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Kiwi Family Otago Limited - Woodhaugh Rest Home

Introduction

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

The audit has been conducted by 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: Kiwi Family Otago Limited

Premises audited: Woodhaugh Rest Home

Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit: Start date: 31 January 2017 End date: 31 January 2017

Proposed changes to current services (if any): The service has been verified as suitable to provide medical level care under their current hospital certification

Total beds occupied across all premises included in the audit on the first day of the audit: 35

Kiwi Family Otago Limited - Woodhaugh Rest Home Date of Audit: 31 January 2017 of 29

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

Woodhaugh rest home and hospital is privately owned. Woodhaugh provides rest home and hospital level of care for up to 80 residents. On the day of the audit there were 35 residents.

This certification audit was conducted against the relevant Health and Disability Standards and the contract with the district health board. The audit process included the review of policies and procedures, the review of resident and staff files, observations, and interviews with family, residents, management, staff and the general practitioner.

This audit also included verifying the service as suitable to provide medical level care under their current hospital certification.

The facility manager is a registered nurse and appropriately qualified and experienced to manage aged care. She is supported by the owner, team of registered nurses and long serving staff. Staff receive education and have policies and procedures in place to guide them in the safe delivery of care.

There are on-going environmental improvements and current renovations occurring.

Areas for improvement identified at this certification audit are related to electronic security of resident information, dating and signing of care plans, hazard management, communication between staff, electrical equipment checks, and aspects of infection control management.


Consumer rights

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

Standards applicable to this service fully attained.

Information about services provided is readily available to residents and families. The Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) information is available. Policies are implemented to support rights such as privacy, dignity, abuse and neglect, culture, values and beliefs, complaints, advocacy and informed consent. Care planning accommodates individual choices of residents and/or their family/whānau. Residents are encouraged to maintain links with the community. Complaints processes are implemented and complaints and concerns are managed appropriately.

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 facility manager is an experienced registered nurse and is supported by a team of registered nurses and long serving staff.


Organisational performance is monitored through a number of processes to ensure it aligns with the identified values, scope and strategic direction. The business plan has goals documented. Policies and procedures are appropriate to provide support and care to residents’ rest home level needs and a documented quality and risk management programme that is implemented.

Staff receive on-going training and there is a training plan developed and commenced for 2016. Rosters and interviews indicate high levels of staff that are appropriately skilled with flexibility of staffing around client’s needs.

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.

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

There is an admission package about all services and levels of care provided. The registered nurses are responsible for each stage of service provision. A registered nurse assesses and develops the care plan documenting supports, needs, outcomes and goals with the resident and/or family/whānau input. Care plans viewed in resident records demonstrated service integration and were reviewed at least six monthly. Resident files included notes by the general practitioner and visiting allied health professionals.

Medication policies reflect legislative requirements and guidelines. Registered nurses are responsible for administration of medicines and complete annual education and medication competencies. The medicine charts reviewed meet prescribing requirements and were reviewed at least three monthly.

A diversional therapist oversees and implements an activities programme that includes activities of resident interest, outings, entertainment and community visitors. The life enhancement team focus on individual and group exercises as part of the falls prevention programme.


Meals and home baking are prepared and cooked on site by a qualified cook and baker. Individual and special dietary needs are catered for. Menu choices are available. Residents interviewed were satisfied with the meals provided.

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.


Chemical safety is maintained. There are a number of resident rooms under refurbishment. There is adequate equipment provided to ensure the needs of rest home and hospital residents are met. The building holds a current warrant of fitness. A reactive maintenance system is implemented. There are communal lounges and dining areas. There are adequate communal shower and toilets with some rooms with shared toilets. Laundry services are completed off-site. Appropriate training, information, and equipment for responding to emergencies is provided. Documented systems are in place for essential, emergency and security services. There is at least one staff member on duty with a current first aid certificate. There is an approved evacuation plan.

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.

Standards applicable to this service fully attained.


The service actively minimises the use of restraint. All staff receive training on restraint minimisation and management of behaviours that challenge. There were no residents using enablers and no residents using restraint. Staff are trained around managing behaviours that may challenge.

Infection prevention and control

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


The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control coordinator (registered nurse) is responsible for coordinating education and training for staff. The infection control coordinator has completed on-line training. There is a suite of infection control policies and guidelines to support practice. The infection control coordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility.


