillance PA Low 0 1 1 0 0 8

Infection Prevention and Control Standards (of 5): N/A: 3 CI:0 FA: 1 PA Neg: 0 PA Low: 1 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0


Total Standards (of 50) N/A: 29 CI: 0 FA: 10 PA Neg: 0 PA Low: 7 PA Mod: 4 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0

Total Criteria (of 219) CI: 0 FA: 25 PA: 18 UA: 0 N/A: 2

Corrective Action Requests (CAR) Report

Provider Name: The Willows Rest Home Ltd Type of Audit: Surveillance audit Date(s) of Audit Report: Start Date:05-Feb-13 End Date: 05-Feb-13 DAA: The DAA Group Limited Lead Auditor: XXXXXXXX Std Criteria Rating Evidence Timeframe 1.1.13 1.1.13.3 PA

Low Finding: The Nurse Manager stated there is one Health and Disability Commissioner complaint of a historic nature (2011) that remains open. No evidence of this could be located on site. A telephone conversation with the owner/manager, who is in Australia on holiday at the time of audit, confirms this information is at her house. She confirmed a site visit has been undertaken by a representative of the Health and Disability Commissioner and the service is awaiting a written report Action: Ensure the complaints register is maintained to include all complaints, dates and actions taken.

6 months

1.2.3 1.2.3.1 PA Low

Finding: A blank master meeting minute template sighted in policy identifies quality issues and required improvements are to be discussed. This could not be verified on the day of audit as no meetings minutes are on site. They are at the owner/manager's home and she is in Australia on holiday at the time of audit. Action: Ensure documented evidence is available on site to identify the implementation of the quality and risk systems stated in policy.

6 months

1.2.3 1.2.3.5 PA Low

Finding: A blank annual audit schedule sighted in the quality folder covers all key components of service but no audit results are available on the day of audit to verify this. Limited data collection was sighted but only for select dates, such as falls data for July, August, September 2012 only. No meeting minutes could be located. This information is at the owner/manager's house and she is away on holiday. Action: Ensure evidence of how key components of service delivery are linked to the quality a management system are available on site.

6 months

1.2.3 1.2.3.6 PA Low

Finding: One month’s data collection is identified for infection control and three months falls data sighted but no documented evidence can be located on site related to the analysis, or evaluation of results. Meeting minutes are not available to verify communication of results to staff. Action: Ensure quality improvement data that is collected is analysed and evaluated and that the results are communicated as required.

6 months

1.2.3 1.2.3.7 PA Low

Finding: The service has a process in place to measure achievement against the quality and risk management plan. This could not be verified on the day of audit as none of the completed tools were available on site. Data is at the Owner/managers house and she is on holiday in Australia. Action: Ensure policy and processes are followed to measure achievement against the quality and risk management plan.

6 months

1.2.3 1.2.3.8 PA Low

Finding: Corrective action planning could only be evidenced for incidents and accidents. No other documented data was available on site on the day of audit. Action: Ensure corrective action plans are put in place for all areas that require improvement to meet policy and to identify implementation of action.

6 months

1.2.7 1.2.7.2 PA Low

Finding: As no current staff files are available on the day of audit not all staff qualifications can be validated. The qualifications of contracted health professionals are not available for sighting at audit. Action: Ensure all professional qualifications are validated to include scope of practice for service providers.

6 months

1.2.7 1.2.7.5 PA Low

Finding: Only very limited educational evidence can be found on the day of audit. The education plan could not be located. Individual staff education records are kept in staff files which are not on site on the day of audit. Action: Ensure a system to identify, plan, facilitate and record ongoing education is undertaken.

6 months

1.2.9 1.2.9.1 PA Low

Finding: The daily care review summary which is required to be completed by caregivers each shift is not consistently being completed. In two of three files reviewed at audit up to ten shifts have not been documented during a two week period. Action: Ensure the daily care review summary is documented by care staff on a shift by shift basis.

Six months

1.3.3 1.3.3.3 PA Low

Finding: One out of three residents whose file reviewed at audit has not been seen monthly by the general practitioner. There is no documentation present in the resident's clinical file to confirm the resident has been assessed as stable and suitable for three monthly reviews as required by the ARRC contract. The calendar previously used to monitor residents' routine medical reviews is no longer in use and the 'doctor review book' is not consistently completed. Action: Ensure residents are reviewed by the general practitioner at least monthly unless the general practitioner has assessed the resident as stable and suitable for three monthly reviews and the general practitioner has documented this in the residents notes.

Six months

1.3.4 1.3.4.2 PA Moderate

Finding: The care plans are in three of three residents' files sighted at audit are insufficiently documented. Missing from two residents' files are sufficiently detailed strategies to manage episodes of challenging behaviour. One resident has had five falls in five weeks. This resident's care plan has not been reviewed to ensure all strategies to minimise risks have been identified. Short term care plans are not being developed when residents are identified as having an infection. Action: Ensure care plans are sufficiently detailed to identify the short term and long term care needs of residents are identified.

Three months

1.3.8 1.3.8.2 PA Low

Finding: Evaluation of residents' progress towards meeting goals and the components of the care plan have not occurred within the last six months for three of three residents whose files are reviewed at audit. This is in variance to the requirements of the ARRC contract. Action: Ensure residents' progress towards meeting their goals and care plan are evaluated at least six monthly or sooner when clinically indicated as required by the ARRC contract.

