internal audit work book audit work... · reviews. services sharing planning are integrated –...

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Internal Audit Work Book

2009

_______________ Your Name here _______________

2009 Internal Audit Work Book

Index

Index

Audit of Resident Care Plans Page 3

Informed Consent Survey Page 5

Satisfaction Survey – eight essential elements Page 6

Audit of Complaints Page 7

Food Handling Audit Page 8

Audit of Laundry Services Page 9

House Keeping Audit Page 10

Audit of Single Use Items Page 11

Personal Cares Audit Page 12

Review Success of Corrective Actions:

Audit of Resident Care Plans Page 13

Informed Consent Survey Page 15

Survey of Back Pain Page 16

Audit of Complaints Page 17

Satisfaction Survey Page 18

Food Handling Audit Page 19

Audit of Laundry Services 0

House Keeping Audit Page 21

Audit of Single Use Items Page 22

Personal Cares Audit Page 23

Audit of Call Bells Page 24

Self Survey of Fluids Available to Residents in the Home Appendix 1

Self Survey of Diabetic Meal Planning Appendix 2

Norovirus Outbreak Preparedness Self Survey Appendix 3

_______________ Your Name here _______________

www.HH.net.nz Page 1 of 1 Issued: 01.01.09

Audit Calendar Crossed off as they are completed.

Audit Jan Feb Mar April May June July Aug Sept Oct Nov Dec Care Planning

Δ

Δ

Informed Consent

Δ

Δ

Satisfaction

Δ

Δ

Complaints

Δ

Δ

Kitchen

Δ

Δ

Laundry

Δ

Δ

Housekeeping Δ

Δ

Single Use Items

Δ

Δ

Call Bells Δ

Δ

Δ

Δ

Δ

Δ

Δ

Δ

Δ

Δ

Δ

Δ

Survey Back Pain

Δ

Δ

Hand Washing Survey

Δ Δ

Personal Cares Audit

Δ Δ

Menu Self Assessment

Δ

Testing & Calibration of

Equipment

Δ

Review Schedule Significant

Hazard Register

Δ Δ Δ Δ

Disaster Planning

Δ Δ

Business Management

Plan

Δ Δ Δ Δ

Strategic Planning

Δ Δ Δ Δ

Health & Safety

Management System

Δ

_______________ Your Name here _______________


Audit of Resident Care Plans [6 monthly] Date:…………………….. Collated results of at least six Care Plans selected at random. Where requirements are unattained in these plans, look at more: Requirement Yes No We have a register of all residents We record all hospital admissions & record re-admissions [21 days] Resident records are in one integrated file. Photo for ID as appropriate Staff always sign & date records [legibly]when they write updates Records are securely stored – locked up unless in use. PW on PC. Where computer records are used ALL staff use their own login’s. ASSESSMENT Have all new admissions been seen by GP within 24 hours of admission? Comprehensive RN & Risk Assessments are kept up to date by the RN. Have all residents been seen by GP in past 3 months? Meds reviewed? Are there residents who need to see a dentist? Have all residents had a pain & assessment? Susceptible or quiet residents are assessed for depression? We have comprehensive Quality Assessments and we use them. Is the RN / clinician trained to administer Quality Assessments? Where assessments are provided by more than one service is Service Coordination clear?

Is repetition across services minimised Links to other services are clear All services coordinating resident care are recorded Results of assessments are made known to all who need to know. COLLABORATIVE PLANNING. Care planning is shared with family / advocates / resident. Clients are given copies of their plans / access own notes? Those without family ALL have outside Advocates who are involved in reviews.

Services sharing planning are integrated – good linkages shown GOAL SETTING Short term goals are easy to identify – may be called problems Long term goals are easy to identify. Community strengths and assets are noted in care planning Resident & Family are assisted in realistic goal setting. Goals are sensible, realistic, time-limited, measurable & achievable REPORT WRITING Are these words used frequently in report writing? Slept well, Fluids pushed, Same, Satisfactory Watched TV, Passed urine.

Changes are noted clearly signed and dated WHEN they occur. Are falls and infections reported? Have incident forms been filled in? Was enough information on the forms? Are these dated & signed? EVALUATION Evaluations show the degree of goal achievement Changes are initiated where evaluation is less than expected. Staff are aware of resident need This is clearly documented for each individual

_______________ Your Name here _______________


NORMALISATION Is safety of resident possessions documented? Is social interaction noted? Is diversional / occupational therapy individualised? Do activities develop & maintain strengths, skills, interests? Are people from the community involved in activity planning? Is individualised exercise a part of most days for each resident no matter how low?

Problem Area & recommended corrective action Person Responsible By date. e.g. Some of our falls have not been well documented [unsigned / undated / little information] or documented late. Staff need refresher training & an assessment of knowledge.