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 39 0 3 3 0 0

Criteria 0 86 0 4 3 0 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


Attainment against the Health and Disability Services Standards

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

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

For more information on the standards, please click here.

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

Standard with desired outcome

Attainment Rating

Audit Evidence

Standard 1.1.1: Consumer Rights During Service Delivery

Consumers receive services in accordance with consumer rights legislation.

FA Seven residents (three hospital and four rest home) and one relative of a rest home level of care resident confirmed that information has been provided around the code of rights. Residents stated their rights are respected when receiving services and care. There is a resident rights policy in place. Staff attend Code of Rights training. Discussion with three caregivers and three registered nurses (RN) identified they were aware of the code of rights and could describe the key principles of resident’s rights when delivering care.

Standard 1.1.10: Informed Consent

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

FA There are established informed consent policies/procedures and advanced directives. General consents were obtained on admission and sighted in six of six resident files reviewed (two hospital residents and four rest home residents including one under long-term chronic health condition and one younger person). Advance directives for continuing care (where appropriate) were completed and on the resident files.

An informed consent policy is implemented. Systems are in place to ensure residents, and where appropriate their family/whānau, are provided with appropriate information to make informed choices and informed decisions. The caregivers (CGs) and registered nurses (RNs) interviewed, demonstrated a good understanding in relation to informed consent and informed consent processes.

Family and residents interviewed confirmed they have been made aware of and fully understand informed


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

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

consent processes and that appropriate information had been provided.

Six admission agreements reviewed had been signed.

Standard 1.1.11: Advocacy And Support

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

FA Residents and families are provided with a copy of the Code of Health and Disability Services Consumer Rights and Advocacy pamphlets on entry. Resident advocates are identified during the admission process. Interviews with the residents and relative confirmed their understanding of the availability of advocacy services. An age concern advocate is available to residents and families and attends resident meetings. Staff receive training on the role of advocacy services.

Standard 1.1.12: Links With Family/Whānau And Other Community Resources

Consumers are able to maintain links with their family/whānau and their community.

FA The service has an open visiting policy and family/whānau and friends are encouraged to visit the home and are not restricted to visiting times. Residents interviewed confirmed that family and friends are able to visit at any time. Residents verified that they have been supported and encouraged to remain involved in the community where appropriate. There are regular outings into the community. Community groups visit the home as part of the activities programme.

Standard 1.1.13: Complaints Management

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

FA Information about complaints is provided on admission. Interview with residents inform an understanding of the complaints process. All staff interviewed were able to describe the process around reporting complaints.

There is a complaint register. Complaints for 2016 and 2017 to date were reviewed.

All complaints included investigation, timelines, corrective actions when required and resolutions. Results have been fed back to complainants.

Discussions with residents and family members confirmed that any issues have been addressed and they feel comfortable to bring up any concerns.

One complaint was reviewed by the Health and Disability Commissioner. The complaint was closed by the Commissioner in March 2016 with no further actions required.

Standard 1.1.2: Consumer FA The service has available information on The Health and Disability Commissioner Code of Health and


Rights During Service Delivery

Consumers are informed of their rights.

Disability Services Consumers’ Rights (the Code) at the main entrance to the facility. There is a welcome information folder that includes information about the code of rights. Residents and relatives confirmed they receive sufficient verbal and written information to be able to make informed choices on matters that affect them.

Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect

Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

FA The service provides physical and personal privacy for residents. During the audit, staff were observed treating residents with respect and ensuring their dignity is maintained. Care staff interviewed were able to describe how they maintain resident privacy. Staff attend privacy and dignity and abuse and neglect in-service as part of their education plan. Care staff interviewed state they promote independence with daily activities where appropriate. Resident’s cultural, social, religious and spiritual beliefs are identified on admission and included in the resident’s care plan/activity plan to ensure the resident receives services that are acceptable to the resident/relatives.

Standard 1.1.4: Recognition Of Māori Values And Beliefs

Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

FA There is a Māori health plan and cultural safety and awareness policy to guide staff in the delivery of culturally safe care. The policy includes references to other Māori providers that are available and interpreter services. Management liaise with a local Iwi representative and the Māori liaison group at the DHB for any support or guidance required. There were no residents who identified as Māori on the day of audit.

Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs

Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

FA The service provides a culturally appropriate service by identifying any cultural needs as part of the assessment and planning process. Staff recognise and respond to values, beliefs and cultural differences. Residents are supported to attend church services of their choice and are supported to attend other community groups as desired.

Standard 1.1.7: Discrimination FA The staff employment process includes the signing of an employment agreement that covers a code of


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

conduct. Professional boundaries are defined in job descriptions. Staff were observed to be professional when carrying out their duties. Staff are trained to provide a supportive relationship based on sense of trust, security and self-esteem. Interviews with care staff described how they build a supportive relationship with each resident. Residents and the relative interviewed stated they are treated fairly and with respect.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

FA The management are committed to providing a service based on the mission statement and philosophy of care. This was observed during the day with the staff demonstrating a caring attitude to the residents. The service has implemented policies and procedures that provide a good level of assurance that it is adhering to relevant standards. Registered nurses and caregivers have access to internal and external education opportunities. Facility meetings and shift handovers enhance communication between the teams and provide consistency of care.

Standard 1.1.9: Communication

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

FA Residents interviewed felt comfortable in approaching the facility manager or clinical lead for any concerns. Residents have the opportunity to feedback on service delivery through two monthly resident meetings held with an age concern advocate. Accident/incident forms reviewed evidenced that relatives are informed of any incidents/accidents. The relative interviewed stated they have been notified promptly of any changes to resident’s health status. A resident/family meeting was held prior to renovations to keep them informed of building changes and hazards.

Residents and family are informed prior to entry of the scope of services and any items they have to pay for that is not covered by the agreement. An interpreter service is available if 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 Woodhaugh rest home provides residential services for up to 80 residents requiring rest home or hospital (geriatric) level care (31 dual-purpose rooms and 49 rest home). On the day of the audit one wing was closed for renovation and there were 35 residents – 24 at rest home level care including one on a younger person with disability contract and one on a long-term chronic conditions contract, and 11 at hospital level of care.

This audit also included verifying the service as suitable to provide medical level care under their current hospital certification. There is links to allied health providers if needed.

The facility is now the only facility owned by the owners who previously owned other facilities. The facility manager (a registered nurse) provides clinical and organisational oversight has been at the service since December 2016. The facility manager’s signed job description documents clinical leadership and facility management responsibilities. She is supported by two clinical leads (senior registered nurses), one of


whom recently tendered their resignation. The manager reports weekly by email to the owner and the owner visits the facility at least monthly (as reported by the owner).

The goals and direction of the service are well documented in the business plan and the progress toward previous goals has been documented.

The manager has had community based aged care experience and a clinical lead position previously.

Standard 1.2.2: Service Management

The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers.

FA The manager reported that in the event of her temporary absence a clinical lead (who was temporary manager before her employment) fills her role with support from the owners and other staff.

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

The manager facilitates the quality programme and ensures the internal audit schedules are implemented. Corrective action plans have been developed, implemented and signed off when service shortfalls were identified.

Quality improvement processes are in place to capture and manage non-compliances. They include internal audits, hazard management, risk management, incident and accident and infection control data collection and complaints management. All quality improvement data is discussed at monthly safety/quality/risk/staff meetings.

There are relevant policies and procedures that are reviewed regularly. These have been updated to include InterRAI requirements.

There is a current risk management plan. The company quality manager/privacy officer has completed training on the update to the health and safety legislation. The service health and safety officer has resigned and a RN is currently orientating to the health and safety role. The newly appointed health and safety officer is to attend external training when available. Health and safety policies have been updated to reflect health and safety legislative changes. Not all identified hazards were being managed appropriately.

There are resident and relative surveys conducted and analysed with corrective action plans developed when required. The August 2016 resident survey demonstrated a high level of satisfaction with the service and improvements identified as needed in the building have or are being addressed and the service had


worked to improve the food service following the surveys.

Falls prevention strategies are in place for individual residents.

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 The accident/incident process includes documentation of the incident and analysis and separation of resident and staff incidents and accidents on an electronic database. Ten incidents sampled for January 2017 (the system was new in December 2016) demonstrated appropriate documentation and clinical follow-up. All forms were completed by registered nurses. Accidents and incidents are analysed monthly with results discussed at safety/quality/risk/staff meetings.