Six months

1.3.12 1.3.12.1 PA Moderate

Finding: The medication standing orders are signed by the general practitioner but the document is undated. The standing orders are insufficiently documented and do not consistently include indications for use and maximum dose limits for medications included. Records verifying the medication refrigerator temperature is being monitored and is within accepted parameters is not available for sighting at audit. Action: 1) Ensure standing orders are sufficiently detailed in line with current best practice guidelines and that these have been reviewed and signed by the general practitioner within the last twelve months. 2) Ensure that records are available / accessible to verify that the refrigerator used to store medications is being monitored at an appropriate frequency and is within the required temperature range.

Three months

1.3.12 1.3.12.3 PA Moderate

Finding: Records are not available for review at audit to verify that all staff administering medications have been assessed as competent to do so in the last twelve months. Action: Ensure that records are available / accessible to demonstrate all staff administering medications have been assessed as competent to do so every twelve months.

Three months

1.3.13 1.3.13.1 PA Low

Finding: Records are not available for review at audit to verify that the current menu in use at The Willows Home and Hospital has been assessed by a dietitian as being suitable to meet the nutritional needs of residents. The cook advises the menu has been reviewed by the dietitian however records to verify this are reported to be held by the owner/manager who is currently overseas. Action: Ensure records are available / accessible to verify that the menu has been reviewed by the dietitian and the menu is appropriate to meet the nutritional needs of residents.

Six months

1.3.13 1.3.13.5 PA Low

Finding: 1) Policies / procedures or staff orientation records in relation to food services are not available for review at audit. 2) Staff advise the temperature of the refrigerator and freezer in the kitchen are checked on a two weekly basis only. Records verifying these checks and that the temperatures are within the required range are not available for review at audit as these records are currently at the owner / manager's home and she is overseas. Action: 1) Ensure that policies and procedures are available / accessible for staff on all required components of kitchen and food services. 2) Ensure that relevant temperatures are being monitored in a timely manner in the kitchen and that temperatures are within required parameters. 3) Ensure that required records and other applicable documentation is readily available on site.

Six months

1.4.3 1.4.3.1 PA Low

Finding: Not all communal toilet and bathroom areas have locks to allow privacy or any system to show if the area is engaged or vacant as required to meet policy. Action: Ensure toilet and bathroom areas allow residents' privacy to undertake personal cares

6 months.

3.5 3.5.7 PA Low

Finding: Surveillance for residents who develop infections is occurring. Infection surveillance data / documentation for 2012, including results, analysis, corrective action planning (where applicable) and communication of results is not available for review at audit. Action: Ensure records are available / accessible to verify infection control data is analysed, evaluated, and the results communicated to relevant personnel in a timely manner.

Six months

Continuous Improvement (CI) Report

Provider Name: The Willows Rest Home Ltd Type of Audit: Surveillance audit Date(s) of Audit Report: Start Date:05-Feb-13 End Date: 05-Feb-13 DAA: The DAA Group Limited Lead Auditor: XXXXXXXX

1. HEALTH AND DISABILITY SERVICES (CORE) STANDARDS OUTCOME 1.1 CONSUMER RIGHTS 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, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. STANDARD 1.1.9 Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication.

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

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

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

Open disclosure principles are implemented as described in policy. This is confirmed during interview with five of five residents (four hospital and one rest home level care) and two of two family/whanau members. If staff have any concerns they document this in residents' files and family/whanau are informed as sighted in four of four file reviews (three hospital and one rest home). Incidents and accident forms sighted identify that family/whanau are informed as appropriate. The Cultural Safety Policy identifies acceptable communication methods for different cultures, such as do not make direct eye contact with Maori. Staff education related to communication was undertaken in August 2012 and 14 staff attended. Interviews with seven of seven staff (two RNs, three health care assistants, one kitchen hand and a cook) confirm their knowledge and understanding of good communication techniques, such as body language. The service has three residents with English as a second language. The Nurse Manager (NM) confirms that there are staff who speak all required languages and that family/whanau assist when required. Interpreter services would be used as required to meet policy requirements. ARRC requirements met.

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

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

Finding Statement Corrective Action Required:

Timeframe:

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



Timeframe:

STANDARD 1.1.10 Informed Consent Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

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


How is achievement of this standard met or not met? Attainment: FA Staff interviews with two RNs and the NM confirm advance directives are acted upon where valid. Documentation shows that the resident can only sign an advance directive if they are deemed competent by the GP. If they do not have an advanced directive the decision is made by a medical practitioner as described in policy. This in confirmed in four of four file reviews. One of the four residents' files reviewed also has a living will which is identified on the care plan. This was an area identified for improvement in the previous audit and is now fully attained.

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



Timeframe:

STANDARD 1.1.13 Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld.

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


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

Policy identifies consumers' rights to make a complaint. Seven of seven staff interviews confirm they understand the process and implement policy as required. The complaints process is discussed as part of the entry to the facility and complaints forms are available from the desk at the entrance of the facility. Interviews with five of five residents and two of two family/whanau members confirm their knowledge and understanding of the complaints process. The complaints register sighted contains compliments and complaints related to 2012 only. All complaints sighted are closed off. The service has one open complaint with the Health and Disability Commissioner which could not be verified at the time of audit as the information is held off site. This is an area identified for improvement. There are many more compliments than complaints sighted. ARRC requirements are met.

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



Timeframe:

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

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

The complaints register sighted identifies that there were three complaints of a minor nature in 2012. These complaints are all completed and actions taken are recorded. The Nurse Manager stated there is one Health and Disability Commissioner complaint of a historic nature (2011) that remains open. No evidence of this could be located on site. A telephone conversation with the owner/manager, who is in Australia on holiday at the time of audit, confirms this information is at her house. She confirmed a site visit has been undertaken by a representative of the Health and Disability Commissioner and the service is awaiting a written report.