Trainer & Manager 21.03.08

Audit Comments: Audited by: ……………………………………………Designation: ………………………… Audited by: ……………………………………………Designation: ………………………… Date: ……………………………………… Signed Off at Review Meeting: ………………………….. [Manager]

_______________ Your Name here _______________


Informed Consent Formal Audit Date:…………………… [6 monthly with Audit of Care Plans]

Note attainment YES All clients have filled in and signed consent forms for essential cares

Code of Rights is available in different languages www.hdc.org.nz

Staff have training in the Code of Rights [especially sections 5,6 & 7]

Resident choices & decisions are recorded and acted upon.

Where there is doubt about a person’s competence to consent the GP or other clinician will use recognised tools to evaluate competence.

Where a person is not competent a suitable Advocate will be found

Advance directives may be documented and acted upon where valid.

All staff have received training about consent and informed consent. Staff taking consents have additional training.

All clients are informed of their right to withdraw consent and where there is refusal that alternative options will be considered.

A multidisciplinary Team should conduct this audit. i.e. Persons with different roles in the

organisation, [e.g. Client Representative, Kuia or Komatua, board member, Manager,

Team Leader, other Health Professional] rather than the by the person collecting

Informed Consents.

Conducted by:___________________________ Designation______________________ Conducted by:___________________________ Designation______________________ Conducted by:___________________________ Designation______________________ Problem Area & recommended corrective action Person Responsible By date. e.g. Not all staff trained well enough need training and knowledge assess. Manager 21.03.08

Sign off at Review Meeting: ___________________________ Date:_________________ [Manager]

_______________ Your Name here _______________


Concerns & Complaints Audit Date:…………….. Link to Satisfaction Survey [6 monthly] Is there a clear way that clients realise that they have the right to complain? [This can be demonstrated through satisfaction audit].

Requirement Yes No We have a Complaints Register – it is up to date Staff receive training in Complaints Management Staff WILL document verbal complaints Information about the Right to Complain is clearly displayed for residents.

Information on the Right to Advocacy is clearly displayed Person responsible for timely action & follow up of complaints is:

Copies of Right to Complain are available for people to take away. Complaints:

Are written on the correct form These are shown to the Team Leader / Manager as soon as possible They are resolved at the lowest level possible If more than trivial a Complaints Outcome Form is used People who complain receive written copies of the outcomes of

complaints

Verbal complaints are documented discretely so that we have the opportunity for improvement.

Complaints about challenging behaviours inspire support from management.

We have a suggestion box so that complaints may be anonymous? Resident meetings are a forum for suggestion and a place where any complaints and concerns are discovered?

Where complaints and suggestions come through resident meetings good suggestions ARE actioned.

Problem Area & recommended corrective action Person Responsible By date. e.g. We don’t have a Suggestion Box Residents & Diversional Ther. 21.03.08

Audited by: …………………………………………Designation: ……………………………. Audited by: …………………………………………Designation: ……………………………. Date: ……………………………………… Signed Off at Review Meeting: ………………………….. Date: ………………….

_______________ Your Name here _______________


[Manager]

Food Handling Audit Date:………………. [6 monthly or more often as required] Choose someone who does not usually work in the kitchen to conduct this audit. Do not ask the kitchen staff to prepare for the audit. Conduct it anytime. Refrigerator Inspection: Temperature 0 – 4 degrees Celsius Y N Have temperature recordings been missed or unsafe temperatures ignored? Is there any cooked food in the fridge that has no date on it? Are jugs that uncovered or is there any left over food more than 24 hours old? Is their any cooked and raw food stored together? Can thawing food drip onto other food? Are the seals on the doors perished? Or does the freezer leak? In walk in coolers, are heavy items stored up high, hard to lift or floor crowded? Freezer Inspection: Temperature minus 18 degrees Celcius Y N Are there bags or containers without labels? Are there old frozen goods on top of fresh ones? Have temperature recordings been missed or unsafe temperatures ignored? Safe Food Handling Y N It is easy to wash your hands – good hand washing basin! There are plenty of gloves and a staff first aid box. Is there good environmental cleaning in kitchen/dining room after EVERY meal? No pets ever. No mice or vermin. No smoking in the kitchen ever. No build up of grease or dust on extractors. The place looks and smells clean and tidy. No cracks or rips in lino. The floor is easy to clean. The Fire Blanket is easy to access quickly. The Fire extinguisher for the kitchen is fully functional. Food Enjoyment & Quality Y N Plenty of information is available about special diets residents might need. Special equipment is available for those who need it – straws, spoons, cups etc. Resident food satisfaction has been surveyed & survey results acted upon. There is plenty of fresh fruit for residents every day and out of meal times. Susceptible residents have dietician input – especially if under weight / frail / diabetic People from different cultures enjoy there own preferred food often enough Special diets are provided for those that need them. Problem Area & recommended corrective action Person Responsible By date. e.g. Build up of grease on extractor hood Cleaner & cook 21.03.08

Please write on reverse of page if you need more room. Signed:………………………………………………[person conducting audit] Signed off at Review Meeting: …………………………………….[Manager]

_______________ Your Name here _______________


Laundry Services Audit Date:………………. [6 monthly or more frequently as required] It’s a good idea to use your Health & Safety Representatives for this audit.