The facility manager is aware of situations that require statutory reporting. Police were notified around missing staff files and a VRE infection was reported.

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.

FA Six staff files sampled (the facility manager, two registered nurses, the diversional therapist, the cook and one caregiver) showed appropriate employment practices and documentation. Current annual practicing certificates are kept on file.

The orientation package provides information and skills around working with residents with aged care needs and was completed in all staff files sampled.

There is an annual training plan in place and implemented that has included all required training. All six staff files sampled contained a current annual performance appraisal.

Residents and families stated that staff are knowledgeable and skilled.

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 documented rationale for staffing the service. Staffing rosters were sighted and staff on duty to match needs of different shifts and needs of residents. There is a registered nurse on duty at all times. This was confirmed by rosters, registered nurse interview and caregiver interview. Registered nurses work either eight or twelve hour shifts. In addition to the registered nurse on the floor, the two clinical leads (senior registered nurses) have five hours each of non-resident contact time per week and the facility manager (a registered nurse is on duty 24 hours per week).

There are dedicated housekeeping staff who undertake cleaning duties. Laundry is completed off site. Caregiver position descriptions document appropriate care and support tasks.


Staff, residents and family interviewed confirmed that staffing levels are adequate.

Standard 1.2.9: Consumer Information Management Systems

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

PA Low The service retains relevant and appropriate information to identify residents and track records. Files and relevant resident care and support information can be accessed in a timely manner.

All resident files are in both electronic and hard copy as the service transitions to an electronic documentation system. All staff have individual log-in details and until the day of the audit any staff member with a log-in could access the resident information to which they had access on site (not all staff have all access rights) from any computer in the country with internet access.

Individual resident files sampled demonstrated service integration. Medication charts are in a separate folder with medication and this is appropriate to the service.

Electronic progress notes are legible, dated and identified to the relevant staff member including designation. Not all care plans were signed and dated.

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 Residents’ entry into the service is facilitated in a competent, equitable, timely and respectful manner. Pre-admission information packs including information on the services are provided for resident and families. Admission agreements for long term residents aligned with all contractual requirements. Exclusions from the service are included in the admission agreement.

Standard 1.3.10: Transition, Exit, Discharge, Or Transfer

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

FA Planned exits, discharges or transfers were coordinated in collaboration with the resident and family to ensure continuity of care. There were documented policies and procedures to ensure exit, discharge or transfer of residents is undertaken in a timely and safe manner. The residents and their families were involved for all exit or discharges to and from the service.

Standard 1.3.12: Medicine Management

FA There are policies and procedures in place for safe medicine management that meet legislative requirements. Registered nurses who administer medications have been assessed for competency on an annual basis. Registered nurses complete syringe driver training. Education around safe medication


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

administration has been provided. Medications received (robotic rolls) are checked on delivery by the RN. All medications are stored safely. All eye drops are dated on opening. The medication fridge is monitored daily and temperatures are within acceptable ranges.

All 12 medication charts reviewed (eight rest home and four hospital) met legislative prescribing requirements. The GP has reviewed the medication charts three monthly.

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 All meals at Woodhaugh are prepared and cooked on site in the main kitchen. The service employs a qualified chef and baker. All staff involved in preparation and serving of foods have received in-service on food safety. The four-week menu was reviewed in May 2016 and now offers two choices of meats and desserts at the main midday meal. Pureed meals have been reviewed and presented in an attractive manner as sighted. The daily menu is written up on a board with a backlight which is easily seen and read. On the day of audit food service staff were observed offering choice of meals. There were two meal trolleys with meals being served directly from bain-marie pots. Residents were shown the choice of desserts before being served. Staff were observed assisting residents with meals and fluids. Residents were offered second helpings. Residents interviewed in the dining room on the day of audit were satisfied with the meal portions and choice. Resident dislikes and special dietary requirements are known and accommodated. Fresh fruit in covered containers are freely available to residents. A variety of food themes are provided such as high teas, pancake days, cream cake days and lazy breakfasts.

There is a main kitchen and a satellite kitchen off the dining room where breakfast is prepared and has tea making facilities. A separate area has dishwashing facilities for morning and afternoon tea dishes. All fridge and freezer temperatures are monitored daily. End cooked temperatures are taken and recorded. All perishable goods are date labelled.