Finding Statement The Nurse Manager stated there is one Health and Disability Commissioner complaint of a historic nature (2011) that remains open. No evidence of this could be located on site. A telephone conversation with the owner/manager, who is in Australia on holiday at the time of audit, confirms this information is at her house. She confirmed a site visit has been undertaken by a representative of the Health and Disability Commissioner and the service is awaiting a written report. Corrective Action Required: Ensure the complaints register is maintained to include all complaints, dates and actions taken.

Timeframe: 6 months

OUTCOME 1.2 ORGANISATIONAL MANAGEMENT Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. STANDARD 1.2.1 Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

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



The organisation's Business Plan is used to inform staff of the future scope and direction of the service. It is reviewed annually by the owner/manager and changed when required. The organisation’s mission statement and philosophy are identified. The Quality and Risk Plan sets out the actions to be taken to meet the business planning goals. Interviews with two of two family/whanau and five of five residents (four hospital and one rest home) confirm that the services offered meet all their needs. The owner/manager was not available on the day of audit but she has owned the facility since 1999 and has worked in the aged care field for many years. The NM's job description identifies her authority, accountability and responsibility for the provision of clinical services. She is a registered nurse (RN) with a current practising certificate as sighted. She has worked in aged care for over eight years and as NM for six years. She confirmed that she undertakes education related to aged care to meet Nursing Council of New Zealand and contractual requirements. This could not be verified in writing the day of audit as the NM's staff file is not on site. ARRC requirements are met.

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



Timeframe:

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



Timeframe:

STANDARD 1.2.3 Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

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


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

Policies and procedures sighted are up-to-date, aligned with current good practice and service delivery and put in place to meet legislative requirements. They are managed by XXXXXXXXX and new updates sent to the facility are placed into the policy folders as required. Obsolete documents are kept electronically and the hard copy destroyed.

The risk register sighted covers all aspects of service delivery. Risks are described under the major headings of care services, external, cleaning and laundry and kitchen. Documentation sighted related to incidents and accidents identifies that new risks identified have a corrective action put in place. One example identifies that a toilet chair was removed following an incident. Interviews with seven of seven staff (two RNs, three health care assistants, one kitchen hand and one cook), confirm they understand the quality and risk management system. They confirm any corrective actions and/or quality improvements that are required are discussed at staff meetings. No meeting minutes were available on the day of audit and this cannot be verified. There is a clearly set out quality and risk management system with identified goals stated in policy. Policy identifies key components of service delivery shall be explicitly linked to the quality management system and that there is a process in place to measure achievement of the implemented plan. No documentation was available on the day of audit to verify this process occurs. One month’s data collection is identified for infection control and three months falls data sighted but no documented evidence can be located on site related to the analysis, or evaluation of results. Meeting minutes are not available to verify communication of results to staff. Corrective actions sighted for issues that arise from incidents and accidents. Staff verbalise instances where quality improvements have been put in place, such as the use of buckets to place individual resident's dirty laundry in and the change to incident and accident forms and reporting methods. Only limited data collection could be evidenced. With the exception of incident and accident data, no documentation was available on the day of audit to show that data collected is analysed or evaluated and that results are shared with staff and residents as appropriate. Owing to lack of documented evidence being available on the day of audit to verify the systems stated in policy are followed there are five areas identified for improvement. ARRC requirements for D17.7b, D17.7e, D19.1b are not met and D19.4 is partially met.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low There is a clearly set out quality and risk management system with identified goals stated in policy. The policy manual is available to all staff. Interviews with seven of seven staff confirm they understand the quality processes and that corrective actions are discussed at staff meetings. A blank master meeting minute template sighted in policy identifies quality issues and required improvements are to be discussed. This could not be verified on the day of audit as no meetings minutes are on site. They are at the owner/manager's home and she is in Australia on holiday at the time of audit.

Finding Statement A blank master meeting minute template sighted in policy identifies quality issues and required improvements are to be discussed. This could not be verified on the day of audit as no meetings minutes are on site. They are at the owner/manager's home and she is in Australia on holiday at the time of audit. Corrective Action Required: Ensure documented evidence is available on site to identify the implementation of the quality and risk systems stated in policy.

Timeframe: 6 months

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



Timeframe:

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



Timeframe:

Criterion 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system. This shall include, but is not limited to:

(a) Event reporting;

(b) Complaints management;

(c) Infection control;

(d) Health and safety;

(e) Restraint minimisation.

Audit Evidence Attainment: PA Risk level for PA/UA: Low Policy identifies that key components of service delivery shall be explicitly linked to the quality management system. This is monitored via ongoing audits, data collection, and discussion in staff meetings. A blank annual audit schedule sighted in the quality folder covers all key components of service but no audit results are available on the day of audit to verify this. Limited data collection was sighted but only for select dates, such as falls data for July, August, September 2012 only. No meeting minutes could be located. This information is at the owner/manager's house and she is away on holiday.

Finding Statement

A blank annual audit schedule sighted in the quality folder covers all key components of service but no audit results are available on the day of audit to verify this. Limited data collection was sighted but only for select dates, such as falls data for July, August, September 2012 only. No meeting minutes could be located. This information is at the owner/manager's house and she is away on holiday. Corrective Action Required: Ensure evidence of how key components of service delivery are linked to the quality and management system is available on site.

