certificaiton audit summary · web viewcameron house rest home limited current status: 14 november...

Cameron House Rest Home Limited

Current Status: 14 November 2012

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 and NZS8134.3:2008) on the audit date(s) specified.

General overview

Cameron House provides rest home level of care for up to 20 residents. On the day of the audit there were 15 residents. Families and residents interviewed expressed satisfaction with the service provided.

All the shortfalls identified in the previous certification audit around resuscitation forms, quality management programme, conducting a review of some policies and procedures; conducting performance appraisals for all staff as per policy; conducting care plan evaluations in a timely manner; reviewing aspects of medication management; provide safe food handling training for kitchen staff; ensuring all electrical appliances are tested and tagged; and reviewing of the infection control programme and corresponding policies and procedures, have been addressed.

This audit identified that improvements are required around the completion of short term care plans and an aspect of medication management.

Audit Summary as at 14 November 2012

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

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

Indicator Description Definition

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 as at 14 November 2012

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

Standards applicable to this service fully attained.

Organisational Management as at 14 November 2012

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 as at 14 November 2012

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

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

Safe and Appropriate Environment as at 14 November 2012

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 as at 14 November 2012

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


Infection Prevention and Control as at 14 November 2012

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.


HealthCERT Aged Residential Care Audit Report (version 3.9)

Introduction

This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health.

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

It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.

Audit Report

Legal entity name: Manis Aged Care Ltd

Certificate name: Cameron Courts Rest Home

Designated Auditing Agency: Health & Disability Auditing NZ

Types of audit: Certification

Premises audited: Cameron Courts Rest Home, 57 Grigg St, Ashburton

Services audited: Rest Home

Dates of audit: Start date: 14 October 2013 End date: 14 October 2013

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: 31

Audit Team

Lead Auditor XXXXXX Hours on site

7 Hours off site

5

Other Auditors XXXXXX Total hours on site

7 Total hours off site

5

Technical Experts Total hours on site

Total hours off site

Consumer Auditors Total hours on site

Total hours off site

Peer Reviewer XXXXXX Hours 2

Sample Totals

Total audit hours on site 14 Total audit hours off site 12 Total audit hours 26

Number of residents interviewed 6 Number of staff interviewed 8 Number of managers interviewed

Number of residents’ records reviewed

6 Number of staff records reviewed 5 Total number of managers (headcount)

3

Number of medication records reviewed

12 Total number of staff (headcount) 27 Number of relatives interviewed 4

Number of residents’ records reviewed using tracer methodology

1 Number of GPs interviewed

Declaration

I, XXXXXX, Director of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of the Designated Auditing Agency named on page one of this report (the DAA), an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of the DAA Yes

b) the DAA has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes

c) the DAA has developed the audit summary in this audit report in consultation with the provider Yes

d) this audit report has been approved by the lead auditor named above Yes

e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes

f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable

g) the DAA has provided all the information that is relevant to the audit Yes

h) the DAA Auditing Agency has finished editing the document. Yes

Dated Tuesday, 26 November 2013

Executive Summary of Audit

General OverviewCameron Courts provides rest home level of care for up to 31 residents. On the day of the audit there were 31 rest home residents. There are two owners, one of whom is an enrolled nurse. The owners are supported by a clinical nurse manager (registered nurse), a part time registered nurse and a contracted qualtiy management consultant.There are improvements required around the trend analysis of incident/accident data, the evaluation of consumer/next of kin surveys, aspects of care planning, medication management, chemical safety and the anaylsis of infection control data.

Outcome 1.1: Consumer RightsCameron Courts endeavours to ensure that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. The service functions in a way that complies with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Information about the code of rights and services is easily accessible to residents and families. Policies are implemented to support residents’ rights. Information on informed consent is included in the admission agreement and discussed with residents and relatives. Informed consent processes are followed and residents' clinical files reviewed evidence informed consent is obtained. Care plans accommodate the choices of residents and/or their family/whānau. Complaints and concerns are actively managed and well documented.

Outcome 1.2: Organisational ManagementCameron Courts has two owners, one of whom is an enrolled nurse (EN). Clinical oversight is provided by two part time registered nurses (one is appointed clincial manager). The owner/managers, clainial nurse manager and registered nurse (RN) are responsible for the implementation of the quality and risk management programme. The quality and risk management programme includes service philosophy , goals and a quality planner. Key components of the quality management system link to three monthly quality meetings and staff meetings. Residents and family satisfaction surveys are completed annually. Health and safety policies, systems and processes are implemented to manage risk. Discussions with residents and families identified that they are fully informed of changes in health status. Improvements required where the consumer/next of kin survey is collated and analysed for potential corrective actions and incident accident data is collated and analysed.There is an orientation programme that provides new staff with relevant information for safe work practice and an in-service education programme that exceeds eight hours annually and covers relevant aspects of care and support. Human resource policies are in place including a documented rationale for determining staffing levels and skill mixes. There is a roster that provides sufficient and appropriate coverage for the effective delivery of care and support.

Outcome 1.3: Continuum of Service DeliveryThe service has admission and entry policies and procedures. Needs assessment approval is required prior to entry for rest home level of care. Service information is made available in the facility brochures and booklets. Residents/relatives confirmed the admission process and the admission agreement was discussed with them. RN's are responsible for each stage of service provision. The sample of residents' records reviewed provide evidence that the RN has

completed an initial assessment and care plan on admission. There is evidence of resident/family participation in the development of the care plans. Long term care plans are reviewed at least six monthly. Risk assessments are completed where a clinical risk is identified. There is an improvement required around long term care plans, and interventions to support management of clinical conditions and short term needs. Care plans demonstrate service integration and guide all staff in cares. The General Practitioner (GP) examines the resident within 48 hours of admission and three monthly thereafter. Resident files include notes by the GP and allied health professionals. There are policies and procedures for medicine management. Registered nurses and caregivers responsible for the administration of medicines complete annual medication competencies and education. The medicines records reviewed include documentation of allergies and sensitivities. The GP reviews the medication records three monthly. There is an improvement around the prescribing of ‘as required’ medications, checking of controlled drugs and review of standing orders. The activities programme is facilitated by a Diversional Therapist (DT). The activities programme provides varied options and activities that meet the consumer group. Each resident has an individualised activity plan. Links with the community are maintained and van outings are arranged on a regular basis. All food is cooked on site. Residents' nutritional needs are identified and accommodated with alternative choices provided. Meals are well presented, homely and the menu plans have been reviewed by a dietitian. Food and fridge temperatures are recorded. Hot food temperatures are monitored. The cooks are qualified and all staff have undertaken food safety and hygiene training.

Outcome 1.4: Safe and Appropriate EnvironmentThere are waste management policies and procedures for the safe disposal of waste and hazardous substances including sharps. Chemicals are labelled and stored appropriately on delivery. There is an improvement required around the storage and labelling of chemical bottles in the cleaning area. The interior of the home is clean and tidy. There is appropriate protective equipment and clothing for staff. The building holds a current warrant of fitness and holds a current approved evacuation scheme approval. Residents interviewed state the facility is warm, comfortable and has a homely atmosphere. Planned internal and external maintenance schedules are in place. Equipment is serviced annually. Hot water temperatures in resident areas are monitored monthly. External areas are safe for residents and family members.

Outcome 2: Restraint Minimisation and Safe PracticeDocumentation of policies and procedures and staff training demonstrate residents are experiencing services that are the least restrictive. There were no residents requiring restraint or enabler use at the facility on audit day.

Outcome 3: Infection Prevention and ControlInfection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. These reflect the needs of the service and are readily available for staff access. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and also as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon.There is an improvement required as currently analysis of infection control data collected is not completed

Summary of Attainment

CI FA PA Negligible PA Low PA Moderate PA High PA Critical

Standards 0 37 0 5 2 0 0

Criteria 0 86 0 5 2 0 0

UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited

Standards 0 0 0 0 0 5 0 1

Criteria 0 0 0 0 0 8 0 0

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

HDS(C)S.2008 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.

PA Low

HDS(C)S.2008 Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

PA Low Finding statements and corrective actions have not been developed for resident/consumer survey conducted in April 201

Ensure that surveys are evaluated with identified issues managed through corrective actions process.

90

HDS(C)S.2008 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.

PA Low


HDS(C)S.2008 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.

PA Low Trending and analysis of monthly incident and accident data collected by the service is not evidenced completed

Ensure trend analysis of incident and accident data collected occurs.

90

HDS(C)S.2008 Standard 1.3.5: Planning

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

PA Low

HDS(C)S.2008 Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.

PA Low Two of the six long term care plans in residents files sampled did not reflect the current needs of the resident. i) One resident is an insulin dependent diabetic and there is no reference in the long term care regarding the need for insulin to manage the diabetes or a diabetic management plan. ii) A second resident is a medication controlled diabetic. There is no reference to the long term care plan that the resident is diabetic. The GP instructions on admission of resident is to monitor monthly blood sugar levels. The instruction is not included in the long term care plan and there is no blood

Ensure long term care plans reflect the residents current medical condition, clinical management, and monitoring instructions are followed

90


sugar monitoring monthly.

HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions

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

PA Low

HDS(C)S.2008 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.

PA Low i) There are no interventions documented on the short term care plan for sacral pressure area. The short term care plan has not been evaluated. RN advised the pressure area has healed.ii) One resident has lost 3kg in two months. The reviewed long term care plan September 2013 states the resident’s goal is to maintain weight between 60-65kg. The resident is now 56kg. There is no short term care plan in place. The nutritional assessment is not dated and there is no acknowledgment of weight loss.

Ensure short term care plans are completed when there is an acute change in the residents condition/needs.

60

HDS(C)S.2008 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.

PA Moderate

HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to

PA Moderate i) CD liquids are not checked weekly. ii) The

(i)Ensure weekly checks of Controlled drugs include

7


manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.

standing orders have not been reviewed since 2010. iii) Four of 12 medication charts sampled did not have a prescribed indication for use of prn medication.

liquids. (ii) Ensure standing orders are reviewed annually. (iii) Ensure PRN medications have an indication for use prescribed on the medication chart

HDS(C)S.2008 Standard 1.4.6: Cleaning And Laundry Services

Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

PA Moderate

HDS(C)S.2008 Criterion 1.4.6.3 Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.

PA Moderate The cleaner’s trolley is not stored in a locked area. Two bottles of chemicals on the cleaning trolley are unlabelled.

There is a requirement to store the cleaning trolley safely. Chemical bottle are required to be labelled with manufacturer labels.

30

HDS(IPC)S.2008 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.

PA Low

HDS(IPC)S.2008 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.

PA Low Infection control data is collected monthly, however there is no evidence of issues/trend patterns analysis being completed.

Ensure that trend analysis of the infection control data collected occurs.

90

Continuous Improvement (CI) Report

Code Name Description Attainment Finding

NZS 8134.1:2008: 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 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1)Consumers receive services in accordance with consumer rights legislation.

ARC D1.1c; D3.1a ARHSS D1.1c; D3.1a

Attainment and Risk: FA

Evidence:

The Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) is incorporated into care. Discussions with three health care assistants, the enrolled nurse who is one of the two owners, and clinical nurse manager identified their familiarity with the code of rights. A review of six of six care plans, three monthly staff meetings confirms that the service functions in a way that complies with the code of rights. Training around the code of rights and complaints was last provided in January 2013 with 11 staff attending. The auditors noted respectful attitudes towards residents on the day of the audit.

Criterion 1.1.1.1 (HDS(C)S.2008:1.1.1.1)Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.


Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2)Consumers are informed of their rights.

ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii


Evidence:

D6,2 and D16.1b.iii The information pack provided to residents on entry includes how to make a complaint, code of rights pamphlet and advocacy information. Code of rights leaflets are available at the front entrance of the service. Code of rights posters are on the walls in the service. Client right to access advocacy services is identified for residents and advocacy service leaflets are available at the entrance to the service. If necessary, staff will read and explain information to residents as stated by the two caregivers and enrolled nurse interviewed. Information is also given to next of kin or enduring power of attorney (EPOA) to read to and discuss with the resident in private. Six of six residents and four family members interviewed were able to describe their rights and advocacy services particularly in relation to the complaints process. Discussions with three health care assistants, clinical nurse manager and owner/manager identified they are aware of the right for advocacy and how to access and provide advocacy information to residents if needed.

Criterion 1.1.2.3 (HDS(C)S.2008:1.1.2.3)Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.2.4 (HDS(C)S.2008:1.1.2.4)Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3)Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4


Evidence:

D3.1b, d, f, i The service has a philosophy that promotes dignity and respect, quality of life, involving residents in decisions about their care, consultation, encouraging wellness and facilitating mixing with others. The home's mission focuses on providing the highest possible standard of care with respect and dignity. The three health care assistants and clinical nurse manager described care being provided with dignity and respect. The diversional therapist is an integral part of the service and also treats residents with respect and a positive attitude to the activities programme.D14.4 There are clear instructions provided to residents on entry regarding responsibilities of personal belongings in their admission agreement. Personal belongings are to be documented and included in resident files if the resident choses to complete this. D4.1a Resident files reviewed (six of six) identified that cultural and /or spiritual values, individual preferences are identified and these are discussed as part of the three monthly staff meetings as issues are identified as described by the clinical nurse manager.The service has policies and procedures that are aligned with the requirements of the Privacy Act and Health Information Privacy Code. Residents' support needs are assessed using a holistic approach. The initial and on-going assessment includes gaining details of people’s beliefs and values with the clinical nurse manager interviewed stating that the care plans are completed with the resident and family ( where appropriate). Interventions to support beliefs and values are identified and evaluated. Residents are addressed by their preferred name and this is documented in six of six files reviewed. A policy is available for the staff to assist them in managing resident practices and/or expressions of intimacy and sexuality in an appropriate and discreet manner with strategies documented if required to manage any inappropriate behavior. There is a policy that covers abuse and neglect and staff have completed training last in January 2013.

D5.4q Discussions with three health care assistants confirm that residents are able to access spiritual support of their preference and the diversional therapist ensures that there is a church service monthly. During the resident admission, spirituality and religion are discussed and documented. Six of six residents and four family members interviewed are able to confirm that their privacy and dignity was respected and staff were observed to be respectful on the day of the audit.Education on spirituality was conducted 21-Mar-13 with 13 staff attending.An audit on personal safety and privacy was conducted in April 2013 with no corrective actions identified.

Criterion 1.1.3.1 (HDS(C)S.2008:1.1.3.1)The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.2 (HDS(C)S.2008:1.1.3.2)Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.6 (HDS(C)S.2008:1.1.3.6)Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.7 (HDS(C)S.2008:1.1.3.7)Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.


Evidence:

Finding:

Corrective Action:


Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4)Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i


Evidence:

A3.2 The Maori health plan includes a description of how they will achieve the requirements set out in A3.1 (a) to (e)The service has policies to support practice i.e. guidelines for the provision of culturally safe services for Maori residents and cultural awareness. Maori health plan and ethnicity awareness policy/procedure includes health definitions, concepts and ideology, Maori models of health - te whare tapa wha, cultural safety, treaty of Waitangi, protocol for mourning and care of Maori before and after death. Treaty of Waitangi training last conducted in March 2011.D20.1i: The plan includes contact details for local Maori, Maori health services and local marae. Discussions with three health care asssistants and the clinical nurse manager and a registered nurse confirms that they are aware of the need to respond appropriately to individual cultural difference. There are currently no residents who identify as Maori. Education on Cultural Safety and Nursing Pratice from a Maori Perspective was conducted on 25-Jan-13 with 15 staff attending. The service has developed a link with Hokonui Runanga.An audit on cultural safety and spiritual beliefs was conduted in May 2013, no corrective actions were required.

Criterion 1.1.4.2 (HDS(C)S.2008:1.1.4.2)Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.3 (HDS(C)S.2008:1.1.4.3)The organisation plans to ensure Māori receive services commensurate with their needs.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.5 (HDS(C)S.2008:1.1.4.5)The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6)Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d


Evidence:

D3.1g The service provides a culturally appropriate service by assessing resident needs on admission, a social profile is gathered as is psycho-social needs, spiritual requirements and family/significant other links. Cultural awareness training conducted in March 2011 and August 2012.D4.1c Six care plans reviewed included the residents social, spiritual, cultural and recreational needs.There are extensive policies to support cultural and spiritual needs. There is a values and beliefs section in the care plan. Residents interviewed (six) stated that they felt the service did the best they could to meet their individual values and beliefs and praised the service for support provided. Residents indicated that they are consulted and involved in the identification of spiritual religious and or cultural beliefs. Relatives interviewed (four) stated that they felt they were valued, consulted and kept informed.

Criterion 1.1.6.2 (HDS(C)S.2008:1.1.6.2)The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs.


Evidence:

Finding:

Corrective Action:


Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7)Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e


Evidence:

There are policies and procedures to ensure consumers are not subjected to discrimination, coercion, harassment or sexual harassment. These policies are supported by the code of residents’ rights policy, complaints policy, abuse and neglect policy - all of which are implemented. The policies include support for the resident throughout their engagement with the service. Residents interviewed (six) did not feel as if they were discriminated against. Staff training provided around code of rights in January 2013. Education on the ageing process occurred in April 2013 with nine staff attending.

Criterion 1.1.7.3 (HDS(C)S.2008:1.1.7.3)Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8)Consumers receive services of an appropriate standard.

ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c


Evidence:

A2.2 Services are provided at Cameron Courts that adhere to the health and disability services standards. The service has policies and procedures and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards including those standards relating to the Health and Disability Services (Safety) Act 2001. The policies and procedures are provided by an external

management consultant who provides regular updates and reviews of the quality programme.There is an implemented quality improvement programme with an audit schedule implemented, review of complaints, management of incidents and accidents, documentation of any restraint or enabler use and documentation of infections with infection control surveillance completed.D1.3 All approved service standards are adhered to.D17.7c There are implemented medication competencies for caregivers and the nurses and a training programme implemented. The clinical nurse manager, registered nurse and enrolled nurse (owner) interviewed described being able to access education through the CDHB and NZACA.There are clear ethical and professional standards and boundaries within job descriptions. Six of six residents and four family members interviewed spoke very positively about the care provided using phrases such as “lovely staff”, “provide good care” and a “homely place and feel”.

Criterion 1.1.8.1 (HDS(C)S.2008:1.1.8.1)The service provides an environment that encourages good practice, which should include evidence-based practice.


Evidence:

Finding:

Corrective Action:


Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9)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


Evidence:

D12.1 Non-Subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so. The Cameron Courts information booklet is provided to residents on entry and this comprehensively includes information around rights, complaints, abuse and

neglect etc.D16.1b.ii The residents and family are informed prior to entry of the scope of services and any items they have to pay that is not covered by the agreement.D16.4b Four relatives state that they are always informed when their family members health status changes. Incident forms reviewed in 2013 indicate that family are informed of the event and if not, the reason is noted.D11.3 The information pack is available in large print and advised that this can be read to residents. The service has policies and procedures available for access to interpreter services noting that there are no residents requiring interpreting services.There is an open disclosure policy, a complaints policy and an incident and accident policy and staff have had training around the code of rights including advocacy and open disclosure in January 2013. Six of six residents and four family members interviewed state they were welcomed on entry and were given time and explanation about services and procedures. Resident meetings occur three monthly and family are invited to this. The owner/ manager and clinical nurse manager have an open-door policy.

Criterion 1.1.9.1 (HDS(C)S.2008:1.1.9.1)Consumers have a right to full and frank information and open disclosure from service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.9.4 (HDS(C)S.2008:1.1.9.4)Wherever necessary and reasonably practicable, interpreter services are provided.


Evidence:

Finding:

Corrective Action:


Standard 1.1.10: Informed Consent (HDS(C)S.2008:1.1.10)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


Evidence:

Interviews with three health care assitants who have had experience working both morning, afternoon and night shifts, confirmed that they were familiar with the requirements to obtain informed consent. They described asking residents what clothing they wished to wear, choice of food on menu, and if they were ready for personal care requirements. The health care assistants interviewed were aware of the residents’ right to decline or refuse. Informed consent education was conducted in march 2013 with 14 staff attending. There is a resuscitation policy and resuscitation decision form that is completed appropriately. Resuscitation orders are completed for residents who are competent to make the decision.D13.1 there were six admission agreements sighted and all six had been signed.D3.1.d Discussion with four family members identified that the service actively involves them in decisions that affect their relatives lives.An audit on informed consent was completed in March 2013 with no corrective actions identified.

Criterion 1.1.10.2 (HDS(C)S.2008:1.1.10.2)Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.4 (HDS(C)S.2008:1.1.10.4)The service is able to demonstrate that written consent is obtained where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.7 (HDS(C)S.2008:1.1.10.7)Advance directives that are made available to service providers are acted on where valid.


Evidence:

Finding:

Corrective Action:


Standard 1.1.11: Advocacy And Support (HDS(C)S.2008:1.1.11)Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f


Evidence:

D4.1d; Discussion with four family and six residents identified that the service provides opportunities for the family/EPOA to be involved in decisions and they state that they have been informed about advocacy services.ARC D4.1e, The resident file includes information on resident’s family/whanau and chosen social networks. Resident’s access to advocacy services is identified with information available at the entrance to the service. Information provided to residents prior to entry to the service includes advocacy information. Staff are aware of the right for advocacy and how to access and provide advocacy information to residents if needed and training has been provided last in January 2013.The clinical nurse manager described informing residents of advocacy services.

Criterion 1.1.11.1 (HDS(C)S.2008:1.1.11.1)Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.


Evidence:

Finding:

Corrective Action:


Standard 1.1.12: Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12)Consumers are able to maintain links with their family/whānau and their community.

ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f


Evidence:

D3.1h Discussion with the clinical nurse manager registered nurse, three health are assistants, six residents and four family members identified that residents are supported and encouraged to remain involved in the community and external groups. Family are encouraged to be involved with the service and care. Relatives interviewed stated they could visit at any time. The service has open visiting hours.D3.1.e Interview with the activity coordinator described how residents are supported and encouraged to remain involved in the community and external groups. The facility activity programme encourages links with the community. Activities programmes include opportunities to attend events outside of the facility including activities of daily living e.g. shopping. Entertainers are included in the rest home activities programme.

Criterion 1.1.12.1 (HDS(C)S.2008:1.1.12.1)Consumers have access to visitors of their choice.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.12.2 (HDS(C)S.2008:1.1.12.2)Consumers are supported to access services within the community when appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.1.13: Complaints Management (HDS(C)S.2008:1.1.13)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


Evidence:

The service has complaints management policies and procedures in place.D13.3h. A complaints procedure is provided to residents and their family within the information pack at entry.Complaint forms are available at the entrance to the building. Staff are aware of the complaints process and to whom they should direct complaints. The complaint process is in a format that is readily understood and accessible to residents/family. Six of six residents and three of three family members interviewed confirm they are aware of the complaints process and they would make a complaint to the manager of other staff if necessary. There is a complaints register in place. A complaints folder is maintained with the documentation related to each complaint including sign off of the complaint. Three complaints have been received to date in 2013. All evidence that the complaints have been resolved to the complainant’s satisfaction.An audit on complaints management was conducted in March 2013 with no corrective actions required.

Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1)The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3)An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.


Evidence:

Finding:

Corrective Action:


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 (HDS(C)S.2008:1.2.1)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


Evidence:

The facility has two owners who reside in Auckland. One of the oweners is an enrolled nurse and the other has a background in finance.The owners are supported by a clnical nurse manager and contracted quality management consultant.The facility provides rest home level care for 31 resdients. Occupancy on the day of audit was 31 residents.ARC,D17.3di (rest home), the owner/manger (enrolled nurse) and clinical nurse manager(RN) have maintained at least eight hours annually of professional development activities related to managing a rest home.

Criterion 1.2.1.1 (HDS(C)S.2008:1.2.1.1)The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3)The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.


Evidence:

Finding:

Corrective Action:


Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2)The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers.

ARC D3.1; D19.1a; E3.3a ARHSS D3.1; D4.1a; D19.1a


Evidence:

In the absence of the owners the facility is managed by the clinical nurse manager. She is supported by the owners and another registered nurse. The service has a number of policies and procedures at a service level that are structured to provide appropriate safe quality care to residents that require rest home level care that have been provided by the contracted quality management consultant. The service consults with a dietitian for advice on nutrition as needed. Allied health professionals are accessed on an as required basis. Physiotherapy and occupational therapy are accessed through referral to the CDHB on an 'as required' basis.D19.1a; a review of the documentation, policies and procedures and from discussion with staff identified that the service operational management strategies, QI programme which includes culturally appropriate care, to minimise risk of unwanted events and enhance quality.

Criterion 1.2.2.1 (HDS(C)S.2008:1.2.2.1)During a temporary absence a suitably qualified and/or experienced person performs the manager's role.


Evidence:

Finding:

Corrective Action:


Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3)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

Attainment and Risk: PA Low

Evidence:

The service has a business risk assessment and management plan and this includes a quality plan for 2012-2015. The service has in place a range of policies and procedures to support service delivery that are reviewed and updated regularly by the external management consultant who is contracted to provide this service. Quality data is collected and evaluated and used for quality improvement. Key components of the quality system link to service delivery. Corrective actions are documented against identified issues as these occur through internal audits and complaints. Trends and analysis of infection control and incident/ accident data is not evidenced occurring. (Link to #1.2.4.3 and 3.5.7)There is a document control system. All policies include the date the policy was last reviewed and a review date. Documents no longer relevant to the service are removed and archived. Discussion with three health care assistants, clinical nurse manager, the cook, activities coordinator and the owner/ manager identified that staff are familiar with the policies and procedures. There are implemented health and safety policies that include hazard identification. There is a quarterly health and safety and OSH meeting which includes monitoring of hazards, and risks. There is a proactive maintenance schedule implemented and issues are managed promptly as these arise. A review of the documentation indicates that maintenance issues and hazards are resolved promptly. The service has policies, procedures, processes and systems that support the provision of clinical care and support including care planning.D5.4 Cameron Courts have the following policies/ procedures to support service delivery; 1) Continence Policy. 2) Challenging behaviour policy. 3) Pain management policy and procedure.4) Personal grooming and hygiene policy5) Skin integrity management policy.6) Wound care policy and procedures. 7) Transportation of subsidised residents policy and procedure includes costs, resident, and staff safety.8) D10.1 A policy around death and dying.9) Vehicle/transportation policy. The diversional therapist and the manager both drive residents and both have a current driver’s license.Security and safety policies and procedures are in place to ensure a safe environment is provided. Emergency plans ensure appropriate response in an emergency.