The service has implemented improvements around the meal in response to resident complaints. The number of complaints have reduced and residents stated they are involved in providing regular feedback on meals through meetings and surveys. Resident satisfaction in meals for October 2016 was 72.2%.

Standard 1.3.2: Declining Referral/Entry To Services

Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by

FA There is an admission information policy. The reasons for declining entry would be if the service is unable to provide the care required or there are no beds available. Management communicate directly with the referring agencies and family/whānau as appropriate if entry was declined.


the organisation, where appropriate.

Standard 1.3.4: Assessment

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

FA The RN completes an initial assessment on admission including risk assessment tools. An InterRAI assessment is undertaken within 21 days of admission and six monthly, or earlier due to health changes. Resident needs and supports are identified through the on-going assessment process in consultation with significant others. InterRAI assessments, assessment notes and summary were in place for all resident files sampled.

Standard 1.3.5: Planning

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

FA Resident files reviewed were resident focused and individualised. Identified support needs as assessed were included in the care plans. Care plans evidenced resident (as appropriate) and family/whānau involvement in the care plan process. Relatives interviewed confirmed they were involved in the care planning process.

Resident files demonstrate service integration and evidence of allied healthcare professionals involved in the care of the resident such as the physiotherapist and dietitian. Short-term care plans were in place for short-term needs.

Standard 1.3.6: Service Delivery/Interventions

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

FA When a resident's condition alters, the registered nurse initiates a review and if required a GP consultation. There is evidence that family members were notified of any changes to their relative’s health including (but not limited to) accident/incidents, infections, health professional visits and changes in medications. Discussions with families were documented in the resident’s progress notes and family contact chart.

Adequate dressing supplies were sighted in the treatment room. Wound management policies and procedures are in place. Initial wound assessments and on-going evaluations were in place for four skin tears (one resident with two skin tears), one resident with an ulcer and two residents with blisters. There was a range of equipment readily available to minimise pressure injury. There were no pressure injuries on the day of audit. There is access to a wound nurse specialist at the DHB as required.

Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified.

Short-term care plans document appropriate interventions to manage short-term changes in health such as wounds or weight loss.

Monitoring forms are used, for example observations, weight, food and fluid, behaviour, blood sugar levels and neurological signs.


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 There is a qualified diversional therapist employed from 8am to 4pm Monday to Friday to coordinate and implement the integrated rest home/hospital activity programme.

The activity programme meets the individual physical, emotional and intellectual recreational needs of the residents. The programme includes (but not limited to); word games, physical activities such as bowls, quoits, air hockey, music, entertainment, poems, news and views, reminiscing and crafts. One-on-one time is spent with residents who choose not to or are unable to participate in group activities. New activities have been introduced such as weekly “high teas”, cream cake day, ice-cream Sundays and lazy breakfast monthly on Saturdays. A beauty retreat room has been created for pampering and the hairdresser.

A life enhancement team (DT, senior caregiver and residential care officer) has been formed to focus on exercises’ and the walking group as part of the falls prevention programme.

Residents are encouraged to maintain community links and have regular outings to cafes’, shopping, concerts and clubs. Church services are held monthly on-site.

Residents provide regular feedback on the activity programme through resident meetings and surveys. Resident files reviewed identified individual profiles, activity plans and six monthly evaluations.

Standard 1.3.8: Evaluation

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

FA All initial care plans reviewed were evaluated by the RN within three weeks of admission. Long-term care plans have been reviewed at least six monthly or earlier for any health changes. The written evaluation documents the resident’s progress against identified goals. The GP reviews the residents at least three monthly or earlier if required. On-going nursing evaluations occur as indicated and are documented within the progress notes.

Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External)

Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet

FA Referral to other health and disability services is evident in the resident files sampled. The service facilitates access to other medical and non-medical services. Referral documentation is maintained on resident files.

There are documented policies and procedures in relation to exit, transfer or transition of residents. The residents and the families are kept informed of the referrals made by the service.


consumer choice/needs.

Standard 1.4.1: Management Of Waste And Hazardous Substances

Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

FA There are implemented policies in place to guide staff in waste management. The staff interviewed were aware of practices outlined in relevant policy. Staff were observed wearing personal protective clothing while carrying out their duties (link 3.1). There is a small locked sluice area located in each side of the home. Chemicals are provided by a contracted chemical provider. All chemicals sighted were labelled correctly and stored safely throughout the facility. Safety data and product use sheets were available. Staff had completed chemical safety training.