Timeframe: 6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low There is limited evidence of quality data collection. An analysis of monthly incident and accident data indicates corrective actions are taken accordingly for any issues that arise. One example relates to the correct use of shower chairs to ensure resident safety. One month’s infection control data collection is sighted for January 2013. Interviews with staff confirm that the analysed and evaluated data results are discussed at monthly staff meetings. Three months falls data sighted but no documented evidence can be located on site related to the analysis, or evaluation of results. Meeting minutes are not available to verify communication of results to staff. Interviews with seven of seven staff, five of five residents (four hospital and one rest home) and two of two family/whanau members confirm they are kept fully informed.

Finding Statement One month’s data collection is identified for infection control and three months falls data sighted but no documented evidence can be located on site related to the analysis, or evaluation of results. Meeting minutes are not available to verify communication of results to staff. Corrective Action Required: Ensure quality improvement data that is collected is analysed and evaluated and that the results are communicated as required.

Timeframe: 6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The Quality Assurance Policy states the following strategies/tools are utilised to ensure quality: -Audits covering all areas of service and care -exception reporting -resident and staff satisfaction surveys -staff and resident meetings -staff annual appraisals -ongoing evaluation of training and education Seven of seven staff interviews and the Nurse Manager confirm that all the above processes are undertaken.

Finding Statement The service has a process in place to measure achievement against the quality and risk management plan. This could not be verified on the day of audit as none of the completed tools were available on site. Data is at the Owner/managers house and she is on holiday in Australia. Corrective Action Required: Ensure policy and processes are followed to measure achievement against the quality and risk management plan.

Timeframe: 6 months

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low Corrective actions sighted for issues that arise from incidents and accidents. Staff verbalise instances where quality improvements have been put in place, such as the use of buckets to place individual resident's dirty laundry in and the change to incident and accident forms and reporting methods. Corrective action planning could only be evidenced for incidents and accidents. No other documented data was available on site on the day of audit.

Finding Statement Corrective action planning could only be evidenced for incidents and accidents. No other documented data was available on site on the day of audit. Corrective Action Required: Ensure corrective action plans are put in place for all areas that require improvement to meet policy and to identify implementation of action.

Timeframe: 6 months

Criterion 1.2.3.9 Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk;

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



Timeframe:

STANDARD 1.2.4 Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner.

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



Policy and procedures implemented identify that statutory and/or regulatory obligations related to essential notification reporting of issues, such as serious events or infection control outbreaks, are understood by the service. This is confirmed during interview with three of three RNs (one being the NM who is the infection control coordinator). Adverse events are recorded via incident and accident forms. The forms sighted for 2012/2013 show that corrective actions are put in place as required. For example, a resident sustained a scratch from a toilet chair and the chair was replaced. Incident and accident forms have been updated as a quality improvement. From October 2012 a new field has been put on the forms which identify residents' blood pressure, respirations, oxygen saturation, temperature, pulse, limb check and pain evaluation. The forms are completed in duplicate. One copy goes into the resident's file and the other copy is faxed to the GP if a resident is involved. The form is then placed in a file containing all incident and accident forms. During interview the GP confirms this process is undertaken. Interviews with seven of seven staff confirm they document all adverse, unplanned or untoward events. A review of three hospital and one rest home resident file, interviews with two of two family/whanau members and five of five residents (four hospital and one rest home) confirm they are informed of any concern of accidents.

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



Timeframe:

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



Timeframe:

STANDARD 1.2.7 Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

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



Good employment practices which meet legislative requirements are identified in policy. The appointment of appropriate service providers is identified in Human Resources policies. Job descriptions are sighted for the nurse manager, RN, EN, health care assistant, kitchen hand, cook, cleaner, laundry and activities coordinator. Only one staff member file was available on site the day of audit. This is for a staff member who is no longer employed. A review of the file identifies all processes shown in policy related to employment are followed. The orientation/induction process covers the essential components of service provision. Key policies are included in the orientation pack, such as confidentiality, complaints, advocacy, the Age Related Care Health (ARCH) code of ethics and incident and accidents. This is confirmed by a telephone interview undertaken with an RN who works night duty. She has only been employed for one month. She stated her orientation involved being mentored on all rostered shifts by a senior RN. She said working some day shifts allowed her to understand each resident and identify their care levels. Current staff members' files are not available on the day of audit. The two RNs on duty were able to produce their annual practising certificates but no other qualifications (including of contracted health professionals) could be validated. Staff interviews confirm that regular education is undertaken and that all clinical staff hold current first aid certificates. The NM stated there is a yearly education calendar but it could not be located on the day of audit. Education records sighted for onsite education from July to October 2012. This shows that staff attendance is very good and that a range of topics are discussed. The NM said education is undertaken in blocks as described in the ARCH education documents sighted. Two areas are identified for improvement related to not being able to verify education or validation of professional qualification. ARRC requirements D17.6, D17.7 and D17.8 could not be verified on the day of audit.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low Two RNs on duty hold current annual practising certificates. As no current staff files are available on the day of audit not all staff qualifications can be validated. Records related to contracted health professionals qualifications are not available for review at audit.

Finding Statement As no current staff files are available on the day of audit not all staff qualifications can be validated. The qualifications of contracted health professionals are not available for sighting at audit. Corrective Action Required: Ensure all professional qualifications are validated to include scope of practice for service providers.

Timeframe: 6 months

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



Timeframe:

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



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The NM stated during interview that there is an annual plan in place for staff ongoing education. This includes off site and in-service education. The education plan cannot be located during audit. Records of individual staff education are reported by the nurse manager to be maintained in individual staff files which are not available for review at audit. Staff interviews confirm they are asked if there are any specific educational areas they would like included. Seven of seven staff interviews confirm they are happy with the education provided and that it relates to the roles they undertake. Interviews with two of two family/whanau members and five of five residents (four hospital and one rest home) indicate that services are provided in a safe and effective manner and that all their needs are met.