There are infection control policies and procedure, a restraint policy and health and safety policies and procedures.D19.2g: Falls prevention strategies are in place that include an exercise programme, completion of falls risk assessments, and review of resident footwear and use of mobility aides.The service has a number of meetings designed to support discussion and review of quality data including quarterly staff meetings and quarterly quality, kitchen, infection control, restraint, health and safety and OSH. There are three monthly residents meetings. Minutes of the resident meeting which occurred 09-Oct-13 were sighted. Consumer/next of kin surveys are conducted annually. An improvement is required around the evaluation of completed surveys.

Criterion 1.2.3.1 (HDS(C)S.2008:1.2.3.1)The organisation has a quality and risk management system which is understood and implemented by service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.3 (HDS(C)S.2008:1.2.3.3)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.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.4 (HDS(C)S.2008:1.2.3.4)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.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5)Key components of service delivery shall be explicitly linked to the quality management system.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.6 (HDS(C)S.2008:1.2.3.6)Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.


Evidence:There is an internal audit schedule 2013 and internal audits have been completed as per the audit shedule. A resdient/consumer survey conducted in Apri 2013 evidences that are over all very satisfied with the service. However, a survey evaluation has not been conducted for follow up and corrective actions identified.

Finding:Finding statements and corrective actions have not been developed for resident/consumer survey conducted in April 201

Corrective Action:Ensure that surveys are evaluated with identified issues managed through corrective actions process.

Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7)A process to measure achievement against the quality and risk management plan is implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.8 (HDS(C)S.2008:1.2.3.8)A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.9 (HDS(C)S.2008:1.2.3.9)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.


Evidence:

Finding:

Corrective Action:


Standard 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4)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


Evidence:

D19.3b; There is an incident and accident policy that includes definitions, and outlines responsibilities including immediate action, reporting, monitoring and corrective action to minimize and debriefing.

Incidents/accidents and near misses are investigated and a log of incidents occurs monthly. However an improvement is required as trending and analysis of monthly incident and accident data is not being completed.There is a discussion of incidents/accidents at quarterly staff meetings and quarterly health and safety and quality meetings.D19.3c Discussions with the owner/manager and clinical nurse manager confirms that there is an awareness of the requirement to notify relevant authorities in relation to essential notifications. The facility had an outbreak of “flu like symptoms in July 2012. Documentation sighted evidenced contact with the CDHB and Public Health was given notification of the outbreak at the time of the event.There is an open disclosure policy and family members interviewed stated they are informed of changes in health status. Training for staff around open disclosure was last held in February 2013. Eleven of eleven incident/accident forms reviewed for September 2013 document whether or not family have been informed and all indicate that family are kept informed appropriately.The three health care assistants, registered nurse and clinical nurse manager interviewed are all familiar with the incident/accident reporting process and describe discussion of these at the staff meeting.

Criterion 1.2.4.2 (HDS(C)S.2008:1.2.4.2)The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.4.3 (HDS(C)S.2008:1.2.4.3)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.


Evidence:

There is an adverse events policy. Incidents, accidents and near misses are investigated. Incidnet and accident forms are completed at the time of the event and evidence RN follow up.

Finding:Trending and analysis of monthly incident and accident data collected by the service is not evidenced completed

Corrective Action:Ensure trend analysis of incident and accident data collected occurs.


Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7)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


Evidence:

The recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications and experience. A copy of practising certificates including the registered nurse, enrolled nurse and general practitioners is kept. There are comprehensive human resources policies including recruitment, selection, orientation and staff training and development. Five staff files were reviewed (clincial nurse manager, activities cordinator, cook and two healthcare assitants). Reference checks are completed before employment is offered and these were sighted in five staff files reviewed. The service has in place an orientation programme that provides new staff with relevant information for safe work practice. Three healthcare assistants were able to describe the orientation process and stated that they believed new staff were adequately orientated to the service. Orientation checklists were evident in five of five staff files reviewed.Discussion with the owner/manager, clinical nurse manager, one registered nurse and three health care assistants confirm that a comprehensive in-service training programme is in place that covers relevant aspects of care and support and meets requirements. There is an in-service calendar for 2013. The annual training programme exceeds eight hours annually. Health care assistants interviewed have either completed the national certificate in care of the elderly or have commenced the aged care education programme. The registered nurse attends external training including conferences, seminars and sessions provided by the local DHB. The owner/manager (enrolled nurse) has attended education and training sessions. Education provided in 2013 included: incontinence products, code of rishts and cofidentialty, documentation and communication, Incontinence management, informed consent, spiritualtiy, ageing process, first aid training, safe food handling, medication administration, infections control, weight management sexulaity and intimacy

and death dyng and loss and grief. Education on cultural safety of nursing practice from a Maori perspective was conducted in January 2013 with 15 staff attending. Restraint training to be provided in Novemebr 2013. Fire evacuation drill last conducted 30-May-13. Training occurs monthly and records include date, session topic, and names of attendees. There is evidence of session content, evaluations conducted following training and the service advised that those staff who do not attend training are given opportunity to access training session content.On review of five staff files all had signed position descriptions, police checks and reference checks are documented.

Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2)Professional qualifications are validated, including evidence of registration and scope of practice for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3)The appointment of appropriate service providers to safely meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4)New service providers receive an orientation/induction programme that covers the essential components of the service provided.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.5 (HDS(C)S.2008:1.2.7.5)A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8)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


Evidence:

Staffing levels and skill mix policy in place. Sufficient staff are rostered on to manage the care requirements of the rest home residents. The clinical nurse manager works Monday- Wednesday and provides on call after hours and weekend cover. There is another registered nurse who works morning shifts Thursday –Sunday.Roster includes: One senior health care assistant works 0700 - 1515; one health care assistant works 0700-15.00 and one health care assistant works 08.00-12.00.In the afternoons there is one senior health care assitant who works 15.00-23.15 and another health care assitant who works 1500-2300.At night there is one health care assistant who works 2300-0715 and one who works 23.00-7.00 on duty.Interviews with three health care assistants, six residents and four family members identify that staffing is adequate to meet the needs of residents.

Criterion 1.2.8.1 (HDS(C)S.2008:1.2.8.1)There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.


Evidence:

Finding:

Corrective Action:


Standard 1.2.9: Consumer Information Management Systems (HDS(C)S.2008:1.2.9)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


Evidence:

The service retains relevant and appropriate information to identify residents and track records. This includes comprehensive information gathered, at admission, with the involvement of the family. There is sufficient detail in resident files to identify residents' on-going care history and activities. Resident files are in use that are appropriate to the service. There are policies and procedures in place for privacy and confidentiality. Staff can describe the procedures for maintaining confidentiality of resident records. Files and relevant resident care and support information can be accessed in a timely manner.D7.1 Entries are legible, dates and signed by the relevant health care assistant, enrolled nurse, registered nurse or other staff member including designation. Residents files are protected from unauthorized access by being locked away in a cupboard at the nurses’ station.Informed consent is obtained from residents/family on admission to display photographs. Information containing sensitive resident information is not displayed in a way that can be viewed by other residents or members of the public.Individual resident files demonstrate service integration. This includes medical care interventions. Medication charts are in a separate folder with medication and this is appropriate to the service.

Criterion 1.2.9.1 (HDS(C)S.2008:1.2.9.1)Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.7 (HDS(C)S.2008:1.2.9.7)Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.9 (HDS(C)S.2008:1.2.9.9)All records are legible and the name and designation of the service provider is identifiable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.10 (HDS(C)S.2008:1.2.9.10)All records pertaining to individual consumer service delivery are integrated.


Evidence:

Finding:

Corrective Action:


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 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1)Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.

ARC A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2; E3.1; E4.1b ARHSS A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2


Evidence:

There is a policy for resident admissions that includes responsibilities, assessment processes and time frames. The service communicates with needs assessors and the Ashburton Hospital AT & R team when a bed becomes available. There is currently a waiting list and admissions are prioritised according to the resident’s needs. Enquiry forms are maintained and there are follow up phone calls to the clients on the waiting list. Potential clients receive an information pack. The pack includes all relevant aspects of service delivery and residents and or family/whānau are provided with associated information such as the H&D Code of Rights,' complaints information, advocacy, and admission agreement. Four relatives and six residents interviewed stated that they had received the information pack and had received sufficient information prior to and on entry to the service. NASC approvals and signed service agreements sighted. The admission checklist ensures all admission documentation is completed within the timeframes.