Standard 1.4.2: Facility Specifications

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

PA Moderate

The building is two storeys with stair and lift access. One wing of nine beds has been closed due to renovations. All residents are currently located within two wings on the ground floor. The building has a current building warrant of fitness that expires on 1 August 2017. The owner/director oversees the maintenance. A daily maintenance log records maintenance requests and is signed off when requests have been addressed. Planned maintenance includes monthly monitoring of hot water temperatures and quarterly checks of all call bells. Corrective actions have been taken for any non-compliance. Essential contractors are available 24 hours. There have been a number of environmental improvements made including a café and hair salon, flooring in hallways replaced for ease of cleaning and mobility, bathrooms re-painted and new fixtures, improved dining area, improved entrance way, improved storage areas and on-going refurbishment of resident rooms.

Not all electrical equipment has been tested and tagged on the due date.

The two lounge areas are designed so that space and seating arrangements provide for individual and group activities.

There is safe access with ramps and rails to the outdoor areas and internal courtyard with seating and shade.

Caregivers interviewed stated they had adequate equipment for the safe delivery of care including electric beds, two sling hoists. A new wheel-on weigh scale has been purchased and two air-alternating pressure prevention mattresses, hoists and pressure injury resources.

Standard 1.4.3: Toilet, Shower, And Bathing

PA Low There are sufficient communal toilets and showers to cater for residents located on the ground floor in the rest home/hospital. Some rooms have shared ensuites. The upstairs bedrooms are not in use as the


Facilities

Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

disabled toilet area has not been renovated as identified in the previous partial provisional audit. The nine-room wing closed for renovation includes an upgrade of the shower and toilet rooms. Communal toilet facilities have a privacy locking system. Handwashing facilities are available for all residents. There are adequate numbers of shower rooms including two large showers to accommodate hospital residents and their showering equipment. Shower chairs sighted were in a good state. Privacy curtains were in place in all shower rooms. Bathroom facilities have been re-painted and have new fixtures. Shower and toilet rooms sighted on the day of audit met infection control standards.

Standard 1.4.4: Personal Space/Bed Areas

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

FA All rooms are single. Residents rooms are of an appropriate size to allow care to be provided at the residents assessed level of care (rest home or hospital) and for the safe use and manoeuvring of mobility aids for residents. Residents are encouraged to personalise their bedrooms.

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

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

FA The communal areas in the rest home include two separate lounges (one within each side of the facility). One large lounge within the main part of the facility is divided into two areas, one area with a TV and the other a quieter reading/activity area. The third lounge has external opening doors. There is a lounge and small dining area in the upstairs unoccupied area.

The front entrance has been fully refurbished and includes a café area where residents and families can have tea/coffee or snacks or a meal together.

A hairdressing/pampering room is now available and well utilised. The resident dining room has been fully refurbished including new dining tables and chairs. The facility has a gym area where the DT has exercise sessions following the Otago exercise plans. The communal areas are easily accessible for residents with mobility aids or the assistance of staff.

Standard 1.4.6: Cleaning And Laundry Services

Consumers are provided with safe and hygienic cleaning and laundry services

FA There are weekday and weekend cleaners that carry out cleaning duties in the morning and evenings. They have access to a range of approved chemicals, cleaning equipment and protective clothing (link 1.3). The standard of cleanliness is monitored through the internal audit programme. The residents and relative interviewed were satisfied with the standard of cleanliness in the facility.

All linen is laundered off-site by a contracted commercial laundromat. Colour coded linen bags are used.


appropriate to the setting in which the service is being provided.

Linen is collected and delivered daily. There were adequate linen supplies in cupboards on the day of audit. Personal clothing will be laundered off-site as from 1 February 2017 (contract letter sighted). The service has a domestic washing machine and dryer which have had electrical checks.

Standard 1.4.7: Essential, Emergency, And Security Systems

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

FA There are policies and procedures on emergency and security situations including how services will be provided in health, civil defence or other emergencies. All staff receive emergency training on orientation and on-going. Disaster procedures flip charts are available for quick reference. Civil defence supplies are readily available. The kitchen holds at least three days of food and there is a barbeque available for cooking. There is sufficient water stored on-site. There is a four-hour battery backup for emergency lighting and call bells.

There is an approved fire evacuation scheme in place dated 16 December 2016. Six monthly fire drills are held. There is a first aider on duty at all times.

Residents’ rooms, communal bathrooms and living areas all have call bells. Security policies and procedures are documented and implemented by staff. The buildings are secure at night with afterhour’s doorbell access.

Standard 1.4.8: Natural Light, Ventilation, And Heating

Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

FA All bedrooms have heating some with Skope electric heaters and others with wall heaters (link 1.4.2.1). Communal areas have panel heaters. All bedrooms and communal rooms have windows. There is a plan to install heat pumps/air conditioning units (installation quote sighted).

Standard 3.1: Infection control management

There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and

PA Moderate

A registered nurse has been in the role since November 2016. She has a job description that outlines the responsibility of the role. The infection control coordinator is responsible for the collation of infection events and reporting to the combined infection control team/staff meeting monthly. The infection control programme has been reviewed annually.

The service had an outbreak in March 2016 of VRE (vancomycin resistant enterococci) which affected three residents. Relevant authorities were notified. Infection control management around readily available supplies and infection control awareness require improvement.


scope of the service.

Standard 3.2: Implementing the infection control programme

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

FA The infection control coordinator has been in the role two months and has completed the MoH on-line infection control course. The infection control team (infection control coordinator, facility manager, DT, clinical lead/RN, caregiver and cook) attend on-site infection control education provided September 2016 on multi-resistant organisms. The infection control team are supported by the general manager/RN.

The infection control coordinator has access to GPs, laboratory service, the infection control nurse specialist and public health departments at the local DHB for advice and the NZ nurses organisation.

Standard 3.3: Policies and procedures

Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

FA The infection control policies include a comprehensive range of standards and guidelines including defining roles and responsibilities for the prevention of infection, training and education of staff. Infection control procedures developed in respect of the kitchen, laundry and housekeeping incorporate the principles of infection control. The policies are developed and reviewed by the general manager/RN in consultation with an external infection control consultant.

Standard 3.4: Education

The organisation provides relevant education on infection control to all service providers, support staff, and consumers.

FA The infection control coordinator is responsible for coordinating/providing education and training to staff. Training on infection control is included in orientation and as part of the annual training schedule. Hand hygiene competencies are completed on orientation and annually. Infection control is discussed at handovers with care staff. Caregivers interviewed could describe standard precautions for the prevention of infection.

Resident education is expected to occur as part of providing daily cares as appropriate.


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 There is a policy describing surveillance methodology for monitoring of infections. The infection control coordinator collates information obtained through surveillance to determine infection control activities and education needs in the facility. Infection control data and relevant information is communicated to staff. Definitions of infections are in place appropriate to the complexity of service provided. Infection control data, trends and analysis is discussed at the infection control committee/staff meetings and at handovers. Monthly infection control reports are provided to staff.

There has been one vancomycin resistant enterococci outbreak affecting three residents. Relevant authorities were notified.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The service philosophy includes that restraint is only used as a last resort. There were no residents at the time of the audit using restraint or enablers. Staff have received training around managing behaviours that challenge.


Specific results for criterion where corrective actions are required

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

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

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

Criterion with desired outcome

Attainment Rating

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

PA Moderate

During the audit, there were two significant hazards within the facility. One resulted from an issue that had occurred on the morning of the audit. Warning signs were erected, staff alerted and a contractor was arranged to rectify the issue on the evening after the audit (the repair needed the corridor to be clear so was to occur after residents retired for the evening). This hazard was appropriately managed. The second major hazard related to an area that was reported as a ‘closed’ wing under renovation. Tour of the facility identified that there was still one resident residing in the area (the resident had declined to move) and that all residents could access the hazardous area. Hazards included building materials and tools and uneven and unpainted surfaces. After auditors identified the risk, the hazards in the area able to be accessed were removed and the rest of the wing was securely blocked off from resident access. The issue was briefly identified in the hazard

During the audit an area of the building with significant hazards could be accessed by residents.

Ensure all identified hazards are actively managed and minimised.