Finding Statement Only very limited educational evidence can be found on the day of audit. The education plan could not be located. Individual staff education records are kept in staff files which are not on site on the day of audit. Corrective Action Required: Ensure a system to identify, plan, facilitate and record ongoing education is undertaken.

Timeframe: 6 months

STANDARD 1.2.8 Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

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



The Staffing Levels and Skill Mix Policy is implemented by the service. A review of eight weeks of staff rosters identifies that the service ensures that staff numbers shown are maintained by replacing staff for annual leave and sick leave. The skills mix identifies that all shifts are covered by a registered nurse. The NM stated that if additional staff is required owing to an increase in resident acuity levels, more clinical staffing hours are allocated. This is confirmed during staff interviews, including a RN who works night duty. All clinical care is overseen by the NM. Staff retention is very good; one RN has been working at The Willows Home and Hospital for 21 years, three health care assistants have worked there for 17,16 and 11 years respectively. The kitchen hand has been there for 6 years. The cook said she has worked at the facility for over 15 years but had a break and has been back for two years. Interviews with two of two family/whanau members, five residents (four hospital and one rest home) and observation on the day of audit identify that care is delivered in a safe and effective manner by experienced staff. Residents confirm all their needs are met. ARRC requirements are met.

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



Timeframe:

STANDARD 1.2.9 Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

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


How is achievement of this standard met or not met? Attainment: PA Low An area for improvement was identified at the last audit for criterion 1.2.9.6. This has been included at this audit in 1.2.9.1 (highly relevant criterion). At audit clinical records are sighted to be dated, timed and the name and designation of the person making the entry noted. A new area for improvement is raised at this audit. The daily care review summary which is required to be completed by caregivers each shift for every resident is not consistently being completed. In all three files reviewed at audit there are shifts where no documentation is recorded. In two of three files reviewed at audit up to ten shifts have not been documented during a two week period

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low An area for improvement was identified at the last audit for criterion 1.2.9.6. This has been included at this audit in 1.2.9.1 (highly relevant criterion). At audit clinical records are sighted to be dated, timed and the name and designation of the person making the entry noted. A new area for improvement is raised at this audit. The daily care review summary which is required to be completed by caregivers each shift for every resident is not consistently being completed. In all three files reviewed at audit there are shifts where no documentation is recorded. In two of three files reviewed at audit up to ten shifts have not been documented during a two week period.

Finding Statement The daily care review summary which is required to be completed by caregivers each shift is not consistently being completed. In two of three files reviewed at audit up to ten shifts have not been documented during a two week period. Corrective Action Required: Ensure the daily care review summary is documented by care staff on a shift by shift basis.

Timeframe: Six months

OUTCOME 1.3 CONTINUUM OF SERVICE DELIVERY Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. STANDARD 1.3.3 Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

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



The assessment, planning, provision of care and evaluation of care is conducted by a RN in consultation with the resident / family, medical and care staff. Three of three residents' files reviewed (one rest home and two hospital level of care) indicate that assessments and care planning is conducted by a RN. The two RNs sighted at audit have current practising certificates which are sighted. Medical assessments and reviews are conducted by the facility general practitioner. Health care assistants provide the majority of personal care to the residents. During staff interviews, three of the caregivers interviewed have worked at the facility for between 11 and 17 years. The cook has worked in the facility for an accumulated total of 14 years. The health care assistant’s in-service education programme (sighted) for 2012 contains relevant education for the service setting. Care is planned and coordinated by registered nurses. The GP routinely visits weekly and sooner when clinically required and to ensure new admissions are seen within two days of arrival. The GP confirms he is available 24 hours a day, seven days a week (24/7) via phone for staff if they are concerned about a resident. The GP confirms that the RNs follow up on requests made by him and he cannot recall a time when his instructions have not been carried out. The GP advises when he reviews patients it is very rare for him to be surprised by the resident's presenting condition as the RNs are normally very good and communicating changing residents' needs to him in a timely manner. An area for improvement is identified relating to ensuring the GP documents that residents are stable and suitable for three monthly GP review (as required by the ARRC contract). All seven residents' medication records sighted verify the GP has reviewed the resident’s medications within the past three months as required by the ARCC contract. There is a handover between each shift. The RN on the finishing shift provides a verbal handover to the ongoing RN and caregivers. The four health care assistants interviewed and one RN interviewed confirm the handovers are effective at communicating residents' needs. Changes in care, incidents / adverse events, infections and medication changes are all discussed during the handover. In addition RNs have a communication diary where key messages are also communicated (sighted).

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



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low Three of three residents' files are reviewed at audit. None have documented evaluations of progress towards meeting the care plan and goals within the last six months in variance to the requirements of the ARRC contract. This is raised as an area for improvement in criterion 1.3.8.2 Tracer one: Resident receiving hospital level care XXXXXX This information has been deleted as it is specific to the health care of a resident. Tracer two: Resident requiring rest home level care. XXXXXX This information has been deleted as it is specific to the health care of a resident. All seven residents whose medication records reviewed at audit contain evidence of medication reviews occurring by the GP within the previous three months.

Finding Statement One out of three residents whose file reviewed at audit has not been seen monthly by the general practitioner. There is no documentation present in the resident's clinical file to confirm the resident has been assessed as stable and suitable for three monthly reviews as required by the ARRC contract. The calendar previously used to monitor residents' routine medical reviews is no longer in use and the 'doctor review book' is not consistently completed. Corrective Action Required: Ensure residents are reviewed by the general practitioner at least monthly unless the general practitioner has assessed the resident as stable and suitable for three monthly reviews and the general practitioner has documented this in the resident’s notes.