D13.3 The admission agreement reviewed aligns with a) -k) of the ARC contractD14.1 exclusions from the service are included in the admission agreement.D14.2 the information provided at entry includes examples of how services can be accessed that are not included in the agreement

Criterion 1.3.1.4 (HDS(C)S.2008:1.3.1.4)Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.


Evidence:

Finding:

Corrective Action:


Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2)Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate.

ARHSS D4.2


Evidence:There is a declining entry section in the admission procedure. The service records document the reason for declining service should this occur and communicates this to residents/family/whānau. The reason for declining would be if the client did not meet the rest home level of care provided at the facility or there were no beds available. There currently a waiting list. There are no declined records. Declined clients would be referred back to the referrer in a timely manner to discuss referral options. Click here to enter text

Criterion 1.3.2.2 (HDS(C)S.2008:1.3.2.2)When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services.


Evidence:

Finding:

Corrective Action:


Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3)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


Evidence:

There is a policy and process that describe resident’s admission and assessment procedures. A registered nurse undertakes the assessments on admission, with the initial RN assessment completed within 24 hours of admission. An initial care plan is also completed on admission. The admission information, medical notes, allied health notes, progress notes, staff input, resident and family input form the basis of the long term care plan developed within three weeks of admission. The activities assessment is competed within two weeks of admission. Medical assessments are completed within 48 hours of admission by the GP in all six resident files sampled. The GP examines the resident at least three monthly and records the resident as stable to be seen again in three months. Earlier reviews are evident for residents requiring more frequent monitoring. Residents retain their own GP's and there are a number of GP's that provide medical services. There is a 0800 after hours RN who triages the call and makes contact with the on call GP to phone or visit the facility. A range of assessment tools completed on admission are evident in the six resident files sampled. Including (but not limited to); a) admission and food and nutrition information b) Braden pressure area risk assessment, c) continence assessment d) coombes fall risk assessment e) mobility support guide f) pain scale assessment g) Robinsons resident acuity assessment There is a verbal handover between shifts and written handover sheet with resident significant events documented. Daily progress notes are maintained. A stamp "resident checked two hourly and safe" is used in progress notes where applicable and signed. All six files identified integration of allied health professionals including GP medical notes, podiatry notes, letters and referrals to other allied health professionals and specialists. The palliative care team at the Ashburton hospital are readily accessible for resources and support for palliative and end of life care and advice. D16.2, 3, 4: The six resident files reviewed identified that in all six files a nursing assessment was completed within 24 hours and the long term care plan was completed within three weeks. There is documented evidence in six resident files sampled that the care plans are reviewed by an RN at least six monthly or earlier if resident health changes are completed. Five resident files sampled evidenced written evaluations are completed at least six monthly. One residents had not been in the service long enough for a review to have been completed. D16.5e: Six resident files reviewed identified that the GP had seen the resident within two working days. It was noted in resident files reviewed that the GP has assessed the resident three monthly and records the resident as stable and to be seen 3 monthly. More frequent examination occurs when a resident health status changes.

Six rest home resident files are sampled:

Tracer Methodology:

XXXXXX This information has been deleted as it is specific to the health care of a resident.

Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1)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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.3 (HDS(C)S.2008:1.3.3.3)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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.4 (HDS(C)S.2008:1.3.3.4)The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4)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


Evidence:

The RN completes a comprehensive initial nursing assessment within 24 hours of admission. The initial assessment includes showering and grooming, skin care, mobilising, eating and drinking, cultural needs, elimination and continence, communication (hearing and sight), behaviour, pain, social and spiritual needs, sexuality and intimacy and any other needs as identified throughout the admission and assessment process. Baseline blood pressure, pulse and weight recordings are taken on admission and recorded. The RN ensures the new resident and their family have received an orientation to the facility. The initial assessment forms the basis for the long term care plan developed within three weeks of admission. The resident profile and activities assessment is completed within two weeks of the resident’s admission. Nursing diagnosis is identified with resident goals, objectives and interventions identified. A range of assessment tools completed on admission include (but not limited to); a) admission and food and nutrition information b) Braden pressure area risk assessment, c) continence assessment d) coombes fall risk assessment e) mobility support guide f) pain scale assessment g) Robinsons resident acuity assessment The GP completes a medical assessment within 48 hours of admission.

Criterion 1.3.4.2 (HDS(C)S.2008:1.3.4.2)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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.5: Planning (HDS(C)S.2008:1.3.5)Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

ARC D16.3b; D16.3f; D16.3g; D16.3h; D16.3i; D16.3j; D16.3k; E4.3 ARHSS D16.3b; D16.3d; D16.3e; D16.3f; D16.3g


Evidence:The initial assessment forms the basis for the long term care plan developed within three weeks of admission. There is documented evidence the care plans have been developed with the resident and family involvement where appropriate. Resident needs, goals, objectives and interventions are identified, agreed and care to be delivered is explained. The long term care plan covers all areas of support identified as follows; mobility, continence, activities of daily living, dietary needs, medication, pain management, sleep and comfort, communication/sensory, memory loss/confusion, behaviour management, respiratory function, psycho-social/cultural/sexuality/intimacy, skin/wound and any additional needs. Residents' files include; resident admission details, general consent form, advance directive, family/whanau/resident representative contact sheet, NASC assessment, medical notes/GP faxes/laboratory results, care plan documents, progress notes, risk assessments and monitoring forms, activities resident profile/activity care plan, accident/incident and infection event logs. Significant events and communication with families are documented on the relative contact form in front of the progress notes. Six residents and four relatives confirmed on interview they are involved in the development of care plans. Short term care plans are used for short term/acute needs. Short term care plans describe a problem/diagnosis, objective/goal, intervention and evaluation. Short term care plans sighted in resident files sampled include; skin tear, rash, athlete's foot, nausea and vomiting and cellulitis. D16.3k, Short term care plans are in use for changes in health status.D16.3f; Six resident files reviewed identified that family were involved.

Criterion 1.3.5.2 (HDS(C)S.2008:1.3.5.2)Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.


Evidence:

Long term care plans are developed within three weeks of admission in six of six resident files sampled. Four of six long term care plans reflect the current needs of the resident.

Finding:Two of the six long term care plans in residents files sampled did not reflect the current needs of the resident.

XXXXXX This information has been deleted as it is specific to the health care of a resident.

Corrective Action:Ensure long term care plans reflect the residents current medical condition, clinical management, and monitoring instructions are followed


Criterion 1.3.5.3 (HDS(C)S.2008:1.3.5.3)Service delivery plans demonstrate service integration.


Evidence:

Finding:

Corrective Action:


Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6)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


Evidence:

Cameron Courts provides services for residents requiring rest home level of care. Individualised long term care plans are completed. When a resident's condition alters, the registered nurses initiate a review and if required, GP or specialist consultation. The three healthcare assistants (HCA's) and RN interviewed stated that they have all the equipment referred to in care plans necessary to provide care including spenco mattresses, shower chairs, high rise toilet seats, transfer belts, chair scales, sling hoist, pressure cushions, walking frames, wheelchairs. Residents and relatives interviewed state the residents needs are being met and they are receiving appropriate clinical and medical care. D18.3 and 4 Dressing supplies are available and a treatment room is stocked for use.Continence products are available (sighted) and resident files include a urinary continence assessment, bowel management, and continence products allocation for day and night use. Nurse specialist continence advice is available as needed and the RN could describe the referral process. Male catheterisations are carried out by medical staff at the Ashburton hospital. The RN's and health care assistants have attended continence education.Wound assessment and wound management plan and wound dressing application records are in place for the one open wound on lower leg that has recently healed. There is evidence of ongoing evaluations and photographs. Short term care plans are used for minor abrasions and skin tears. The Registered Nurse interviewed described the referral process should they require assistance from the practice nurses or wound care specialist. Pain assessments are completed on admission for residents with identified pain, new pain episodes or exacerbation of chronic pain. The pain assessments are reviewed at least six monthly for all residents prescribed pain relief. The effectiveness of pain relief is written into the progress notes. Monitoring forms sighted include blood sugar levels, neurological observations, weight monitoring, blood pressure and pulse. RN's fax the GPs regarding changes in resident health status, suspected infections, new admission, medication requests and these are filed in the resident files. There is access to visiting geriatricians and psychogeriatricians from Christchurch by GP referral. There is an improvement required around i) weight loss monitoring and interventions and ii) the documentation of interventions for pressure area management.

Criterion 1.3.6.1 (HDS(C)S.2008:1.3.6.1)The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.


Evidence: i) There is a short term care plan in place for a sacral pressure area. ii) Residents are weighed monthly. There are calibrated chair scales available. The food services are notified of any identified residents with weight loss. There is a dietitian available by referral.