Requirement Yes No Written Policy & Procedure is readily available to staff. There is good hand washing with flowing soap & paper hand towels. The flow of laundry goes from dirty to clean without crossing its tracks Staff use covered containers to transport dirty laundry in There are enough covered containers and linen trundlers There are plenty of gloves and antibacterial hand rub & good rubbish bins Information on the laundry process is posted where it is easy to see Good instructions on the washing & drying cycles are easy to understand The laundry is clean and usually smells nice Contaminated laundry:

Is processed separately If bleach is used there is a measure and good instructions on usage Water proof aprons & gloves & goggles are readily available Eye rinse is easy to do [tap water is acceptable but saline is nicer] Disinfection is adequate

Chemicals are labelled & stored safely [bleach & detergents & House hold cleaners only]. We have a Material Safety Data Sheet for each one used.

Washing machines & driers work properly & are well maintained. Instructions for their use are easy to understand There is a person responsible for the smooth running of the laundry Resident clothing is washed carefully so as not to be harmed or lost. There is good signage about Standard Precautions Staff are observed carrying bundles of linen against their uniforms [undesirable] Linen is placed on the ground in resident rooms or in the laundry [undesirable] Staff are seen to wash their hands after contact with used linen [desirable] Problem Area & recommended corrective action Person Responsible By date. e.g. Policy & Procedure is out of date Consultant & Manager 21.03.08

Signed:………………………………………………[person conducting audit] Signed off at Service Review: …………………………………….[designation]

_______________ Your Name here _______________


House Keeping Audit Date:……………….

Requirement Yes No Written Policy & Procedure is readily available to staff. Residents clean their own areas or help us if they can & if they choose to. There is good hand washing with flowing soap & paper hand towels. We have a dedicated cleaner – staff don’t cope with dual jobs Cleaners know their responsibilities – they have a job description. The cleaner / s feel that they have enough cleaning product / equipment Are there enough cleaning hours at the times we need them? Does the Home smell clean and nice? Are there any cobwebs in window corners or high up on ceilings? Is there food left under tables after meals? Are tables wiped after meals? Do chairs have sticky arms or unclean appearance to upholstery? Are skirting boards clean? Are floor surfaces clean? Are there any residents who refuse to have their rooms cleaned? Is this OK? Cleaning Products:

Household / commercial cleaners and bleach is all that we use. If bleach is used there is a measure and good instructions on usage Water proof aprons & gloves & goggles are readily available We have a dedicated cleaning trolley or basket We have a safe place for cleaning equipment & solutions


Windows are sufficiently clean that dirt & grime is not easily noticed. Ants, vermin etc are adequately controlled. Do animals that are pets place a burden upon cleaning? The Home is sufficiently tidy. There is good access. It is not cluttered. Staff have easy access to a well stocked Staff First Aid box. Infection Control:

Cleaner / s are trained in Standard Precautions & Hazardous Waste. Cleaners attend refresher training when it is offered. Cleaners DO NOT wear gloves from room to room. Cleaners are seen to wash their hands after cleaning each room. Cleaners have dedicated heavy gloves to clean toilets. Each toilet has its own toilet brush. Cleaners have their own plastic apron.

Problem Area & recommended corrective action Person Responsible By date. The cleaner has left and Care Staff are cleaning as well as caring. Need to hire or delegate existing staff into cleaning role.

Manager ASAP

Signed:………………………………………………[person conducting audit.] Signed off at H&S Review: …………………………………….[designation]………………

_______________ Your Name here _______________


Audit of Single Use Items Date:…………………. [6 monthly] Definition: A Single Use Item is equipment or product that is only used once, then it must be discarded. We will also look at items only used by one resident and not communally shared. RE USED? Single Use Equipment / Supplies Yes No Syringes Blood glucose monitoring machines Needles in BM testing equipment Needles for injection Dressing Packs or the trays / forceps within. Indwelling catheters Gloves Product Used more than once but only by one resident NOT shared Yes No Dressing trays Oxygen masks / tubing / Spacers Soap / shampoo Combs - person hair items are not shared Razors – no razors are shared Toothbrush / toothpaste Talcum powder Eye drops – discarded after 7 – 10 days Ointments / creams / jells – for individuals and not shared Problem Area & recommended corrective action Person Responsible By date. e.g. Male residents are sharing a razor. More need to be purchased so that each has their own.

Manager & Advocate for TC new resident

ASAP

Audited by: ……………………………………………Designation: ………………………… Signed Off at Review Meeting: ………………………….. [Manager]

_______________ Your Name here _______________


SURVEY TO HELP IMPROVE CARE? More accurate results are gained if this survey is provided by someone that does not usually work in the Home. Are staff friendly and kind?