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



Timeframe:

STANDARD 1.3.4 Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

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


How is achievement of this standard met or not met? Attainment: PA Moderate Care plans present in three of three files reviewed at audit are insufficiently detailed and do not provide sufficient guidance for staff in relation to managing individual resident’s challenging behaviour, falls and infections. This is identified as an area that continues to require improvement.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Moderate The area identified as requiring improvement at the last audit remains as an area requiring improvement. The care plans are in three of three residents' files sighted at audit are insufficiently documented. Missing from two residents' files are sufficiently detailed and individualised strategies to manage episodes of challenging behaviour. The hospital level care resident audited has had five falls in five weeks. This resident's care plan has not been reviewed to ensure all strategies to minimise risks have been identified. Despite this health care assistants are able to articulate changes that have been made to how they provide care to attempt to minimise falls risks. Two of two residents who have been diagnosed with recent infections do not have a short term care plans developed in relation to their changing care needs. The RN and CM interviewed confirm this is an oversight.

Finding Statement The care plans are in three of three residents' files sighted at audit are insufficiently documented. Missing from two residents' files are sufficiently detailed strategies to manage episodes of challenging behaviour. One resident has had five falls in five weeks. This resident's care plan has not been reviewed to ensure all strategies to minimise risks have been identified. Short term care plans are not being developed when residents are identified as having an infection. Corrective Action Required:

Ensure care plans are sufficiently detailed to identify the short term and long term care needs of residents are identified.

Timeframe: Three months

STANDARD 1.3.6 Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

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


How is achievement of this standard met or not met? Attainment: FA There are sufficient supplies of dressing equipment and continence aids to meet the resident’s needs (sighted and confirmed at interview with two of two caregivers and the RN). Five of five residents and two of two family members interviewed express satisfaction with the care that they or their relative receives at the facility and report that a high standard of care is provided. Where residents have changing care needs there is evidence of this being communicated to the general practitioner in a timely manner for three of three residents whose files are reviewed. Despite care plans not being sufficiently detailed, residents are receiving the required care for infections, dietary needs, for skin issues and following falls as resident care needs are being effectively communicated via other methods, including shift handover.

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



Timeframe:

STANDARD 1.3.7 Planned Activities Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service.

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


How is achievement of this standard met or not met? Attainment: FA The activities coordinator (AC) also works as a health care assistant. There are allocated hours provided for organisation and provision of the activities programme. The AC advises an assessment, which includes identification of residents' interests, hobbies and social needs, is undertaken as a component of the admission process and this is sighted in three of three residents' files reviewed. This form is completed with input from the resident and their family. The AC advises that based on this, individual activity plans are developed and sighted in three of three residents' files reviewed at audit. All are dated as having been redone in January 2013. The AC advises information for individual plans is then combined to form the overall activity programme. This ensures that options are available to meet each resident’s individual needs. The activities plan sighted at audit includes a range of news and current affairs activities, crafts, games, outings, beautician and nail care, and sing-a-longs / music. The AC plans individual one on one activities where this is needed to assist the resident socialising. All three residents interviewed and two of two family members interviewed confirm the activities available are appropriate and they join in activities of their choosing. The AC has a cupboard where activities supplies are kept (sighted).

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



Timeframe:

STANDARD 1.3.8 Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

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



If a resident is not responding to the services or interventions being delivered, or their health status changes, then this is discussed with the GP (confirmed at interview with the GP) and changes to care planned and implemented. Where antibiotics have been prescribed these are sighted to be administered and the course completed. Additional fluids are provided where applicable. Care plans are not always updated and / or short term care plans are not always developed in relation to short term care needs, including development of infections. This is raised as an area for improvement in criterion 1.3.4.2. Two residents are noted to be receiving nutritional supplements as the residents are noted to have reduced appetite and dietary intake. Two of two caregivers interviewed confirm they provide small meals and snacks regularly as well as the nutritional drink. There is daily monitoring of residents' bowel patterns and laxatives and other interventions given when required.

ARRC requirements are not met for all criterion audited.

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.

Audit Evidence Attainment: PA Risk level for PA/UA: Low The area identified as requiring improvement at the last audit remains as an area requiring improvement. Evaluation of residents' progress towards meeting goals and the components of the care plan have not occurred within the last six months for three of three residents whose files are reviewed at audit. This is in variance to the requirements of the ARRC contract. The RN and the clinical manager at audit confirm this is an area that requires further work.

Finding Statement Evaluation of residents' progress towards meeting goals and the components of the care plan have not occurred within the last six months for three of three residents whose files are reviewed at audit. This is in variance to the requirements of the ARRC contract. Corrective Action Required: Ensure residents' progress towards meeting their goals and care plan are evaluated at least six monthly or sooner when clinically indicated as required by the ARRC contract.


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



Timeframe:

STANDARD 1.3.12 Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

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



A policy and procedure provides a framework for medication management. Medication is stored in a locked room. The key is carried by a RN. Photographs are used to identify residents and tablet medication is ordered via robotic packs. Medication reconciliation is sighted to be occurring. Areas requiring improvement identified at audit includes ensuring records are available to verify monitoring is occurring of the medication refrigerator and that it is within required range, and ensuring medication standing orders are sufficiently documented. Records verifying all nursing staff who administer medications have been assessed as competent to do so in the last twelve months are not available for sighting at audit. The clinical manager (CM) advises health care assistants do not administer medications. There is a policy which provides a framework for residents to self-administer medications and this policy is sighted at audit. The CM and RN interviewed advice there are currently no residents who are self-administering medications. Medication prescriptions are individually signed by the prescriber. Sample signatures of the prescriber and the staff administering medications are maintained. Where medications are discontinued a date is noted or alternatively the course of treatment specified at the time the prescription is initiated. Records in controlled drugs registers are detailed and meet accepted practices. All five residents and two family members interviewed confirm they are kept well informed of changes made to medications. The residents advise staff tell them what is being administered each time medication is given; this practice is observed at audit. Not all ARRC contract requirements are met for criterion audited.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Moderate There is a policy which provides a framework for medication management (dated 18 June 2010 and sighted). The organisation now used robotic packs instead of Medico blister packs. A review of seven residents' medication charts and seven residents' robotic packs demonstrates medications are being ordered, supplied and administered as prescribed. Where a resident refuses a medication this is documented on the medication record. During audit the clinical manager was observed undertaking the medication round. A trolley was pre-prepared with a jug of fluid, cups and spoons to ensure medications can be administered without being handled. Medications are stored in a locked cupboard /room, the key is held by the RN. Medications are removed from the robotic roll by the RN and placed in a designated tray in alphabetical order for ease of review prior to the scheduled administration time. Medications are kept within the visual sight of the CM at all times and photographs used to verify the identity of residents prior to the administration of medications. Medications are signed for once administered. Allergies are noted as being assessed on all seven resident medication records sighted and all seven medication records are documented to have been reviewed by the GP within the last three months as required by the ARRC contract. Medication reconciliations are sighted to be occurring. Controlled drugs (CD) are ordered for named residents. A CD register is maintained and contains clear documentation. All entries are legible and signed by a RN and one other. At audit a caregiver observed verifying the medication order, CD count / balance and the administration of the medication. The medication standing orders are signed by the general practitioner but the document is undated. The standing orders are insufficiently documented and do not consistently include indications for use and maximum dose limits for medications included. This is an area requiring improvement. Records verifying the medication refrigerator temperature is being monitored and is within accepted parameters is not available for sighting at audit. The CM advises testing is undertaken by the owner's son who confirmed via telephone interview that fortnightly testing is being undertaken and all records are held by the owner / manager who is away overseas at the time of audit. This is also an area requiring improvement.

Finding Statement The medication standing orders are signed by the general practitioner but the document is undated. The standing orders are insufficiently documented and do not consistently include indications for use and maximum dose limits for medications included.

Records verifying the medication refrigerator temperature is being monitored and is within accepted parameters is not available for sighting at audit. Corrective Action Required: 1) Ensure standing orders are sufficiently detailed in line with current best practice guidelines and that these have been reviewed and signed by the general practitioner within the last twelve months. 2) Ensure that records are available / accessible to verify that the refrigerator used to store medications is being monitored at an appropriate frequency and is within the required temperature range.


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

Audit Evidence Attainment: PA Risk level for PA/UA: Moderate The clinical manager (CM) advises only registered nurse administer medications. The CM advises there is a competency assessment form which is used to assess RN's competence in relation to medication management. These records are reported to be in the staff personnel files which are at the home of the owner /manager who is overseas at the time of audit. The RN interviewed could not remember having her competency for medication management assessed internally and states her practices have been observed in the past as a component of external audits. The area identified as requiring improvement at the last audit remains as an area requiring improvement.

Finding Statement Records are not available for review at audit to verify that all staff administering medications have been assessed as competent to do so in the last twelve months. Corrective Action Required: Ensure that records are available / accessible to demonstrate all staff administering medications have been assessed as competent to do so every twelve months.


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



Timeframe:

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



Timeframe:

STANDARD 1.3.13 Nutrition, Safe Food, And Fluid Management A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

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



There are processes in place to identify and communicate residents' dietary needs and food and beverage likes and dislikes. This occurs at admission and subsequently if the resident's need changes. At interview the cook advises there are two residents who are being provided with nutritional supplements to optimise the residents' nutritional needs. The names of diabetic residents are well known to the kitchen staff. Health care assistants are observed assisting residents to eat where required. Five of five residents interviewed and two family members confirm the food provided meets the residents' needs. The cook advises the menu in use has been reviewed by the dietitian around the time of the last audit. Records are not available for review at audit to verify that the current menu in use at The Willows Home and Hospital has been assessed by a dietitian as being suitable to meet the nutritional needs of residents. Policies and procedures, staff training records and temperature monitoring forms in relation to food and nutrition services are not available for review at audit as these are at the owner /manager's home and she is overseas. This is an area requiring improvement. Not all ARRC contract requirements are met for criteria audited.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The cook advises the menu in use has been reviewed by the dietitian around the time of the last audit. Records are not available for review at audit to verify that the current menu in use at The Willows Home and Hospital has been assessed by a dietitian as being suitable to meet the nutritional needs of residents.

Finding Statement

Records are not available for review at audit to verify that the current menu in use at The Willows Home and Hospital has been assessed by a dietitian as being suitable to meet the nutritional needs of residents. The cook advises the menu has been reviewed by the dietitian however records to verify this are reported to be held by the owner/manager who is currently overseas. Corrective Action Required: Ensure records are available / accessible to verify that the menu has been reviewed by the dietitian and the menu is appropriate to meet the nutritional needs of residents.