Finding:i) There are no interventions documented on the short term care plan for sacral pressure area. The short term care plan has not been evaluated. RN advised the pressure area has healed.ii) One resident has lost 3kg in two months. The reviewed long term care plan September 2013 states the resident’s goal is to maintain weight between 60-65kg. The resident is now 56kg. There is no short term care plan in place. The nutritional assessment is not dated and there is no acknowledgment of weight loss.

Corrective Action:Ensure short term care plans are completed when there is an acute change in the residents condition/needs.


Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7)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


Evidence:

The diversional therapist (DT) in training through career force has been at the facility for two years and worked as an HCA previously. The DT is a member of the regional DT support group. The DT has completed ACE education papers, dementia course and first aid (to paramedic level). The DT is medication competent. DT hours are 20 per week from Monday to Friday and does some volunteer hours in the weekends if there are community functions on that residents are attending such as the Ashburton show, monthly senior citizens social. A resident profile that includes interests, community links and hobbies is completed as soon as practical after admission. The resident/family are involved in the development of the activity care plan within three weeks of admission and six monthly review. The DT is in the process of changing over the care plan format and co-ordinating the reviews with the RN. There is good communication with the clinical team and the DT attends the RN handover which ensures she is aware of any resident physical or cognitive concerns. Transport forms for resident outings are sighted by the RN prior to outings. Resident meetings are held two monthly with feedback and suggestions received to be included in the monthly activity programme. All residents receive a copy of the weekly programme which is also displayed on the notice board. Weekly activities include newspaper reading, walks, scrabble, bowls and crafts, happy hour, housie. Theme months are planned with relevant activities. There are a variety of entertainers and visitors to the facility including school children, pet visits, musical groups, Altrusa ladies for cards and games and other rest homes visit for inter-home competitions. The Glee club (singing therapy) has recently formed with good attendence. The DT makes contact with all residents daily and spends one on one time (discussion, hand massages) with residents who do not wish to partcipate in group activities. There is a large lounge for group activities and entertainment and a conservatory where individual or small group activities can take place. There is a weekly devotion service which is interdenominational. Several residents maintain their links with the community and regularly attend community functions for blind foundation, probus and the 206 club which is a social programe with transport provided by the DHB. The facility has its own van for transport and there is the maxi taxi booked monthly for outings. The residents enjoy outings and afternoon teas that follow the heritage trails of Ashburton including the museums. A recent outing to the motorbike museum was enjoyed. Six residents interviewed are satisfied with the variety of activities, outings and entertainment. They have the opportunity to provide input into the activity programme.

D16.5d Resident files reviewed identified that the individual activity plan is in the process of being reviewed at the clinical care plan review. A schedule is in place.

Criterion 1.3.7.1 (HDS(C)S.2008:1.3.7.1)Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8)Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

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


Evidence:

All initial care plans are developed by an RN within three weeks of admission and evaluated at least six monthly. There is a three monthly review by the GP. There is documented evidence that the long term care plan evaluations are up to date in four of six resident files sampled. Two residents have not been at the service long enough for a long term care plan evaluation. In four of six resident files overall changes in health status are documented and followed up (link 1.3.5.2). Four long term care plan reviews sampled are signed as completed by the RN. There written evaluations that align with each of the care plan support needs and goals identified. There is a MDT approach to the review of the long term care plan coinciding with the GP three monthly review. The resident/family/whanau are invited to attend the care plan review for discussion and provide written comment. Discussions with family are documented on the relative contact form. Short term care plans are in place for short (acute) term needs. Five of six resident files evidenced evaluation of the short term care plan with ongoing problems transferred to the long term care plan or resolved (link 1.3.6.1). Six residents and four relatives confrimed on interview they are involved in the review process of care plans. Six monthly evaluations or earlier if resident health changes are completed by the RN with input from HCA's, the GP, the diversional therapist, resident/family/whanau and any other relevant person.

D16.4a Care plans are evaluated six monthly more frequently when clinically indicatedD16.3c: All initial care plans were evaluated by the RN within three weeks of admission

Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2)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.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3)Where progress is different from expected, the service responds by initiating changes to the service delivery plan.


Evidence:

Finding:

Corrective Action:


Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9)Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4


Evidence:

The service facilitates access to other medical and non-medical services. The RN interviewed confirms they can initiate nursing referrals for continence, wounds, assessment team (NASC) , nurse practitioner mental health and psychiatric services, speech language therapist. The GP initiates specialist referrals. There is consultation and notification of referrals made and residents/families are informed of referrals and options. Referrals sighted in the residents’ files are for clinical nurse specialist AT&R, consultant neurologist, consultant psychiatrist and memory specialist, diabetic retinopathy, sleep and respiratory clinic. There is a visiting podiatrist six weekly. The community physiotherapist is by referral however residents have the option to access phyiotherapy privately. D16.4c; the service provided an examples of where a residents condition had changed and the resident was reassessed for a higher level of care. D 20.1 discussions with registered nurses identified that the service has access to continence nurse, wound nurse, assessment team (NASC) , nurse practitioner mental health and psychiatric services, speech language therapist, podiatry, physiotherapist, palliative care nurse, dietitian

Criterion 1.3.9.1 (HDS(C)S.2008:1.3.9.1)Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.


Evidence:

Finding:

Corrective Action:


Standard 1.3.10: Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10)Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


Evidence:

There is a policy that describes guidelines for death, discharge, transfer, documentation and follow up. The information copied and sent with a resident transferring to hospital includes; transfer form, resident details, copy of the medications, GP letter, copy of the relevant progress notes and any other relevant information. Hospital discharge letters and nursing care summaries are received on discharge or transfer back to the facility. The family/whanau are notified of transfers. Notifications are made to the appropriate departments regarding transfers from the facility and death.

Criterion 1.3.10.2 (HDS(C)S.2008:1.3.10.2)Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives.


Evidence:

Finding:

Corrective Action:


Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12)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

Attainment and Risk: PA Moderate

Evidence:

.There are policies and processes that describe the stages of medicine management. RN's and senior healthcare assistants administering medications

complete medication education and practical observations (including subcutaneous insulin) before being registered as medication competent on the medication signing list. Annual competency assessments and education is provided. One RN has completed syringe driver training. Unichem pharmacy are contracted to provide the douglas medico blister packs four weekly and all other pharmaceuticals. All medications received are checked by the RN and HCA on duty. Any discrepancies are fed back to the pharmacy. Expired medications and returns are collected by the pharmacy. A medication returned to the pharmacy list is maintained. All eye drops in used are dated on opening. The locked medication trolley is kept in a locked treatment room. Refridgerated medications are kept in a sealed container in the kitchen. The temperature is monitored daily. There is currently one self medicating resident. There is a self-medication competency in place that is reviewed three monthly and there is monitoring of self administration. The medication folder contains information on NZNO guidelines for the administration of medications, approved abbreviations, and information on medication incidents and reporting process. The 12 medications charts sampled all had photo identification and allergies noted. There is evidence of GP medication reviews three monthly. The medication administration signing sheets are correctly signed for regular and PRN medications record the time of administration. There are no gaps on the signing sheet. D16.5.e.i.2; 12 medication charts reviewed identified that the GP had seen the reviewed the resident 3 monthly and the medication chart was signed.

Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1)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.


Evidence:

i) The contents of the controlled drug (CD) safe are all labelled and within expiry dates. There are weekly controlled drug checks of the CD tablets. There has been a six monthly pharmacy audit completed. ii) Each GP has signed a standing orders list that indicate use, frequency, dose and timeframe for use. iii) Eight of 12 medication charts sampled the GP has prescribed an indication for use of prn medication

Finding:

i) CD liquids are not checked weekly. ii) The standing orders have not been reviewed since 2010. iii) Four of 12 medication charts sampled did not have a prescribed indication for use of prn medication.

Corrective Action:

(i)Ensure weekly checks of Controlled drugs include liquids. (ii) Ensure standing orders are reviewed annually. (iii) Ensure PRN medications have an indication for use prescribed on the medication chart


Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3)Service providers responsible for medicine management are competent to perform the function for each stage they manage.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5)The facilitation of safe self-administration of medicines by consumers where appropriate.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6)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.


Evidence:

Finding:

Corrective Action:


Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13)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


Evidence:

There is a qualified cook on duty daily from 7am to 1pm who prepares and cooks the main midday meal. An afternoon cook completes/prepares/re-heats the team meal and serves. There is a six weekly summer and winter menu that has been reviewed by the dietitian. Breakfast is served to residents in their rooms. The cook receives a resident food and nutrition information form and is notified of any changes to resident’s dietary needs. The cook maintains a resident’s dislikes list. Alternative meals and choices are offered for residents with dislikes. Dietary requirements such as vegetarian, pureed or soft diets are accommodated. Feedback on the meals and menu suggestions are received through the resident meetings, audits and surveys. The kitchen is well equipped with a combi oven and conventional oven. There is large pantry storage with all dry goods in sealed, labelled containers and stored off the floor. There are daily fridge, freezer and dishwasher temperatures recorded. Hot food temperature is checked during cooking and prior to serving. Chemicals are stored in a locked cupboard. Ecolab provide chemical training as required and safety data sheets are readily accessible. Staff are observed wearing hats, aprons and gloves. There is a kitchen cleaning schedule in place. Six residents interviewed are complimentary of the meals. D19.2 staff have been trained in safe food handling. The main cook holds unit standards through Wairekia institute of technology. Cooks have attended weight and nutrition in older people.

Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1)Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2)Consumers who have additional or modified nutritional requirements or special diets have these needs met.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5)All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.


Evidence:

Finding:

Corrective Action:


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.

Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1)Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

ARC D19.3c.v; ARHSS D19.3c.v


Evidence:

There are policies and procedures for the management of waste and hazardous substances and the storage and use of chemicals. All infectious material is double bagged before disposing of into waste bins. Rubbish is collected weekly by a contracted wastes disposal collector. There is recycling of cardboard and other items. Approved sharps containers are used for the safe disposal of sharps. Laundry, kitchen and sluice room chemicals are stored safely in locked areas. There is an improvement required around the safe storage and labelling of cleaning chemicals (link 1.4.6.3). Ecolab provide the facility chemicals, safety data sheets and on site chemical safety training as required. There is protective equipment available including face shield, gloves and plastic aprons however these are required to be readily accessible at the point of use (corrected on day of audit).

Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1)Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.1.6 (HDS(C)S.2008:1.4.1.6)Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2)Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a; D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4


Evidence:

The building has a current building warrant of fitness that expires 1 July 2014. There is an approved evacuation scheme. Contracted fire inspection services carry out monthly fire safety tests. The owner/manager oversees the daily maintenance as requested in the maintenance record book. The owner/manager engages contractors for specific maintenance requirements such as electrical or plumbing work. Clinical equipment (chair scales, oxygen regulator, blood pressure equipment) have been calibrated. The electrical contractors are booked to complete the equipment annual electrical warrant of fitness. Hot water temperatures in resident areas are monitored monthly and are within the acceptable temperature range. The corridors are wide enough for the safe use of mobility equipment. There is easy access to safe outdoor areas, gardens and pathways. Ramps and rails are in place. There is outdoor seating and shaded areas. Amenities include staff areas, administration areas, nurse’s office and resident hairdresser’s area. ARC D15.3; The following equipment is available, spenco mattresses, shower chairs, high rise toilet seats, transfer belts, chair scales, sling hoist, pressure cushions, walking frames, wheelchairs.

Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1)All buildings, plant, and equipment comply with legislation.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.4 (HDS(C)S.2008:1.4.2.4)The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.6 (HDS(C)S.2008:1.4.2.6)Consumers are provided with safe and accessible external areas that meet their needs.


Evidence:

Finding:

Corrective Action:


Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3)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


Evidence:

There are an adequate number of communal toilets and shower rooms in each wing. Communal toilets and showers are spacious enough to be able to use mobility aids, shower stools and other appropriate equipment to tend to the resident’s personal hygiene requirements. There are engaged/vacant signage on the toilet/shower doors. Handrails are appropriately placed to support the resident. The six residents interviewed state the staff are respectful and ensure their privacy and dignity is maintained when attending to their personal hygiene requirements.

Criterion 1.4.3.1 (HDS(C)S.2008:1.4.3.1)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.


Evidence:

Finding:

Corrective Action:


Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4)Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii


Evidence:

All bedrooms are single and provide adequate space for the residents to move about safely with the use of mobility aids. Resident bedrooms are personalised. Bedrooms viewed are carpeted and have appropriate fixtures and furnishings that are maintained. Six residents interviewed are happy with their rooms and enjoy the view from their rooms.

Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1)Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.


Evidence:

Finding:

Corrective Action:


Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5)Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

ARC E3.4b ARHSS D15.3d


Evidence:

The communal dining and main lounge room are spacious with good natural light. The villa type building which has been modernised and refurbished in of some the communal areas retains a homely atmosphere. There is a conservatory area where smaller groups of residents can meet, spend quiet activity

time such as reading or time with visitors. Recreational activities are held in the main lounge. There are several seating alcoves throughout the facility. Seating is appropriate and placement allows for group or individual activities to take place. There is a resident phone available

Criterion 1.4.5.1 (HDS(C)S.2008:1.4.5.1)Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6)Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e


Evidence:

The linen and personal clothing are laundered off site at Ashburton dry cleaning services. The dirty linen is collected into linen bags and collected from the external laundry door. Clean laundry is delivered to the clean entry door for distributing to the linen storage areas and resident rooms. The night staff do any ironing required. The laundry area has one autoed washing machine and dryer that is used for the kitchen washing only. There is a clean/dirty area in the laundry. There is a cleaner employed for three hours every second day to clean all hand basins, clearing rubbish and vacuuming throughout the facility. The nightshift caregivers carry out cleaning duties throughout the night that includes washing of floors, cleaning of showers and toilets. There is a small sluice area with the chemicals kept in a locked cupboard. Ecolab provide quality control reports on the effectiveness of cleaning products. Six residents interviewed are satisfied with the laundering of their personal clothing and the cleanliness of their bedrooms. The environment was clean and tidy on the day of audit. There is an improvement required around the safe storage and labelling of cleaners chemicals.

Criterion 1.4.6.2 (HDS(C)S.2008:1.4.6.2)The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.6.3 (HDS(C)S.2008:1.4.6.3)Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.


Evidence:

Ecolab provide the chemicals for cleaning and the laundry. There are product use wall charts and safety data sheets.

Finding:

The cleaner’s trolley is not stored in a locked area. Two bottles of chemicals on the cleaning trolley are unlabelled.

Corrective Action:

There is a requirement to store the cleaning trolley safely. Chemical bottle are required to be labelled with manufacturer labels.


Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7)Consumers receive an appropriate and timely response during emergency and security situations.

ARC D15.3e; D19.6 ARHSS D15.3i; D19.6

Attainment and Risk: Not Audited

Evidence:

There are emergency management plans in place to ensure health, civil defence and other emergencies are included. The emergency readiness plan includes fire policy and instructions, medical emergency, earthquake, flood, prowlers and intruders, and civil defence emergencies. The service has emergency equipment and supplies that are accessible. Emergency training is included in the orientation. Fire and evacuation notices are posted throughout the rest home. Residents are informed of fire evacuation process on admission and as appropriate. The service has an approved evacuation plan dated July 2010. Fire drills are conducted six monthly. Cameron House has a civil defence pack and emergency lighting, alternative energy, gas barbeque, bottled gas, water supply, blankets and bulk food for three days stored. The facility has a contingency plans for back up supplies.

Criterion 1.4.7.1 (HDS(C)S.2008:1.4.7.1)Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.3 (HDS(C)S.2008:1.4.7.3)Where required by legislation there is an approved evacuation plan.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.4 (HDS(C)S.2008:1.4.7.4)Alternative energy and utility sources are available in the event of the main supplies failing.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.5 (HDS(C)S.2008:1.4.7.5)An appropriate 'call system' is available to summon assistance when required.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.6 (HDS(C)S.2008:1.4.7.6)The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.


Evidence:

Finding:

Corrective Action:


Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8)Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

ARC D15.2f ARHSS D15.2g


Evidence:

There is radiator heating throughout the communal areas and corridors and fan heating in the bedrooms. Six residents interviewed state the environment is warm and the bedrooms are warm. There is adequate ventilation with opening windows in all areas and doors that can be safely opened to the outdoors. There are large windows in the main lounge, dining and conservatory areas. All bedrooms have large windows that allow natural light into the rooms.

Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1)Areas used by consumers and service providers are ventilated and heated appropriately.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2)All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.


Evidence:

Finding:

Corrective Action:


NZS 8134.2:2008: Health and Disability Services (Restraint Minimisation and Safe Practice) Standards

Outcome 2.1: Restraint Minimisation

Services demonstrate that the use of restraint is actively minimised.

Standard 2.1.1: Restraint minimisation (HDS(RMSP)S.2008:2.1.1)Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


Evidence:

Documented systems are in place to ensure the use of restraint is actively minimized. The clinical nurse manager is the restraint coordinator. The facility was not utilising restraint or enabler use on audit day. Staff interviews and staff records evidence guidance has been given on restraint minimisation and safe practice, enabler usage and prevention and/or de-escalation techniques. Policies and procedures include definition of restraint and enabler that are congruent with the definition in NZS 8134.0. The Restraint minimisation policy identifies that enablers are voluntary and the least restrictive option.Staff education on challenging behaviour management was conducted in March 2012. Restraint education was conducted in 2011 and scheduled for November 2013. Restraint minimisation and safe practice audit was conducted in March 2013 and July 2013 with no corrective actions required.

Criterion 2.1.1.4 (HDS(RMSP)S.2008:2.1.1.4)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.


Evidence:

Finding:

Corrective Action:


Outcome 2.2: Safe Restraint Practice

Consumers receive services in a safe manner.