☺ Not always Yes Sometimes Often Always Are you kept waiting when you really need us to help you?

☺ Always Often Usually Sometimes Never Do personal cares [e.g. help with cleaning teeth or putting things away] get missed?

☺ Never Maybe Sometimes Often Yes Are staff too helpful rather than letting you manage yourself even if you are slow?

☺ Never Usually Sometimes Often Always Do care staff leave your room tidy after helping with care?

☺ Not really Usually Sometimes Often Always Are care staff gentle? Do you feel that they are caring towards you?

☺ Not really Sometimes Often Mostly Always Do staff tell you what to do, rather than ask if you would like to do something?

☺ Never Once Sometimes Not really Often Do staff dress nicely [clean and tidy]?

☺ Never Maybe Sometimes Often Always

Please write on the back suggestions that you would like to make. You have the right to make suggestions. All suggestions will be considered. Signed [Anonymous if you wish]:______________________________ Date:_____________

[Resident] Combined results are graphed and discussed at Service Review Meetings to improve our service.

_______________ Your Name here _______________


ARE YOU HAPPY WITH OUR SERVICE ?

[3 - 6 monthly survey or upon client exit from service] I know how to make a complaint.

☺ Not Confident Capable Confident Staff use my preferred name.

☺ Never Sometimes Always Staff are respectful and courteous

☺ Never Usually Sometimes Often Always My privacy is respected and staff knock before entering my room

☺ Never Usually Sometimes Often Always I eat the kind of food I like the most and it is good for me

☺ ☺ Never Usually Sometimes Mostly Always I am doing enjoyable things and I look forward to activities and outings

☺ NO Maybe YES I get enough visitors.

☺ Never Usually Sometimes Often Always Staff realise where I come from and respect me for who I am.

☺ Never Usually Sometimes Often Always

Please write on the back suggestions that you would like to make. You have the right to make suggestions. All suggestions will be considered. Signed [Anonymous if you wish]:______________________________ Date:_____________

[Resident] Combined results are graphed and discussed at Service Review Meetings to improve our service.

_______________ Your Name here _______________


Audit of Resident Care Plans [6 monthly] Date:…………………. Collated results of at least six Care Plans selected at random. Where requirements are unattained in these plans, look at more: Requirement Yes No We have a register of all residents We record all hospital admissions & record re-admissions [21 days] Resident records are in one integrated file. Photo for ID as appropriate Staff always sign & date records [legibly]when they write updates Records are securely stored – locked up unless in use. PW on PC. Where computer records are used ALL staff use their own login’s. ASSESSMENT Have all new admissions been seen by GP within 24 hours of admission? Comprehensive RN & Risk Assessments are kept up to date by the RN. Have all residents been seen by GP in past 3 months? Have all residents seen dentist in past year? Are there any who need to? Have all residents had a pain & assessment? Susceptible or quiet residents are assessed for depression? We have comprehensive Quality Assessments and we use them. Is the RN / clinician trained to administer Quality Assessments? Where assessments are provided by more than one service is Service Coordination clear?

Is repetition across services minimised Links to other services are clear All services coordinating resident care are recorded Results of assessments are made known to all who need to know. COLLABORATIVE PLANNING. Resident & family were involved in care planning / review The resident has signed their care plan / plan review. Clients are given copies of their plans / access own notes? Those without family ALL have outside Advocates who are involved in reviews.

Services sharing planning are integrated – good linkages shown GOAL SETTING Short term goals are easy to identify – may be called problems Long term goals are easy to identify. Community strengths and assets are noted in care planning Resident & Family are assisted in realistic goal setting. Goals are measurable & achievable REPORT WRITING Are these words used frequently in report writing? Slept well, Fluids pushed, Same, Satisfactory Watched TV, Passed urine.

Changes are noted clearly signed and dated WHEN they occur. Are falls and infections reported? Have incident forms been filled in? Was enough information on the forms? Are these dated & signed? EVALUATION Evaluations show the degree of goal achievement Changes are initiated where evaluation is less than expected.

_______________ Your Name here _______________


NORMALISATION Is safety of resident possessions documented? Is social interaction noted? Is diversional / occupational therapy individualised? Do activities develop & maintain strengths, skills, interests? Are people from the community involved in activity planning? Is individualised exercise a part of most days for each resident no matter how low?

Problem Area & recommended corrective action Person Responsible By date. e.g. Some of our falls have not been well documented [unsigned / undated / little information] or documented late. Staff need refresher training & an assessment of knowledge.

Trainer & Manager 21.03.08

Audit Comments: Audited by: ……………………………………………Designation: ………………………… Audited by: ……………………………………………Designation: ………………………… Date: ……………………………………… Signed Off at Review Meeting: ………………………….. [Manager]

_______________ Your Name here _______________


Informed Consent Formal Audit Date:…………………… [6 monthly with Audit of Care Plans]

Note attainment YES All clients have filled in and signed consent forms for essential cares

Code of Rights is available in different languages www.hdc.org.nz

Staff have training in the Code of Rights [especially sections 5,6 & 7]

Resident choices & decisions are recorded and acted upon.

Where there is doubt about a person’s competence to consent the GP or other clinician uses recognised tools to evaluate competence.

Where a person is not competent a suitable Advocate will be found

Advance directives may be documented and acted upon where valid.

All staff have received training about consent and informed consent. Staff taking consents have additional training.

All clients are informed of their right to withdraw consent and where there is refusal that alternative options will be considered.

A multidisciplinary Team should conduct this audit. i.e. Persons with different roles in the

organisation, [e.g. Client Representative, Kuia or Komatua, board member, Manager,

Team Leader, other Health Professional] rather than the by the person collecting

Informed Consents.

Conducted by:___________________________ Designation______________________ Conducted by:___________________________ Designation______________________ Conducted by:___________________________ Designation______________________ Problem Area & recommended corrective action Person Responsible By date. e.g. Not all staff trained well enough need training and knowledge assess. Manager 21.03.08

Sign off at Review Meeting: ___________________________ Date:_________________ [Manager]

_______________ Your Name here _______________


Do you Hurt at Work? Six monthly audit of staff Wellbeing

Do you REGULARLY feel discomfort at work, or after work, in any of the following places? Only write in BOX 1 or BOX 2 Neck Shoulder Upper back Lower back Sciatic pain [radiating leg pain] Or

I might feel a few twinges sometimes, but mostly I am OK. No I feel no significant pain

List most likely activities to cause ANY symptoms: [please write on back if not enough space] i. ………………….. ii.…………………… iii………………….. Information will be correlated and made available to staff. Individuals will not be identified. Results of this survey will be used to help improve moving and handling challenges faced by staff. I consent to this information being collected so that we can assess the level of back pain among our staff. Signed: ________________________ Date: ___________________

Please help us to improve things for you.

BOX 1

BOX 2

_______________ Your Name here _______________


Why Do You Hurt? Neck Shoulder Upper back Lower back Sciatic pain [radiating leg pain]

1. Did this problem start with an injury? Yes / No 2. If so, how long ago was this injury? _________________________________

Please estimate if you cannot remember exactly. 3. Have you attended Moving and Handling Training in the past 6 months? Yes / No 4. Do you use a computer at home? Yes / No 5. If so, how many hours per day? _________________________________ Please estimate if you cannot remember exactly. 6. What makes your problem worse? 7. What helps it to improve? 8. Do you play regular sport / take regular exercise? [This can be most beneficial].

Please feel free to give us any extra information / ideas on how we might help improve things

for you. Write on the other side of the page. Use this form to follow up those with discomfort.

NB: Private information. Photocopy page & keep in staff files.

Please indicate where you feel discomfort

_______________ Your Name here _______________


Concerns & Complaints Audit Date:……………..

Link to Satisfaction Survey [6 monthly] Is there a clear way that clients realise that they have the right to complain?

[This can be demonstrated through satisfaction audit].

Requirement Yes No We have a Complaints Register – it is up to date Staff receive training in Complaints Management Staff WILL document verbal complaints Information about the Right to Complain is clearly displayed for residents.

Information on the Right to Advocacy is clearly displayed An up to date Complaints Register is maintained Copies of Right to Complain are available for people to take away. Complaints:

Are written on the correct form These are shown to the Team Leader / Manager as soon as possible They are resolved at the lowest level possible If more than trivial a Complaints Outcome Form is used People who complain receive written copies of the outcomes of

complaints

Verbal complaints are documented discretely so that we have the opportunity for improvement.

Complaints about challenging behaviours inspire support from management.

We have a suggestion box so that complaints may be anonymous? Resident meetings are a forum for suggestion and a place where any complaints and concerns are discovered?

Where complaints and suggestions come through resident meetings good suggestions ARE actioned.

Problem Area & recommended corrective action Person Responsible By date. e.g. We don’t have a Suggestion Box Residents & Diversional Ther. 21.03.08

Audited by: …………………………………………Designation: ……………………………. Audited by: …………………………………………Designation: ……………………………. Date: ……………………………………… Signed Off at Review Meeting: ………………………….. [Manager]

_______________ Your Name here _______________


Food Handling Audit Date:………………. [6 monthly or more often as required] Choose someone who does not usually work in the kitchen to conduct this audit. Do not ask the kitchen staff to prepare for the audit. Conduct it anytime. Refrigerator Inspection: Temperature 0 – 4 degrees Celsius Y N Have temperature recordings been missed or unsafe temperatures ignored?

Is there any cooked food in the fridge that has no date on it? Are jugs that uncovered or is there any left over food more than 24 hours old?

Is their any cooked and raw food stored together? Can thawing food drip onto other food? Are the seals on the doors perished? Or does the freezer leak? In walk in coolers, are heavy items stored up high, hard to lift or floor crowded?

Freezer Inspection: Temperature minus 18 degrees Celcius Y N Are there bags or containers without labels? Are there old frozen goods on top of fresh ones? Have temperature recordings been missed or unsafe temperatures ignored?

Safe Food Handling Y N There are separate chopping boards for raw and cooked food. Staff know reheated food is hotter than 70 degrees C for at least 2 minutes. It is easy to wash your hands – good hand washing basin! There are plenty of gloves and a staff first aid box. It is easy to walk around – no boxes of stored things in the way. No pets ever. No mice or vermin. No smoking in the kitchen ever. No build up of grease or dust on extractors. The place looks and smells clean and tidy. No cracks or rips in floor covering. The floor is easy to clean. The Fire Blanket is easy to access quickly. The Fire extinguisher for the kitchen is fully functional. Food Enjoyment & Quality Y N Plenty of information is available about special diets residents might need. Special equipment is available for those who need it – straws, spoons, cups etc. Resident food satisfaction has been surveyed & survey results acted upon. There is plenty of fresh fruit for residents every day and out of meal times. Susceptible residents have dietician input – especially if under weight / frail / diabetic People from different cultures enjoy there own preferred food often enough Problem Area & recommended corrective action Person Responsible By date. e.g. Build up of grease on extractor hood Cleaner & cook 21.03.08

Please write on reverse of page if you need more room. Signed:………………………………………………[person conducting audit] Signed off at Review Meeting: …………………………………….[Manager]

_______________ Your Name here _______________


Laundry Services Audit Date:………………. [6 monthly or more frequently as required] It’s a good idea to use your Health & Safety Representatives for this audit.

Requirement Yes No Written Policy & Procedure is readily available to staff. There is good hand washing with flowing soap & paper hand towels. The flow of laundry goes from dirty to clean without crossing its tracks Staff use covered containers to transport dirty laundry in There are enough covered containers and linen trundlers There are plenty of gloves and antibacterial hand rub & good rubbish bins Information on the laundry process is posted where it is easy to see Good instructions on the washing & drying cycles are easy to understand The laundry is clean and usually smells nice Contaminated laundry:

Is processed separately If bleach is used there is a measure and good instructions on usage Water proof aprons & gloves & goggles are readily available Eye rinse is easy to do [tap water is acceptable but saline is nicer] Disinfection is adequate


Washing machines & driers work properly & are well maintained. Instructions for their use are easy to understand There is a person responsible for the smooth running of the laundry Resident clothing is washed carefully so as not to be harmed or lost. There is good signage about Standard Precautions Staff are observed carrying bundles of linen against their uniforms [undesirable] Linen is placed on the ground in resident rooms or in the laundry [undesirable] Staff are seen to wash their hands after contact with used linen [desirable] Problem Area & recommended corrective action Person Responsible By date. e.g. Policy & Procedure is out of date Consultant & Manager 21.03.08

Signed:………………………………………………[person conducting audit] Signed off at Service Review: …………………………………….[designation]

_______________ Your Name here _______________


House Keeping Audit Date:……………….

Requirement Yes No Written Policy & Procedure is readily available to staff. Residents clean their own areas or help us if they can & if they choose to. There is good hand washing with flowing soap & paper hand towels. We have a dedicated cleaner – staff are not to cope with dual jobs Cleaners know their responsibilities – have a job description. The cleaner / s feel that they have enough cleaning product / equipment Are there enough cleaning hours at the times we need them? Does the Home smell clean and nice? Are there any cobwebs in window corners or high up on ceilings? Is there food left under tables after meals? Are tables wiped after meals? Do chairs have sticky arms or unclean appearance to upholstery? Are skirting boards clean? Are floor surfaces clean? Are there any residents who refuse to have their rooms cleaned? Is this OK? Cleaning Products:

Household / commercial cleaners and bleach is all that we use. If bleach is used there is a measure and good instructions on usage Water proof aprons & gloves & goggles are readily available We have a dedicated cleaning trolley or basket We have a safe place for cleaning equipment & solutions


Windows are sufficiently clean that dirt & grime is not easily noticed. Ants, vermin etc are adequately controlled. Do animals that are pets place a burden upon cleaning? The Home is sufficiently tidy. There is good access. It is not cluttered. Staff have easy access to a well stocked Staff First Aid box. Infection Control:

Cleaner / s are trained in Standard Precautions & Hazardous Waste. Cleaners attend refresher training when it is offered. Cleaners DO NOT wear gloves from room to room. Cleaners are seen to wash their hands after cleaning each room. Cleaners have dedicated heavy gloves to clean toilets. Each toilet has its own toilet brush. Cleaners have their own plastic apron.

Problem Area & recommended corrective action Person Responsible By date. The cleaner has left and Care Staff are cleaning as well as caring. Need to hire or delegate existing staff into cleaning role.

Manager ASAP

Signed:………………………………………………[person conducting audit.] Signed off at H&S Review: …………………………………….[designation]………………

_______________ Your Name here _______________


Audit of Single Use Items Date:…………………. [6 monthly] Definition: A Single Use Item is equipment or product that is only used once, then it must be discarded. We will also look at items only used by one resident and not communally shared. RE USED? Single Use Equipment / Supplies Yes No Syringes Blood glucose monitoring machines Needles in BM testing equipment Needles for injection Dressing Packs or the trays / forceps within. Indwelling catheters Gloves Product Used more than once but only by one resident NOT shared Yes No Dressing trays Oxygen masks / tubing / Spacers Soap / shampoo Combs Razors Toothbrush / toothpaste Talcum powder Eye drops Ointments / creams / jels Problem Area & recommended corrective action Person Responsible By date. e.g. Male residents are sharing a razor. More need to be purchased so that each has their own.

Manager & Advocate for TC new resident

ASAP

Audited by: ……………………………………………Designation: ………………………… Signed Off at Review Meeting: ………………………….. [Manager]

_______________ Your Name here _______________


Audit of Call Bells Month Problem Area / Corrective Action & Person Responsible Signature Jan Date:

Feb Date:

March Date:

April Date:

May Date:

June Date:

July Date:

August Date:

Sept Date:

Oct Date:

Nov Date:

Dec Date:

Instructions: This is a task that may be delegated to any responsible person. Test every call bell. Any that are not functioning perfectly [don’t work, faulty in any way, hard to reach, frayed wires, hard to press] are listed for repair. Sign and date once repaired. Note any repairs or upgrades in the month they occurred. Testing needs to be done at least monthly. Action repairs on any faulty bells as soon as possible if needed.

_______________ Your Name here _______________


Menus: Appendix 1 - Fluids www.HH.net.nz

Rest Home Self Survey Policy: Fluids are readily available – The sensation of thirst in older people is diminished and many need reminding & encouragement to drink at least 8 cups of liquid each day. Reference: Heartbeat catering: Guidelines for older New Zealanders We provide unlimited fluids Water & glasses are available from the cooler

Water & glasses are available at tables Water is available in jugs in rooms – these are refilled twice daily

We provide low fat & saturated milk

Offer reduced fat & standard milk at meal and for snacks. YES NO

Range of Fluids Flavoured milk or milo available A ‘diet’ soft drink available

Quenching juice drink [ e.g. dilute cranberry or pomegranate] Iced tea or Chinese tea Soy drinks

Vegetable juice / thin soups / jellies Fluids Available at these times [Most fluids in the morning]

√ At each meal

√ Between meal snacks √ Supper time

Enough Fluids [Use of Fluid Balance Charts]

√ Help residents who take little fluids

√ Encourage – some residents forget to drink

√ Good variety of fluids

√ Make fluids pleasant – e.g cordials & iced tea served as a round of ‘drinks’. Be aware anyone limiting intake for fear of incontinence

Aids Drinking cups

Soup spoons Flexi-straws Fluid Thickener

Coffee Coffee mornings only for sleepless people Filter or plunger / instant coffees rather than percolated. Effects of caffeine can last up to 8 hours.

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Menus: Appendix 2 Diabetic Foods / Healthy Heart Food www.HH.net.nz

Rest Home Self Survey of Menus Guideline: 1. Rely on vegetables for carbohydrate [e.g. kumera & potatoes, pumpkin, swede, turnips, fruits whole grains or beans]. 2. Avoid saturated fat, salt & sugar. Reference: Heartbeat catering: Guidelines for older New Zealanders Low in unsaturated fat NB: low GI cereals are best

3 serves of vegetables each day 3 serves of bread & cereals 1 serve of good protein every day Low fat milk available

Regular meals To control blood glucose - Regular meals - Evenly spaced throughout the day

Guidelines Use higher fibre cereal & breads Unsweetened fruit for breakfast

Use rice, breads, fruits / vegetables or beans at lunch

Use rice, vegetables, cereals, spaghetti, beans or fruits at dinner. Low fat snacks – fruit, crispbread, cottage cheese, tomato, plain scones, sandwiches, cold falafels, homous.

