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NNNM Enterprises Limited - Lester Heights Hospital Date of Audit: 25 January 2016 of 21

NNNM Enterprises Limited - Lester Heights Hospital

Introduction

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

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

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

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

The specifics of this audit included:

Legal entity: NNNM Enterprises Limited

Premises audited: Lester Heights Hospital

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

Dates of audit: Start date: 25 January 2016 End date: 25 January 2016

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 30

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

Lester Heights is certified to provide rest home and hospital level care for up to 35 residents. On the day of the audit there were 30 residents. This unannounced surveillance audit was conducted against a subset of the Health and Disability standards and the contract with the District Health Board. The audit process included a review of policies and procedures; the review of resident’s and staff files, observations and interviews with residents, relatives, staff and management.

The owner/manager has owned the facility for two years and is supported by a clinical manager and a quality advisor. All are appropriately qualified and experienced. Feedback from residents and relatives is positive.

Two of the three shortfalls identified in the previous audit have been addressed. These were around documentation for personal funds management and activities plans. Improvement continues to be required around medication management. This audit has identified areas requiring improvement around notifying families of incidents, risk management around restraint use, reporting of pressure injuries, first aid training, family input into care planning, registered nurse documentation in progress notes, interRAI assessments, evaluation of short term care plans and residents who self-administer medications. A high risk finding has been identified around wound care documentation.


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.

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

Staff are responsible for notifying family/next of kin of any event that occurs. An interpreter’s policy is in place. Family members and staff, from a range of cultures, are the most common source of interpreter services within the facility. External assistance is available if necessary. The right of the resident and/or their family to make a complaint is understood, respected and upheld by the service. A system for managing complaints is in place.

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.

Services are planned, coordinated, and are appropriate to the needs of the residents. An owner/manager and clinical manager are responsible for the overall day-to-day operations of the facility. A contracted quality advisor provides additional support. Strategic goals are documented for the service and are regularly reviewed.


Quality and risk management processes are maintained. Corrective action plans are implemented where opportunities for improvement are identified. A health and safety programme is in place, which includes a risk management plan, incident and accident reporting, and health and safety processes.

Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice, meeting legislative requirements. An orientation programme is in place for new staff that is specific to their role. On-going education and training for staff is maintained. Registered nursing cover is provided 24 hours a day, seven days a week. There are adequate numbers of staff on duty to ensure residents are safe.

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 medium or high risk and/or unattained and of low risk.

The registered nurses are responsible for care plan development. Residents and family interviewed confirmed that the care plans are consistent with meeting residents' needs. Planned activities are appropriate to the resident’s assessed needs and abilities and residents advised satisfaction with the activities programme. Medications policies are in line with legislation and current regulations. Staff who administer medications have been assessed as competent to do so. Food, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines and additional requirements/modified needs were being met.


Safe and appropriate environmentIncludes 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.

Standards applicable to this service fully attained.

A current building warrant of fitness is posted in a visible location.

Restraint minimisation and safe practice

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


There is a restraint policy that includes comprehensive restraint procedures. The service currently has nine residents assessed as using a restraint and one resident using an enabler. Staff receive training on the principles of restraint minimisation and managing challenging behaviours.

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



The infection control co-ordinator uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections.

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 9 0 5 2 1 0

Criteria 0 29 0 8 2 1 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


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

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

For more information on the standards, please click here.

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

Standard with desired outcome Attainment Rating

Audit Evidence

Standard 1.1.13: Complaints Management

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

FA The complaints procedure is provided to residents and families during entry to the service. Access to complaints forms are located at reception. Complaints forms include contact details for the Health and Disability Advocacy Service.

A record of all complaints received is maintained by the owner/manager using a complaints register. Documentation including follow up letters and resolution demonstrates that complaints are well-managed. All lodged complaints were resolved. This includes one complaint lodged by the district health board in 2015.

Discussions with residents (three hospital level and two rest home level) and families confirmed they were provided with information on the complaints process and remarked that any concerns or issues they had were addressed promptly.

Standard 1.1.7: Discrimination

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

FA The staff files reviewed have job descriptions and employment agreements that have clear guidelines regarding professional boundaries and house rules. Staff interviewed (three healthcare assistants, one registered nurse (RN), one cook, one activities coordinator) confirmed that they abide by these rules as part of their employment agreement.

Systems are in place to manage the comfort fund for residents, which includes

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

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


documenting and reconciling residents’ accounts and implementing issuing receipts. This is an improvement from the previous audit.

Standard 1.1.9: Communication

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

PA Low The open disclosure policy is based on the principle that residents and their families have a right to know what has happened to them and to be fully informed at all times. The policy also describes that open disclosure is part of everyday practice. The care staff interviewed (clinical manager, one registered nurse and three healthcare assistants) understood about open disclosure and providing appropriate information and resource material when required.

Three families interviewed (two hospital level and one rest home level) confirmed they are kept informed of the resident`s status, including any events adversely affecting the resident although evidence of open disclosure and notifying family after an adverse event and/or through the incident/accident system is not consistently being documented.

An interpreter service is available and accessible if required through the local district health board. Families and staff are utilised in the first instance.

Standard 1.2.1: Governance

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

FA All 35 beds at Lester Heights are certified for dual purpose - either for rest home or hospital levels of care. On the day of the audit there were a total of 30 residents living at the facility. Twenty-five residents were admitted under the Aged Residential Care Contract (three rest home level residents of which one was on respite; and twenty-two hospital level residents). Four residents were under the age of 65 on the Young Persons with Disability Contract (hospital level), and one resident was receiving individualised funding under a mental health individual funding contract (hospital level).

The facility had a 2015 strategic plan which identified the purpose, values, scope, direction, goals and specific aims for the calendar year. This plan was regularly reviewed throughout the year with evidence of goals being signed-off when achieved. A 2016 strategic plan is under development. Services are planned to ensure residents’ needs are being met.

At present, Lester Heights Hospital is the only facility owned by the current manager, which she has had for two years. She has previously owned four other aged care facilities in Auckland and Whangarei. The owner/manager was on holiday during this audit. A contracted quality advisor and the clinical manager/RN were responsible for the facility in her absence.

The clinical manager was employed as a registered nurse (RN) seven months


ago. She had taken on the role of clinical manager only one week before this audit. She has 20 years of experience in the aged care sector, which includes clinical manager roles.

The owner/manager has maintained over eight hours annually of professional development activities related to managing an aged care facility as evidenced on her professional development log.

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 A quality and risk management system is being maintained, which is understood and implemented by service providers as confirmed during interviews. Policies and procedures are maintained by the external quality advisor who ensures they align with current good practice and meet legislative requirements. Policies have been updated to reflect processes around interRAI and pressure injuries.

Quality management systems are linked to internal audits, incident and accident reporting, health and safety reporting, infection control data collection and complaints management. Data that is collected is analysed and compared monthly and annually for a range of adverse event data (eg, skin tears, bruising, falls, pressure areas). Corrective actions are documented and implemented where improvements are identified although no corrective action plan was documented to address an increase in pressure injuries. Information is shared with all staff as confirmed in meeting minutes and during interviews.

Staff, residents and family/whanau interviews confirmed any concerns they have were addressed by management and examples of quality initiatives were provided.

A 2015 risk management plan is in place. Staff receive health and safety training, which is initiated during their induction to the service. Actual and potential risks are documented in the hazard register which identifies a risk rating and shows actions to eliminate or minimise the risk. Potentially significant risks were identified at audit for two residents with restraint.

Falls management strategies include sensor mats, and the development of specific falls management plans to meet the needs of each resident who is at risk of falling.

Standard 1.2.4: Adverse Event Reporting

All adverse, unplanned, or untoward events are systematically recorded by the service and reported to

PA Low There is an incident reporting policy that includes definitions and outlines responsibilities including immediate action, reporting, monitoring, corrective action to minimise future events and debriefing. Individual reports are completed for each incident/accident with immediate action noted including any follow up


affected consumers and where appropriate their family/whānau of choice in an open manner.

action(s) required. Incident/accident data is linked to the organisation's quality and risk management programme. Sixteen accident/incident forms were reviewed. Each event involving a resident reflected a clinical assessment and follow up by a registered nurse. Neurology observations were conducted for suspected head injuries. Accident/incident forms for pressure injuries have not been consistently completed for pressure injuries.

The contracted quality advisor and clinical nurse manager reported that they are aware of their responsibility to notify relevant authorities in relation to essential notifications and stated that this has not been required since their last certification audit.

Standard 1.2.7: Human Resource Management

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

PA Low There are human resources policies in place, including recruitment, selection, orientation and staff training and development. Five staff files reviewed (one clinical manager, one RN, three healthcare assistants) included evidence of the recruitment process, signed employment contracts, police vetting, and completed orientation programmes. The orientation programme provides new staff with relevant information for safe work practice. Competencies are completed specific to worker type. Staff interviewed stated that they believed new staff were adequately orientated to the service.

A register of current practising certificates for all health professionals is maintained.

There is an annual education schedule that is being implemented. In addition, opportunistic education is provided. Three of five RN’s have completed their interRAI training. There is insufficient evidence of a minimum of one staff trained in first aid/CPR for every shift.

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 an organisational staffing policy that aligns with contractual requirements and includes skill mixes. The clinical manager is an experienced RN who works full time Monday - Friday. A minimum of one staff RN is on site 24 hours a day, seven days a week.

Staffing is flexible to meet the acuity and needs of the residents. A casual pool of staff are available as needed. Interviews with residents and families confirmed staffing overall was satisfactory.

Standard 1.3.12: Medicine Management

Consumers receive medicines in a safe and timely

PA Moderate The service uses individualised medication sachets which are checked in on delivery. A registered nurse was observed administering medications correctly.


manner that complies with current legislative requirements and safe practice guidelines.

Medications and associated documentation were stored safely and securely except eye drops which were not always dated when they were opened. Medications are reviewed three monthly with medical reviews by the attending GP. Resident photos and documented allergies or nil known were on all 10 medication charts reviewed. An annual medication administration competency is completed for all staff administrating medications and medication training had been conducted.

There is a self-medicating resident’s policy and procedures in place. There was one resident who self-administered medications. A competency assessment had not been completed. Individually prescribed resident medication charts are in use and this provides a record of medication administration information. Medication administration records sampled documented all prescribed medication being administered. One resident had an enema administered that had not been prescribed. Ten of ten medication charts reviewed recorded accurate indications for use of as required medication by the GP and the times for administration for all medications was documented. This is an improvement since the previous audit.

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 the service are prepared and cooked on site by a cook. There is a three weekly winter and summer menu and a cultural menu for Maori residents which were currently under review by a dietitian. Meals are prepared in a well-appointed kitchen and served to the residents in the dining rooms in bain Maries. Kitchen staff are trained in safe food handling and food safety procedures are adhered to. The service records all fridge and freezer temperatures. Staff were observed serving and assisting residents with their lunch time meals and drinks. Diets are modified as required. Resident dietary profiles and likes and dislikes are known to food services staff and any changes are communicated to the kitchen via the registered nurses. Supplements are provided to residents with identified weight loss issues. Resident meetings and surveys allow for the opportunity for resident feedback on the meals and food services generally. Residents and family members interviewed indicated satisfaction with the food service.

Standard 1.3.6: Service Delivery/Interventions

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

PA High InterRAI assessments were completed for three of five resident files sampled (the other resident was on respite care). While all care plans sampled are current, not all evidenced that InterRAI assessments inform care plans or that interventions addressed all identified needs of the residents. Interviews with staff and relatives confirmed the prevision of appropriate interventions; however, two hourly turns are not always documented for residents requiring this. Dressing supplies are


available and a treatment room was stocked for use. Wound documentation is adequate for three of four minor wounds but not for nine pressure injuries. Continence products are available and resident files included a urinary continence assessment, bowel management, and continence products identified for day use, night use, and other management. Specialist continence advice is available as needed and this could be described.

Standard 1.3.7: Planned Activities

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

FA The activities coordinator works 30 hours per week and as required providing an activities programme with support from external providers over five days each week. The programme is planned monthly. Activities planned for the day are displayed on notice boards around the facility. An activity plan is developed for each individual resident based on assessed needs as part of the care plan and are personalised to the resident. This is an improvement since the previous audit. Residents are encouraged to join in activities that are appropriate and meaningful and are encouraged to participate in community activities. There are regular outings. Residents were observed participating in activities on the day of audit. Resident meetings provided a forum for feedback relating to activities. Residents and family members interviewed discussed enjoyment in the programme and the diversity offered to all residents.

Standard 1.3.8: Evaluation

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

PA Low Three of four long term care plans reviewed were updated as changes were noted in care requirements (link 1.3.6.1). Care plan evaluations are comprehensive, related to each aspect of the care plan and recorded the degree of achievement of goals and interventions. Short term care plans are utilised for residents and any changes to the long term care plan were dated and signed. Short term care plans were not always evaluated. Long term care plans sampled were evaluated within the required time frames.

Standard 1.4.2: Facility Specifications

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

FA A current building warrant of fitness is displayed in a visible location (expiry 1 December 2016).

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

FA Infection surveillance and monitoring is an integral part of the infection control programme and is described in infection control policy. