five pillars limited - ministry of health nz...five pillars limited date of audit: 26 november 2014...

Five Pillars Limited Date of Audit: 26 November 2014 of 28

Five Pillars Limited

Introduction

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

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

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

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

The specifics of this audit included:

Legal entity: Five Pillars Limited

Premises audited: Port View Retirement

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 26 November 2014 End date: 27 November 2014

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 21

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


Executive summary of the audit

Introduction

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

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

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

Key to the indicators

Indicator Description Definition

Includes commendable elements above the required levels of performance

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

No short falls Standards applicable to this service fully attained

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

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


Indicator Description Definition

A number of shortfalls that require specific action to address

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

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

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

General overview of the audit

Portview rest home provides rest home level care for up to 27 residents. On the day of audit, there were 21 residents. The facility is one of three facilities owned by three directors (Five Pillars Limited). There is a new manager who is a registered nurse and has been at the service for one week. The manager is supported by the owners, a registered nurse, caregivers and support staff. The service has a contracted general practitioner. Residents and families interviewed were complimentary about the care and service received.

The service has addressed 13 of the 24 previous shortfalls around complaints management, informed consent, Maori specific care plans, chemical safety management storage and training, incident/accident documentation and management, document control, aspects of consumer information, admission agreements, evaluations, restraint and call bell system.

Improvements continue to be required around human resources, annual appraisals, quality programme, medicine management and documentation, aspects of care planning and risk assessment, fire training and management.

This audit has identified further improvements required around the hazard register, staff orientation and weekly checks of the medication fridge and oxygen supplies.


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

Standards applicable to this service fully attained.

The service has an open disclosure policy stating residents and/or their representatives have a right to full and frank information and open disclosure from service providers. There is a complaints policy and an incident/accident reporting policy. Family members are informed in a timely manner when their family members health status changes. The complaints process and forms for completion are available in the reception area. Brochures are also freely available for the Health and Disability and advocacy service with contact details provided. Information on how to make a complaint and the complaints process are included in the admission booklet and displayed throughout the facility.

Organisational management

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

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

The company has a strategic business plan in place. There are organisational goals in place with quality objectives that are linked to the quality improvement system. The service has implemented policies and procedures developed by an aged care consultant. Quality, health and safety and infection control are set agenda items at the staff meetings. Staff interviewed confirmed they are


kept informed on risk management matters and quality improvements. There are improvements required around collation of resident survey and aspects of the quality programme.

All newly employed staff have completed an orientation programme. There is an education planner in place that includes compulsory training for aged care staff. There are improvements required around reference checking, employee’s signatures on recruitment documents, orientation, and overdue annual appraisals.

There is a staffing policy that includes a documented rationale for determining staffing levels and skill mixes for safe service delivery. The staffing roster indicates there are adequate numbers of staff on duty to safely deliver care within a timely manner.

Continuum of service delivery

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


The registered nurse is responsible for each stage of service provision. Assessments are conducted in an appropriate and private manner. Improvement is required to ensure risk assessments and care plans are completed in a timely manner, and that wound documentation and interventions contain all care requirements is documented. The GP reviews residents at least three monthly. During the tour of facility it was noted that all staff treated residents with respect and dignity and residents and families confirmed this.

The activity programme is meaningful and reflects ordinary patterns of life. There are also visits from and to community groups. The current activities assessment is comprehensive and personalised. All food requirements are provided from the onsite kitchen.


There is a choice of foods and the kitchen can cater to specific requests if needed. Resident nutritional needs are recorded and communicated to the kitchen. Residents spoke positively about the food provided.

The service uses the medico blister pack system. All caregivers and the registered nurse have completed annual competencies. Medication profiles are legible, up to date and reviewed at least three monthly by the residents GP. There is an improvement required around three monthly review of the medication prescription by the GP, aspects of medication documentation, weekly checks of the medication fridge and oxygen supplies.

Safe and appropriate environment

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


The building holds a current warrant of fitness that expires 26 April 2015, however there is no approved fire evacuation scheme following building repairs that have now been completed. There are improvements required around an approved fire evacuation scheme and frequency of fire drills.

Restraint minimisation and safe practice

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



There is a restraint policy that includes comprehensive restraint procedures. There is a documented definition of restraint and enablers that aligns with the definition in the standards. There are currently no residents with restraint and no residents using enablers.

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


The infection control programme and its content and detail, is appropriate for the size, complexity, and degree of risk associated with the service. The Infection Control co-ordinators reports surveillance data and infection control matters at staff meetings. All staff receive infection control education on orientation and attend annual education. Infection control audits are included in the annual audit programme.


Summary of attainment

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

Attainment Rating

Continuous Improvement

(CI)

Fully Attained(FA)

Partially Attained

Negligible Risk(PA Negligible)

Partially Attained Low

Risk(PA Low)

Partially Attained

Moderate Risk(PA Moderate)

Partially Attained High

Risk(PA High)

Partially Attained Critical

Risk(PA Critical)

Standards 0 14 0 2 6 1 0

Criteria 0 38 0 6 6 2 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


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

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

For more information on the standards, please click here.

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

Standard with desired outcome Attainment Rating

Audit Evidence

Standard 1.1.10: Informed Consent

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

FA General consents signed by the resident or representative include consent for personal and nursing care, primary medical care, allied health involvement, release of personal and health information, information to family/whanau, photo identification and display, outings. All five resident files contained a signed consent form and an advanced directive. This was a previous audit finding that has now been addressed.

Standard 1.1.13: Complaints Management

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

FA The service has in place a complaints policy and procedure that aligns with Code 10 of the Code of Rights. The Manager/RN is the privacy officer for the organisation. The RN is involved in clinical investigations as necessary.

There have been two verbal and one written complaint entered into the complaints register since the previous audit in May 2014. In each instance, appropriate follow-up action had been taken and was documented. This was a previous audit finding that has now been addressed.

Staff interviewed are aware of the complaints and concerns procedure and confirm discussion takes place at staff meetings around complaints/concerns and outcomes.

D13.3h. A complaints procedure is provided to residents within the information pack

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

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


at entry. Discussion with five residents and two relatives confirmed they were provided with information on complaints and complaints forms and are comfortable approaching management with any concerns/complaints.

Standard 1.1.9: Communication

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

FA The management promote an “open door” policy. Relatives are aware of the open door policy and confirm on interview that the staff and management are approachable and available. Information is provided in formats suitable for the consumer and their family. Accident/incident forms have a section to indicate if family/whanau have been informed (or not) of an accident/incident. Ten of ten incident forms reviewed identified that family were notified. There are residents meeting held regularly with opportunity for feedback on the services (August 2014). Annual resident, relative surveys are completed that provide feedback on all areas of the service (# link 1.2.3.6.). Open disclosure education was last provided March 2014.

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 Ministry of Health “Long-term Residential Care in a Rest Home or Hospital – what you need to know” is provided to residents on entry. Two relatives and five residents interviewed stated they were given sufficient information prior to entry to the service and had the opportunity to discuss information and the admission agreement with management.

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: Two relatives interviewed stated that they are always informed when their family member’s health status changes.

D11.3 The information pack is available in large print and advised that this can be read to residents. The code of rights is in Maori. Interpreter services are available as required.

Standard 1.2.1: Governance

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

FA Port View is a 27 bed facility providing rest home level of care. On the day of audit there were 21 rest home residents.

Port View is one of three facilities owned by three directors trading as Five Pillars Limited. One of the owner/directors lives on site during the week. The manager has recently been employed and has been in the position for 1 week.


The manager is a registered nurse (RN) with considerable experience in community nursing, clinical coordinator residential care services, mental health nursing and has held nursing positions at the hospital. She is supported by the owners (one lives on site during the week and anther owner (RN) visits regularly) the registered nurse who has been the facility manager for 18 months prior to the new manager being appointed and the activities officer who now has administration responsibilities. The manager is also supported by the DHB planning and funding manager. The manager has a current annual practicing certificate and has attended at least hours of professional development relating to management and clinical nursing care prior to her new appointment.

There is a one to five year strategic business plan in place developed and reviewed by the directors. The strategic plan for the facility includes a vision, mission, values and philosophy. The directors are responsible for the financial aspect of the business. There are organisation quality goals (July 2013 – July 2015) developed by the previous manager in consultation with the owners and staff. The quality plan identifies goals for each area of service delivery including an internal and external refurbishment and maintenance plan. An annual review has been completed August 2014.

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 Moderate There are organisational policies to guide the facility to implement the quality management programme including (but not limited to); quality assurance and risk management programme and internal audit schedule. Quality improvement record forms are used by management staff and quality improvements are discussed and recorded on meeting minutes. There are two monthly staff meetings that include staff from all service areas. They have input into the staff meetings. Minutes sighted (13 November 2014) evidence there is discussion around concerns, compliments, health and safety, hazard management, infection control, clinical concerns, audits and quality improvements and general business. Staff interviewed state they are informed on quality and risk management matters such as monthly accident incident and infection control statistics. This was a previous audit finding that has now been addressed. There are two monthly resident meetings chaired by the activity officer (last one August 2014). The activity officer meets formally with the manager three monthly.

The previous manager reported significant or operational concerns to the director as evidenced in corrective action reports however there is no documented evidence of operational reports to governance. This was a previous audit finding that still requires


improvement. The current manager meets with the owner on site daily and one of the other owners (RN) has visited to support the new manager.

Clinical guidelines are in place to assist care staff with such issues as incontinence, challenging behaviour, falls prevention, nutrition and hydration, skin care and wound management and pain management. There is an annual staff training programme that is implemented and based around policies and procedures. There is an internal audit programme with audits completed for; activities, medication, workplace inspection, infection control, hand hygiene, cleaning and laundry service, hazard management, security, waste management and food services. Not all audits have a corrective action report when comments have been documented on the audit report. This is an area requiring improvement.

A number of audits that have been completed since the last audit including but not limited to: challenging behaviour, non-restraint environment, pain management, continence, activity programme, clinical records, security systems, monthly hot water checks, cleaning, food services, laundry services, staff files, staff education, manual handling, disposal of waste, medication, appliance safety and fire evacuation. This was a previous audit finding that has now been addressed.

Resident/relatives are scheduled to occur annually. The results of the resident/relative survey November 2013 have not been collated to identify if there any areas for improvement. This was a previous audit finding that still requires improvement. The resident satisfaction survey for 2014 has recently been completed and is to be analysed.

D5.4 The service has policies and procedures and associated implementation systems to provide a 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.

Policies and procedures have been developed by an external aged care consultant and are in line with current accepted best and/or evidenced based practice. These have now been fully implemented to the service and are to be reviewed regularly. The content of policy and procedures are detailed to allow effective implementation by staff. Staff have all been updated with the new policies and sign that they have read the policy and or procedure change. There is a current documentation control policy and system in place. Interviews with two caregivers and the registered nurse (RN) confirm that new policies are in place. These were previous audit findings that have now been addressed.

D19.3: There is a current Quality and Risk management programme in place that


includes health and safety and hazard identification. Staff report any hazards identified on the hazard memo form. The hazard register which the RN reported is in use was unable to be located on the day of the audit. There are health and safety objectives within the two yearly quality goals. Hazard controls are in place to minimize the risk to residents, visitors and staff. A safety hazard audit check has been completed October 2014. The service has two health and safety delegates who have completed health and safety training.

D19.2g. Falls prevention strategies are in place that includes the analysis of falls incidents and the identification of interventions on a case by case basis to minimise future falls. The RN has attended a fall prevention seminar. Staff have attended use of mobility aides in the elderly (November 2013), safe manual handling with the physiotherapist in May 2014, incidents and accidents and neurological observations in August 2014. A manual handling audit has been completed November 2014.

There is emergency and disaster planning in place around earthquakes, fire, emergencies and other disasters. This includes training and education for staff on orientation and on-going (hazardous waste December 2013, risk management April 2014 and chemical safety in July 2014).

Organisational risks in the risk management plan dated August 2014 are categorised as environmental and equipment, resident safety, financial risk, confidentiality, staff, food services and legal liability. There is evidence of monthly collation, analysis and monitoring of infection control and accidents/incidents. Staff interviewed state they are kept informed, receive information and discuss risk management and hazard identification at the staff meetings.

Standard 1.2.4: Adverse Event Reporting

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

FA As part of risk management and health and safety framework, there is an accident/incident policy, which includes reference to open disclosure, level of seriousness and the responsibility for investigation, corrective actions and quality improvements. There is month by month data collection including (but not limited to): falls, skin tears, bruises, medication and behavioural incidents. When an incident occurs the staff member discovering the incident completes the incident/accident on the computer system. The incident/accident is documented in the progress notes. A falls risk rating is completed by the RN post falls with corrective actions implemented.

Ten incident/accident forms are sampled for October and November 2014. There is documented evidence of the next of kin being notified for all ten incidents reports completed. This was a previous audit finding that has now been addressed. Two


family members interviewed state they are informed of incidents/accidents. The RN collates the incidents/accidents, investigates and reviews, and implements corrective actions as required. This was a previous audit finding that has now been addressed. Monthly data is taken to the staff meetings. The two caregivers interviewed could describe the process for reporting of incidents and accidents.

D19.3b; There is an incident/accident reporting policy that includes definitions and outlines responsibilities including immediate action, reporting, monitoring and corrective action. The incident/accident form includes the reporting of pressure areas (this was a previous audit finding that has now been addressed).

D19.3c: The service documents and analyses incidents/accidents, unplanned or untoward events and provides feedback to the service and staff so that improvements are made. Discussions with management, confirms an awareness of the requirement to notify relevant authorities in relation to essential notifications.

Standard 1.2.7: Human Resource Management

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

PA Low There are human resources policies including recruitment, selection, orientation and staff training and development. Five staff files were reviewed (one nurse manager, one RN, activity officer, one caregiver/team leader and one most recently employed caregiver. The recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications, experience and suitability for the role. One new caregiver does not evidence that reference checks have been completed prior to employment. There are job descriptions sighted in the five files sampled however these have not been signed in all five staff files sampled. Staff files contain house rules/disciplinary documents. There was a previous audit finding around ensuring all recruitment documents are signed by the employee. This still requires further improvement.

There is an orientation programme that includes organisational structure and policies, health and safety, infection control and general information for staff. Staff are orientated to their area of work and complete competencies relevant to their role. The new caregiver and the new facility manager do not have evidence of orientation completed or being formally completed for the new manager. This is an area requiring improvement. Annual appraisals are on file for one of five staff files sampled (two have not been at the service longer than 12 months). This was a previous audit finding that still requires improvement.

There is a documented in-service programme for education that covers compulsory requirements including standard precautions, safe manual handling, medication


administration, cultural awareness training, code of rights, quality risk management, infection control, skin integrity, wound care, pain management and other clinical in service. Continence management education has been completed in July 2014. Food services staff have completed food safety training (November 2013).

Chemical safety has been completed in July 2014. This was a previous audit finding that has now been addressed.

Competencies are identified as relevant to the role. Caregivers and the registered nurse responsible for medication administration complete annual competencies.

Practicing certificates are sighted for the new manager/RN and RN, general practitioner, pharmacist and podiatrist and physiotherapist.

D17.8 Eight hours of staff development or in-service education has been provided annually.

Standard 1.2.8: Service Provider Availability

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

FA There is a staffing rationale policy in place that ensures there are sufficient staff on duty at all times to deliver care safely and within a timely manner.

Staffing rosters sighted and there are an adequate number of staff on duty to meet the resident’s needs on different shifts. The manager/RN and RN are on duty Monday to Friday and available on call after hours. There are two caregivers on the morning, afternoon and night shift. The activity officer is on duty form 9am to 1pm Monday to Friday.

The cooks are on duty from 10am to 6pm. A dedicated cleaner is employed Monday to Friday four hours each morning. A laundry worker is employed Monday to Friday. Caregivers carry out laundry and any cleaning duties in the weekends.

Five residents interviewed confirm that there are sufficient staff on site at all times and staff are approachable and in their opinion, professional, respectful and friendly. Call bells are answered within a reasonable timeframe.

Standard 1.2.9: Consumer Information Management Systems

Consumer information is uniquely identifiable, accurately recorded, current, confidential, and

FA Progress notes sighted (entered on the computer system) include the time of entry, the designation of the staff member completing the progress notes, are accurate and only approved abbreviations are used. This was a previous audit finding that has now been addressed.


accessible when required.

Standard 1.3.1: Entry To Services

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

FA Prior to entry potential residents have a needs assessment completed by NASC services to assess suitability for entry to the service. The service has an information pack available for residents/families/whānau at entry. The information pack includes all relevant aspects of service. The service has admission and care planning policies and family/whānau are provided with information in relation to the service. Information gathered at admission is retained in resident’s record.

D13.3: The admission agreement is that supplied by NZ aged care association and aligns with a) - k) of the ARC contract. All five admission agreements are signed and align with contractual requirements. This was a previous audit finding that has now been addressed.

D 14.1: Exclusions from the service are included in the admission agreement.

D 14.2: The information provided at entry includes examples of how services can be assessed that are not included in the agreement.

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 The supplying pharmacy delivers the medico blister packs and other pharmaceuticals. The medications reconciled by an RN on delivery. This was a previous audit finding that has now been addressed.

Medications are administered by the RN or caregivers who are medication competent. All staff administrating medications competencies are updated annually. This was a previous audit finding that has now been addressed. The RN and caregivers have attended annual medication education in August 2014. Designated staff is listed on the medication administration sheet which shows signatures/initials to identify the administering staff member.

The medication trolley is kept in locked medication room. Medications are stored safely. Controlled drugs are blister packed and recorded in a controlled drug register and stored in a locked cabinet within a locked cupboard in the locked treatment room. Controlled drugs returned to the pharmacy show a nil balance in the controlled drug register. There are currently three residents on controlled drugs for chronic pain relief. There are weekly stocktake checks evidenced in the controlled drug register. This was a previous audit finding that has now been addressed.

The medication fridge is checked weekly and temperatures are within acceptable ranges however there is no documented temperatures since 24 October 2014. There


is also no weekly documented oxygen cylinder checks since 21 August 2014. There are no standing orders in place. There are no self-medicating residents.

One caregiver was observed safely and correctly administrating medications. This was a previous audit finding that has now been addressed.

On review of ten medication charts, two residents have medication discontinued but these have not been signed off by the GP and one resident (admitted six days ago) is refusing to take antibiotics and the RN is unaware. These are areas requiring improvement. PRNs have documented indication for use. The medication folder includes information on insulin, blood sugar monitoring forms, INR charts and pulse charts for residents on digoxin. All eye drops in use are dated on opening.

Sharps are disposed of into an approved biohazard container. Unused medication is returned to the pharmacy for disposal. There is a pharmacy contract in place. The pharmacy is available for advice and support, as and when required. A medication audit has been completed in in October 2014.

D16.5.e.i.2: Eight of ten medication charts reviewed identified that the GP had seen the reviewed the resident three monthly and the medication chart was signed. This is an area requiring improvement.

Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

FA There are two cooks. One works Wednesday to Saturday and one Sunday, Monday and Tuesday. The main cook has been at the service for nine years. There is a four weekly winter and summer menu reviewed by the dietitian June 2013. All meals and baking is done on site. The main meal is at tea time at the suggestion of the residents. Residents interviewed are happy with the main meal at night. Residents enjoy a weekly cooked breakfast. Dietary profiles for new residents are forwarded to the cook. Resident likes and dislikes are known. Alternative meals are offered. Dietary requirements are met. Any changes to residents dietary needs or weight loss is communicated to the cook. Diabetics are catered for and there are protein drinks available. Hot food monitoring is recorded daily. The kitchen is well equipped with slow cookers, gas hobs, electric and conventional over. Fridge and freezer temperatures are recorded daily. Perishable foods are dated and labelled. All food supplies are delivered on a regular basis to meet the menu requirements. Food is stored safely up off the floor in the pantry. The dishwasher is serviced regularly. There is a fire extinguisher and fire blanket in the kitchen.

D19.2: Staff have been trained in safe food handling.


A food services audit has been completed in October 2014.

Two family/whanau members interviewed confirmed that the food meets the approval of their family/whanau member. Five residents confirm that they enjoy the food.

Standard 1.3.4: Assessment

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

PA Moderate There is a range of assessment tools completed on admission and as required for changes to health including but not limited to: a) continence b) coombes falls risk c) waterlow pressure area d) dietary profile e) nutritional assessment and management plan f) pain g) wound assessment h) physiotherapy assessment and care plan for mobility. The InterRAI tool is slowly being introduced. Information gained from these assessments are used to form the initial and long term care plans. One resident file did not evidence risk assessments completed on admission. Three residents on controlled drug pain relief do not evidence pain assessments completed following exacerbation of pain. An improvement is required around risk assessment tools which was a previous audit finding. The new manager is reviewing all residents risk assessments.

Standard 1.3.5: Planning

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

PA Low Care plans are a template document that includes support needs, problem/goal, interventions and evaluation. One resident has challenging behaviours, however the care plan does not include interventions, triggers, managements and monitoring of the challenging behaviours. All assessments and care plans have now been entered on the new computer programme. Five of five residents files sampled include input from GP's, allied health as appropriate and all staff from the facility. The new manager is reviewing all residents care plans. Residents and their family/whanau participate in the care pan and this information is available to other health professionals as needed.

D16.3k: Short term care plans are available for use for short term needs or changes to health status (# link 1.3.8.3).

Standard 1.3.6: Service Delivery/Interventions

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

PA Moderate There is documented evidence that the care plans were reviewed by the registered nurses and amended when current health changes however there is one resident with health deterioration and the care plan has not been updated with interventions to support the current health needs. This was a previous audit finding that still requires improvement. Four care plans reviewed have now been entered on to the new computer programme and evaluated six monthly. There is evidence that a Maori


health care plan is utilised. This was a previous audit finding that has now been addressed. Activity assessments and the activities care plans have been completed by the activities officer. The care being provided is consistent with the needs of residents. This is evidenced by discussions with residents, families, caregivers and a registered nurse. A review of short term care plans, long term care plans, evaluations and progress notes demonstrates integration. There is evidence of three monthly medical reviews. Residents' care plans are completed by the registered nurse. Care delivery is recorded and evaluated by caregivers or registered nurses in the progress notes at least at least daily and entered on to the computer programme. When a resident's condition alters, the registered nurse initiates a review and if required, arranges a GP visit or a specialist referral.

The two caregivers and the registered nurse interviewed stated that they have all the equipment referred to in care plans and necessary to provide care, including transfer belts, pressure care equipment, wheelchairs, wheel chair platform weighing scales, continence supplies, gowns, masks, aprons and gloves and dressing supplies. All staff report that there are always adequate continence supplies and dressing supplies. On the day of the audit supplies of these products were sighted. Five residents interviewed and two family interviewed were complimentary of care received at the facility.

D18.3 and 4 Dressing supplies are available. Wound assessment and wound management plans are in place for three residents with wounds. There are no pressure areas. All three of the documented wounds have been reviewed within the stated timeframe (one family member has input into the residents wound dressings). There is evidence of specialist input for one resident with wounds. There is one resident with a wound (ankle) that does not evidence a wound assessment and management plan. This was a previous audit finding that still requires improvement.

The registered nurses interviewed described the referral process and related form for referral to a wound specialist or continence nurse. Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified for day use, night use, and other management. Specialist continence advice is available as needed and this could be described.

Continence management in-services and wound management in-service have been provided. Continence audit has been competed in November 2014. During the tour of facility it was observed that all staff treated residents with respect and dignity, knocked on doors before entering residents’ rooms and ensured residents’ dignity and privacy was protected when transferring residents to the shower or toilet. Residents


interviewed were able to confirm that privacy and dignity was maintained

Standard 1.3.7: Planned Activities

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

FA The activity officer was previously in the hospitality industry before doing some volunteer work with the service. The activity officer has been with the service for two and a half years and has completed her core competencies with a diversional therapy mentor. She is employed for 20 hours per week (four hours a day) Monday to Friday. Regional meetings occur regularly with emails and updates on activities, functions and events. Residents are invited to inter home concerts, RSA functions and other community events. There are several lounges available for recreational activities which include exercises, newspaper reading, bowls, bingo, quizzes, entertainment and happy hours. Residents on the day of audit were seen to be participating in activities. Birthdays and festive occasions are celebrated. An external contractor provides a wheelchair van for outings. Catholic communion and monthly Christian church services are held on site. There are residents who attend their own church. Other community involvement for residents includes outings to concerts, lunches, cafes, shopping and aerobics at the local stadium.

The activities officer has current first aid certificate. There are two volunteers that assist with the activities programme. There are monthly resident meetings with the manager chaired by the recreational officer (minutes sighted). Suggestions and feedback is received on the activity programme. A monthly activities programme is developed and displayed on facility notice boards. Each resident receives a copy. A large print copy is available for those residents with vision impairment. Daily resident progress notes and attendance sheets are maintained. New residents have a social admission form and activity plan completed. The activity plan is developed within given timeframes and reviewed six monthly. All activity plans have been entered on to the computer programme. There is evidence of resident/family/whanau participation in the development and review of activity care plans in place. Five residents interviewed enjoy the activity programme.

Standard 1.3.8: Evaluation

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

PA Moderate D16.4a Care plans are reviewed and evaluated by the registered nurse six monthly or when changes to care occur as sighted in four of five care plans sampled (# link 1.3.6.1). There are six monthly written reviews that include the RN, GP and resident/family/whanau. All care plans have now been entered on to the new computer programme and evaluated. This was a previous audit finding that has now been addressed. The family/whanau contact record has written evidence of


discussion/meetings held with families/whanau regarding care plan reviews. Short term care plans are available for use for short term or acute needs. Examples of a short term care plan in use include weight loss, however short term care plans were not in place for four residents with unintentional weight loss, one resident with tongue ulcers, two residents with skin tears, one resident with a sore shoulder and three residents with infections. This was a previous audit finding that still requires improvement.

ARC D16.3c: All initial nursing assessment/care plans were evaluated by an RN within three weeks of admission

Standard 1.4.2: Facility Specifications

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

FA The service has a current building warrant of fitness that expires 26 April 2015.

Standard 1.4.6: Cleaning And Laundry Services

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

FA Residents are provided with safe and hygienic cleaning and laundry services. Chemicals are purchased from a contracted supplier and correctly labelled. The service has a secure area for the storage of cleaning and laundry chemicals. There is a designated cupboard alongside the laundry for the storage of cleaning chemicals which is kept locked. This was a previous audit finding that has now been addressed. Safety Data Sheets (MSDS) are readily available and there is spill kit available for body fluid/blood accidents. This was a previous audit finding that has now been addressed.

Standard 1.4.7: Essential, Emergency, And Security Systems

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

PA High The service does not have an approved fire evacuation scheme due to internal building repairs. The new manager has been in contact with the fire service and they are working through the process of obtaining an approved evacuation scheme as the building repairs have now been completed. The new manager is also arranging a compulsory fire drill to take place in December 2014 for all staff. There is no evidence of fire drills held in 2014. Fire drills are required to be carried out six monthly. A fire evacuation audit has been completed in October 2014. The service is required to submit an approved fire evacuation plan on completion of the compulsory fire drill. This was a previous audit finding that still requires improvement. Fire safety is included in the orientation. Monthly fire service checks are completed by an external


contractor. Fire safety extinguishers are checked annually November 2014.

The registered nurse manager and registered nurse have a current first aid certificate. Senior caregivers have current first aid certificates and there is a staff member with a current first aid on every shift. This was a previous audit finding that has now been addressed.

Residents' rooms, communal bathrooms and living areas all have call bells. The call bells ring to the panel in the nurse’s office. A light is activated above the resident door. Call bells are heard throughout the facility. This was a previous audit finding that has now been addressed.

Standard 3.5: Surveillance

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

FA The surveillance policy describes and outlines the purpose and methodology for the surveillance of infections. The infection control coordinator (RN) use the information obtained through surveillance to plan and determine infection control activities, resources and education needs within the facility. A monthly analysis of types of infections, trends, corrective actions and quality initiatives are reported to the staff meeting. Five staff (interviewed) confirm their awareness of infection control matters. Hand hygiene audits and an infection control environmental audit occurred in March 2014 with no corrective actions required. There have been no outbreaks at the service.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA There is a documented definition of restraint and enablers which is congruent with the definition in NZS 8134.0. The policy includes restraint procedures describing consent, assessment, evaluation and review. The policy identifies that restraint is used as a last resort, aligns with current best practice and has provision for emergency restraint. This was a previous audit finding that has now been addressed. There are clear guidelines in the policy to determine what a restraint is and what an enabler is. The service currently has no residents on restraint or using enablers.


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

Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights.

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

Criterion with desired outcome

Attainment Rating

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

Criterion 1.2.3.5

Key components of service delivery shall be explicitly linked to the quality management system.

PA Low The previous manager reported significant service delivery or operational concerns to the director as evidenced in corrective action reports. However there is no documented evidence of operational reports to governance.

There is no documented evidence of operational reports to governance.

Ensure there is a formal governance reporting system in place.

90 days

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 Resident/relatives are scheduled to occur annually.

The results of the resident/relative survey November 2013 have not been collated to identify if there any areas for improvement.

Ensure survey results are collated, acted upon and feedback to the staff and the consumers as appropriate.

90 days

Criterion 1.2.3.8 PA Low There is an internal audit programme Not all audits with areas of non-compliance have a corrective

Ensure all audit are dated, signed


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

with audits completed. action report. with corrective actions.

60 days

Criterion 1.2.3.9

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

PA Low The RN reports that the hazard register in use is current and covers all sources of hazards such as electrical, chemical, clinical, and environmental. Staff report any hazards identified on the hazard memo form.

The hazard register was unable to be located on the day of the audit.

Ensure that the hazard register is readily available at all times.

30 days

Criterion 1.2.7.3

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

PA Low The recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications, experience and suitability for the role. Staff are orientated to their area of work and

(i)One caregiver does not evidence reference checks completed. (ii) There is no evidence that job descriptions are signed in all five staff files reviewed. (iii) One caregiver and

(i)& (ii) Ensure recruitment documents are signed by the employee. (iii)Ensure orientation for all staff is completed. (iv) Ensure appraisals are completed annually.


complete competencies relevant to their role. Annual appraisals are on file for one of five staff files (two have not been at the service longer than 12 months).

one nurse manager do not evidence orientation completed or commenced. (iv) Two staff (one RN and one caregiver /team leader) do not evidence annual appraisals completed.