60 days


addresses/treats the risks associated with service provision is developed and implemented.

register. The addressing of the hazard during the audit has resulted in the risk being assessed as moderate.

Criterion 1.2.9.7

Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.

PA Low The service recently began transitioning to electronic records. All staff have access at varying levels depending on requirements of the role. Every staff member has an individual log on with password security. It was identified during the audit that any staff member could access any data that they could access while on site, from any computer with internet access, including from home. The service arranged for this issue to be rectified during the audit and access is now only through approved computers (all of which are on site).

At the time of the audit the electronic database could be accessed by all staff with a log-in from any computer with internet access meaning all staff had access to confidential resident records from any computer. This issue was addressed during the audit and therefore the risk has been assessed as low.

Ensure that all resident information is stored in a secure and confidential manner.

90 days

Criterion 1.2.9.9

All records are legible and the name and designation of the service provider is identifiable.

PA Low The service is transitioning between paper-based records and electronic records. All care plans sampled were paper-based but not all were signed and dated.

Three of six long-term care plans (all rest home level) were not dated and two of these were not signed.

Ensure all documents have the date and signature/designation of the writer documented.

90 days

Criterion 1.3.3.4

The service is coordinated in a manner that promotes continuity in service delivery and promotes a team

PA Low Clinical registered nurse meetings are being held monthly. The meetings evidence agenda items including restraint, complaints, adverse events, infection control, incident/accidents and health and safety, however meetings do not focus on resident care. Interviews with staff and GP identified a lack of cohesion

There was no documented evidence to indicate liaison or consultation between registered nurses to evidence peer and

Ensure there is a process for communication between RNs to ensure clinical issues or concerns are


approach where appropriate. and communication.

There was no documented evidence to indicate liaison or consultation between registered nurses to evidence peer and collegial support, or communication around residents with changing and complex needs such as weight loss, pressure injuries and residents with changing needs. Registered nurses interviewed reported little collegial support except doing the brief handover daily which focuses on daily needs, not the ‘bigger picture’ of residents.

collegial support, or communication around residents with changing and complex needs such as weight loss, pressure injuries and residents with changing needs.

addressed consistently.

60 days

Criterion 1.4.2.1

All buildings, plant, and equipment comply with legislation.

PA Moderate

Electrical equipment including all kitchen appliances and the dryer and washing machine have had an electrical check annually. All other electrical equipment was due for an electrical warrant of fitness in August 2016.

Resident and environmental electrical equipment has not been tested on the due date of August 2016. This includes electric beds and wall heaters in resident rooms.

Ensure all electrical equipment is tested by an authorised contractor.

60 days

Criterion 1.4.3.1

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

PA Low There are adequate numbers of communal toilets and showers on the ground floor that met the needs of rest home and hospital level of care residents. There is no disabled toilet available in the upstairs wing of nine dual-purpose beds and one rest home bed. The rooms remain unoccupied

The disabled toilet in the upstairs wing has not been completed as identified in the partial provisional audit

Ensure the disabled toilet is completed before hospital level residents are admitted into the dual-purpose beds in the upstairs wing

Prior to occupancy days


Criterion 3.1.9

Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.

PA Moderate

Three caregivers interviewed were aware of infection control practices and hand hygiene. Staff complete hand hygiene competencies. There is no notification for visitors regarding infection control precautions. Hand sanitizers were available for staff but not easily visible for residents and visitors. Adequate supplies of personal protective wear were sighted in supply cupboards and staff were seen to wear gloves and aprons appropriately. There is a staff handwashing station in both wings on the ground floor.

1) There was no signage at the facility entrance informing visitors not to visit if they have been unwell with any vomiting or diarrhoea. 2) Hand sanitizers were not readily available to residents or visitors at the main entrance, reception area or dining room. 3) Personal protective clothing was not readily available at the point of use such as the sluice tub areas. Extra hand sanitizer stations were placed around the facility on the day of audit, plus protective equipment was restocked.

1) Ensure infection control information is readily visible to visitors entering the facility. 2) Ensure there are appropriately placed hand sanitizers for resident and visitor use. 3) Ensure there are adequate supplies of personal protective equipment (gloves, aprons and face masks) at the point of use.

30 days


Specific results for criterion where a continuous improvement has been recorded

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

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

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

No data to display

End of the report.


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