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



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The kitchen is clean and tidy and audit. Food is covered in the refrigerator and items are dated. Dry good are in sealed packets in the pantry or in storage containers which are labelled with the date the product is opened. Policies / procedures related to kitchen processes are not available for sighting at audit. A caregiver advises the information is provided to new staff as a component of the orientation programme. Staff orientation records in relation to food services are not available for review at audit. The cook advises the temperature of the refrigerator and freezer in the kitchen is checked by the owner / managers son. During telephone interview the owner/ managers son advises temperatures are checked on a two weekly basis only. Records verifying these checks and that the temperatures are within the required range are not available for review at audit as these are at the owner / manager's house and she is overseas.

Finding Statement 1) Policies / procedures or staff orientation records in relation to food services are not available for review at audit. 2) Staff advise the temperature of the refrigerator and freezer in the kitchen are checked on a two weekly basis only. Records verifying these checks and that the temperatures are within the required range are not available for review at audit as these records are currently at the owner / manager's home and she is overseas. Corrective Action Required:

1) Ensure that policies and procedures are available / accessible for staff on all required components of kitchen and food services. 2) Ensure that relevant temperatures are being monitored in a timely manner in the kitchen and that temperatures are within required parameters. 3) Ensure that required records and other applicable documentation is readily available on site.


OUTCOME 1.4 SAFE AND APPROPRIATE ENVIRONMENT Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3. STANDARD 1.4.3 Toilet, Shower, And Bathing Facilities Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

ARC E3.3d ARHSS D15.3c


How is achievement of this standard met or not met? Attainment: PA Low There are adequate numbers of accessible toilet and shower facilities conveniently located throughout the facility. Two bedrooms have full ensuites, ten bedrooms have a shared ensuite between two rooms (five ensuites), 15 rooms have a toilet and hand basin. Communal toilet and shower facilities located in each wing do not all have a form of identification or privacy locks to ensure residents' privacy when undertaking personal cares. This is an area for improvement. Interviews with five of five residents did not raise any concerns related to privacy. One area identified for improvement in the previous audit has been fully attained.

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low The area identified for improvement in the previous audit related to the toilet seat in an ensuite being chipped and a hole in the hand basin has been addressed (previous criterion 1.3.4.3). The ensuite has been refurbished. Not all communal toilet and bathroom areas have locks to allow privacy or any system to show if the area is engaged or vacant as required to meet policy. This is a new required improvement.

Finding Statement Not all communal toilet and bathroom areas have locks to allow privacy or any system to show if the area is engaged or vacant as required to meet policy . Corrective Action Required: Ensure toilet and bathroom areas allow residents' privacy to undertake personal cares

Timeframe:

6 months.

2. HEALTH AND DISABILITY SERVICES (RESTRAINT MINIMISATION AND SAFE PRACTICE) STANDARDS OUTCOME 2.1 RESTRAINT MINIMISATION STANDARD 2.1.1 Restraint minimisation Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


How is achievement of this standard met or not met? Attainment: FA The service has no restraint in use. This is confirmed by the restraint register sighted and during interview with seven of seven staff and the NM. Policy clearly states that enablers shall be voluntary and the least restrictive option to promote or maintain resident independence. Policy identifies that the service operates a restraint free environment whenever possible. Staff confirm their knowledge and understanding of safe restraint and enabler use should it be required.

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



Timeframe:

3. HEALTH AND DISABILITY SERVICES (INFECTION PREVENTION AND CONTROL) STANDARDS STANDARD 3.1 Infection control management There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service.

ARC D5.4e ARHSS D5.4e


How is achievement of this standard met or not met? Attainment: FA The infection control programme is dated as being reviewed in February 2012. The programme includes details of the components of the infection prevention and control programme, including surveillance for residents with infections, education / orientation, policy and procedure review, outbreak management, monitoring and advisory role. The programme is appropriate to the service setting. The area identified as requiring improvement at the last audit now meets the criterion.

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



Timeframe:

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.



Surveillance for residents who develop infections is occurring at this facility. The surveillance programme includes: - symptomatic urinary tract infections - respiratory tract infections - skin and wound infections - scabies - gastroenteritis - eye infections Definitions of infection are documented.

Two of three residents' files sighted at audit are identified as having infections within the last three months. These are noted to have been reported through the infection surveillance programme. Data for 2012 infection surveillance programme is not available for review at audit as it is reported to be at the owner /manager's home. January 2012 surveillance data summary is sighted. The CM advises the information is discussed at staff meetings. Minutes are not available for review at audit. Three of three caregivers interviewed confirm being advised in a timely manner of residents who have infections and the required interventions / treatment. This initially occurs via shift handover.

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



Timeframe:

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

Audit Evidence Attainment: PA Risk level for PA/UA: Low Two of three residents' files sighted at audit are identified as having infections within the last three months. These are noted to have been reported through the infection surveillance programme. Data for the 2012 infection surveillance programme, including analysis and trends is not available for review at audit as it is reported to be at the owner /manager's home. January 2012 surveillance data summary is sighted. The CM advises the information is discussed at staff meetings. Minutes are not available for review at audit. Three of three health care assistants (HCAs) interviewed confirm being advised in a timely manner of residents who have infections and the required interventions / treatment. This initially occurs via shift handover. The HCA's are able to identify the names of residents who have been diagnosed with infections in the past month. The information provided is congruent with the surveillance summary list sighted for January 2013.

Finding Statement Surveillance for residents who develop infections is occurring. Infection surveillance data / documentation for 2012, including results, analysis, corrective action planning (where applicable) and communication of results is not available for review at audit. Corrective Action Required: Ensure records are available / accessible to verify infection control data is analysed, evaluated, and the results communicated to relevant personnel in a timely manner.


the willows rest home limited. current status: 05-feb-13 ... · the last audit with the exception...

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