90 days

Criterion 1.3.12.1

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

PA Moderate

The supplying pharmacy delivers the medico blister packs and other pharmaceuticals. Medications are stored safely. Controlled drugs are blister packed and recorded in a controlled drug register and stored within a locked cabinet, in a locked cupboard in the locked treatment room. Controlled drugs returned to the pharmacy show a nil balance in the controlled drug register. Medication signing administration sheets are completed. Eight of ten charts reviewed identified that the GP had seen the resident three monthly and the medication chart was signed.

(i)Two residents have medications discontinued and these have not been signed off by the GP. (ii) One resident is refusing antibiotics and the RN is unaware. (iii) There have been no documented recording of weekly medication fridge temperatures since 24 October 2014. (iv) There have been no documented weekly recordings of oxygen cylinder checks since 21 August 2014. (v) Two medication charts do not show evidence that he GP has reviewed the medication three monthly.

(i)& (ii) Ensure medication management, administration of medications and documentation meet legislative requirements. (iii) & (iv) Ensure that medication fridge temperatures and oxygen cylinders are checked weekly and recordings documented. (v) Ensure that the GP reviews all residents medications charts three monthly and that these are signed.

30 days

Criterion 1.3.3.3

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

PA Moderate

The registered nurse (RN) and manager (RN) are responsible for undertaking the assessments on admission, with the initial care plan completed within 24 hours of admission and the long term care plan completed within three weeks.

One of five files identify that all risk assessments have not been completed on admission (# also refer 1.3.4.2) and the initial nursing care plan was not completed within 48 hours

Ensure all assessments and initial care plans are completed within the required timeframes.

30 days


Criterion 1.3.3.4

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

PA Moderate

Two caregivers one RN interviewed could describe the handover to the oncoming shift that maintains a continuity of service delivery. Progress notes are maintained at least daily and entered on to the new computer programme by caregivers

There is lack of documented evidence in the resident progress notes to support RN input.

Ensure that the RN documents in the progress notes following any change in the resident health.

30 days

Criterion 1.3.4.2

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

PA Moderate

There is a range of assessment tools for use on admission and as required for changes to health including but not limited to: a) continence b) coombes falls risk c) waterlow pressure area d) dietary profile e) nutritional assessment and management plan f) pain g) wound assessment h) physiotherapy assessment and care plan for mobility. Information gained from these assessments are used to form the initial and long term care plans.

(i) One resident did not have assessments completed on admission. (ii) Three residents on controlled drug pain relief do not have pain assessments completed by an RN following exacerbations of pain.

(i) Ensure risk assessment tools are completed on admission and reviewed six monthly. (ii) Ensure pain assessments are completed.

30 days

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 An initial assessment forms the basis of an initial care plan within the first 48 hours to guide staff in the safe delivery of care during the first three weeks of their admission. The RN develops the long term care plan from information gathered over the first three weeks of admission.

One resident has challenging behaviours, however the care plan does not include interventions, triggers, managements and monitoring of the challenging behaviours.

Ensure the residents care plan includes all aspects of interventions to support the residents health needs.

60 days

Criterion 1.3.6.1

The provision of services

PA Moderate

(i) There is documented evidence

(i)One resident with health deterioration does not evidence

(i)Ensure that all interventions in the residents care plans are


and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.

that the care plans were reviewed by the registered nurses and amended when current health changes. (ii) Wound assessment and wound management plans are in place for three residents with wounds.

interventions updated in the care plan to support current health needs. (i) One resident with a wound does not evidence a wound assessment and management plan completed.

updated to support resident health needs. (ii) Ensure that all residents with wounds have a wound assessment and management plan completed (or a short term care plan).

60 days

Criterion 1.3.8.3

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

PA Moderate

Short term care plans are available for use for short term or acute needs

Short term care plans were not in place for four residents with unintentional weight loss, one resident with tongue ulcers, two residents with skin tears, one resident with a sore shoulder and three residents with infections

Ensure that short term care plans are completed for all residents with short term or acute needs.

30 days

Criterion 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.

PA High Fire safety is included in the orientation.

There is no evidence of fire drills held in 2014.

Fire drills are required to be carried out six monthly.

90 days

Criterion 1.4.7.3

Where required by legislation there is an approved evacuation plan.

PA High Monthly fire service checks are completed by an external contractor. Fire safety extinguishers are checked annually November 2014.

The service does not have an approved fire evacuation scheme due to internal building repairs.

The service is required to submit an approved fire evacuation plan.

30 days


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

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

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

No data to display

End of the report.

five pillars limited - ministry of health nz...five pillars limited date of audit: 26 november 2014...

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