Standard 2.2.1: Restraint approval and processes (HDS(RMSP)S.2008:2.2.1)Services maintain a process for determining approval of all types of restraint used, restraint processes (including policy and procedure), duration of restraint, and ongoing education on restraint use and this process is made known to service providers and others.

ARC D5.4n ARHSS D5.4n, D16.6

Attainment and Risk: Not Applicable

Evidence:

Criterion 2.2.1.1 (HDS(RMSP)S.2008:2.2.1.1)The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.2: Assessment (HDS(RMSP)S.2008:2.2.2)Services shall ensure rigorous assessment of consumers is undertaken, where indicated, in relation to use of restraint.



Evidence:

Criterion 2.2.2.1 (HDS(RMSP)S.2008:2.2.2.1)In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to:(a) Any risks related to the use of restraint;(b) Any underlying causes for the relevant behaviour or condition if known;(c) Existing advance directives the consumer may have made;(d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes;(e) Any history of trauma or abuse, which may have involved the consumer being held against their will;(f) Maintaining culturally safe practice;(g) Desired outcome and criteria for ending restraint (which should be made explicit and, as much as practicable, made clear to the consumer);(h) Possible alternative intervention/strategies.


Evidence:

Finding:

Corrective Action:


Standard 2.2.3: Safe Restraint Use (HDS(RMSP)S.2008:2.2.3)Services use restraint safely



Evidence:

Criterion 2.2.3.2 (HDS(RMSP)S.2008:2.2.3.2)Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made:(a) Only as a last resort to maintain the safety of consumers, service providers or others;(b) Following appropriate planning and preparation;(c) By the most appropriate health professional;(d) When the environment is appropriate and safe for successful initiation;(e) When adequate resources are assembled to ensure safe initiation.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.4 (HDS(RMSP)S.2008:2.2.3.4)Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to:(a) Details of the reasons for initiating the restraint, including the desired outcome;(b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint;(c) Details of any advocacy/support offered, provided or facilitated;(d) The outcome of the restraint;(e) Any injury to any person as a result of the use of restraint;(f) Observations and monitoring of the consumer during the restraint;(g) Comments resulting from the evaluation of the restraint.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.3.5 (HDS(RMSP)S.2008:2.2.3.5)A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.


Evidence:

Finding:

Corrective Action:


Standard 2.2.4: Evaluation (HDS(RMSP)S.2008:2.2.4)Services evaluate all episodes of restraint.



Evidence:

Criterion 2.2.4.1 (HDS(RMSP)S.2008:2.2.4.1)Each episode of restraint is evaluated in collaboration with the consumer and shall consider:(a) Future options to avoid the use of restraint;(b) Whether the consumer's service delivery plan (or crisis plan) was followed;(c) Any review or modification required to the consumer's service delivery plan (or crisis plan);(d) Whether the desired outcome was achieved;(e) Whether the restraint was the least restrictive option to achieve the desired outcome;(f) The duration of the restraint episode and whether this was for the least amount of time required;(g) The impact the restraint had on the consumer;(h) Whether appropriate advocacy/support was provided or facilitated;(i) Whether the observations and monitoring were adequate and maintained the safety of the consumer;(j) Whether the service's policies and procedures were followed;(k) Any suggested changes or additions required to the restraint education for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 2.2.4.2 (HDS(RMSP)S.2008:2.2.4.2)Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.


Evidence:

Finding:

Corrective Action:


Standard 2.2.5: Restraint Monitoring and Quality Review (HDS(RMSP)S.2008:2.2.5)Services demonstrate the monitoring and quality review of their use of restraint.

ARC 5,4n ARHSS D5.4n, D16.6


Evidence:

Criterion 2.2.5.1 (HDS(RMSP)S.2008:2.2.5.1)Services conduct comprehensive reviews regularly, of all restraint practice in order to determine:(a) The extent of restraint use and any trends;(b) The organisation's progress in reducing restraint;(c) Adverse outcomes;(d) Service provider compliance with policies and procedures;(e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice;(f) If individual plans of care/support identified alternative techniques to restraint and demonstrate restraint evaluation;(g) Whether changes to policy, procedures, or guidelines are required; and(h) Whether there are additional education or training needs or changes required to existing education.


Evidence:

Finding:

Corrective Action:


NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards

Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1)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


Evidence:

Cameron Courts has an established infection control programme. The infection control programme, its content and detail, is appropriate for the size,

complexity and degree of risk associated with the service. It is linked into the incident reporting system. There is a Quality Improvement meeting which includes discussion and reporting of infection control matters and consequent review of the programme. Minutes are available for staff. Regular audits take place that include hand hygiene, infection control practices, laundry and cleaning. Annual education is provided for all staff.The facility had an outbreak of a “flu” like virus in July 2012 with 20 resdients and 14 staff members affected by the virus.The DHB and Public health were informed of the outbreak. A log of resdient/staff infections were recorded. An outbreak management plan was evidenced completed. Education was provided to staff on infection control. Health care assistants interviewed reported that they had access to infection control resources including gloves, aprons and face masks and were reminded of best practice infection control practices by the clinical nurse manager. Residents and family members interviewed reported receiving information on infection control measures and being updated daily by the clinical nurse manager.

Criterion 3.1.1 (HDS(IPC)S.2008:3.1.1)The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.3 (HDS(IPC)S.2008:3.1.3)The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.9 (HDS(IPC)S.2008:3.1.9)Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.


Evidence:

Finding:

Corrective Action:


Standard 3.2: Implementing the infection control programme (HDS(IPC)S.2008:3.2)There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



Evidence:

The clinical nurse manager is the infection control nurse. There are adequate resources to implement the infection control programme for the size and complexity of the organisation. The infection control (IC) nurse maintains her practice by attending annual infection control updates. The IC nurse and IC team (comprising all staff) has good external support from the local laboratory infection control team and IC nurse consultant. The infection control team is representative of the facility.

Criterion 3.2.1 (HDS(IPC)S.2008:3.2.1)The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.


Evidence:

Finding:

Corrective Action:


Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3)Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a


Evidence:

There is are infection control policy and procedures appropriate to for the size and complexity of the service.D 19.2a: The infection control manual outlines a comprehensive range of policies, standards and guidelines and includes defining roles, responsibilities and oversight, the infection control team and training and education of staff. The policies are developed by an external provider and reviewed and updated annually. Cameron Courts infection control policies include (but not limited to): hand hygiene; standard/transmission based precautions; prevention and management of staff infection; antibiotic and antimicrobial agents; infectious outbreaks management; environmental infection control (cleaning, disinfecting and sterilising); single use items; construction/renovation risk assessment, personal protective equipment, medical waste disposal and sharps and spills management.

Criterion 3.3.1 (HDS(IPC)S.2008:3.3.1)There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.


Evidence:

Finding:

Corrective Action:


Standard 3.4: Education (HDS(IPC)S.2008:3.4)The organisation provides relevant education on infection control to all service providers, support staff, and consumers.



Evidence:

The infection control policy states that the facility is committed to the on-going education of staff and residents. This is facilitated by the infection control nurses with expert support from external providers who provide the service with current and best practice information. All infection control training is documented and a record of attendance is maintained. The IC nurses attend training annually. Education for staff last conducted in May 2013 with 14 staff attending. Visitors are advised of any outbreaks of infection and are advised not to attend until the outbreak has been resolved as evidenced from intection control measures implemented following an out break of a ‘flu” like virus in July 2012. Information is provided to residents and visitors that is appropriate to their needs and this is documented in medical records.

Criterion 3.4.1 (HDS(IPC)S.2008:3.4.1)Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.


Evidence:

Finding:

Corrective Action:


Criterion 3.4.5 (HDS(IPC)S.2008:3.4.5)Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept.


Evidence:

Finding:

Corrective Action:


Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5)Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.


Evidence:

Infection surveillance is an integral part of the infection control programme and is described in Cameron Courts infection control and surveillance policy. Monthly infection data is collected for all infections based on signs and symptoms of infection. An individual resident infection form is completed which includes signs and symptoms of infection, treatment, follow up, review and resolution. Surveillance of all infections are entered on to a monthly infection summary. However no analysis of the infection control data collected is evidenced completed. If there is an emergent issue, it is acted upon in a timely manner. Reports are easily accessible to the owner/manager.

Criterion 3.5.1 (HDS(IPC)S.2008:3.5.1)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.


Evidence:

Finding:

Corrective Action:


Criterion 3.5.7 (HDS(IPC)S.2008:3.5.7)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.


Evidence:

Surveillance methods and processes are completed including implementation of an internal audit. All infections are collected via and infection report form and a monthly infection summary form and discussed at infection control meetings.

Finding:

Infection control data is collected monthly, however there is no evidence of issues/trend patterns analysis being completed.

Corrective Action:

Ensure that trend analysis of the infection control data collected occurs.