Bake, poach, grill, steam. Avoid frying. Managing High Fat

√ Avoid High Fat in the Home’s Menu not just the Diabetic Menu :

- Grill fresh fish rather than regular Friday fatty batter. - Include game or duck, goat or venison - Avoid cheaper mince with higher fat content - Mix lentils in with meat to boost protein & lower fat ratio [the lentils

take on the meat flavor & improve fiber content]

√ Use canned salmon, baked chicken, lean meats √ Fat free options include – soy, lentils, chick peas & beans

Choosing Low Fat / Salt Options

√ Salad dressings of Rice Bran Oil with a dash of vinegar

√ Salad dressings from low fat unsweetened yoghurt

√ Avoidance of full creams & cheeses

√ Flavour up low fat alternatives with fresh fruit. Regular Food [Unless weight reduction desirable]

Small amounts of sugar are OK with high fibre

Use regular jams just spread very thinly Artificial sweetener is liked by some people

Use brown sugar sparingly Carbohydrates at every meal

Breads & Cereals – whole meal & whole grain Fruit – fresh or cooked without added sugar [not dried] Vegetables – fresh or frozen, dark or brightly coloured.

Desert Options BEWARE HIGH SUGAR FRUITS Grapes / Raisins/ Mandarins Dried fruit

Custards, milk deserts, cereal puddings all prepared without sugar. Use artificial sweetener if necessary.

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Norovirus Outbreak Self Survey for Rest Homes www.HH.NET.nz

How Prepared are YOU? ☼ Protection! TRAINING

Ref: SNZ 8134: 2008 Ref: HH.NET Training Module 11 – Infection Control & Outbreak Prevention

Ref: Bug Control Infection Control Manual: www.healthcareproviders.org.nz

□ Have Bug Control Resource Manual for training guide how to put on a gown & outbreak resource!

□ Staff knowledge assessed as competent- Critical Risk Points in Food Preparation.

□ Staff knowledge assessed as competent standard precautions & outbreak response.

□ Staff knowledge assessed as competent- Protecting self using gowns, masks and gloves - practical

SUSCEPTIBLE POPULATION

□ BEWARE catching this on community visits. Stay well away from sick people.

□ We enquire about the health of people where residents go to visit.

☼ Hydration supplies

□ Fluid for sick people Enalyte [or similar hydrating fluid on standby if cannot hold food down]

enough for several sick people over a long weekend on supply at all times

□ Food for sick people Rice cook & strain the juice. Cook fresh green vegetables & strain the juice. Combine vegetable juice water and starch from cooked rice water to nourish sick people.

□ Fluid Balance Chart kept [spares in Infection Outbreak box] Frequent fluids to all sick people. ☼ Resident Care Equipment It’s a good idea to purchase bulk of one colour linen [e.g. bright yellow] to be used only by sick people:

- flagged infectious by colour. - boosts regular supplies - ensures enough linen left for well residents

□ Outbreak towels when towels start to go tatty retire to the outbreak box flannels [more the better / can use disposable] handtowels [very useful double as flannel or towel]

□ Zinc and Castor Oil – Essential to control risk of excoriated skin [sore bottoms] - Chemist should make up 12 small pots very cheaply [one each affected person]

□ Soothing Baby Wipes (one for each toilet and one in each sick person’s room)

□ Protect sofas and cushions before they are soiled

□ Lots of big plastic bags for linen – especially if you decide to send it off site.

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□ Linen Skips: plastic lids / pedal operated and leak proof.

☼ Isolation supplies

□ Laminated Work Instructions for staff. □ Laminated Signage for each door – entrances and sick residents bed rooms

□ Long-sleeved gowns (mark inside and outside with marker pen) Much cheaper in bulk ordered in advance. Can be very expensive if needing same day delivery.

□ Plastic stick-on hooks for back of doors [coat hangers work in an emergency]

□ Hand gel – 2 litre bulk supply: smaller pumps for every sick person’s room / at each entry point / in the lounge and in the dining room.

□ Gloves (at least one months supply at hand at all times)

□ Full face visor masks

□ Masks for people doing the laundry – Capes medical (3N)

□ Best Protection Masks = 3m (N95 Health Care particulate respirator), moulded splash resistant NB: this is a light airborne virus. Visor offers far more protection and is easier to wear. Goggles and masks still expose skin near nose and eyes

□ Shoe covers – don’t tramp the virus to every room.

☼ Cleaning supplies: Outbreak Clean up Box

□ Heavy duty gloves right size for cleaner

□ Bulk supply of detergent

□ Ammonias + Bleach

□ Dust pan + broom

□ Paper towels or news Paper (mop up and discard)

□ Good supply disposable clothes / old linen [retire tatty linen to the outbreak kit]

□ Cleaning products with ammonia (As purchased from supermarket)

□ Disposable hand towels and cleaning cloths (clean toilet/wall area after each use)

□ Bleach sol 1:10 [keep at least 2 litres]

□ Kitchen tidy bags

□ Big bags (knot top)

□ Environmental Cleaning contains outbreaks: Steam Cleaner Walls / Curtains / Mattresses / Furniture [reduces workload / very effective against the virus] NB: It’s a VERY good idea to have a dedicated cleaner on at all times during an outbreak. This can be well worth while as it cuts down risk of spread to well people and directly supports efforts of care staff.

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NOTES

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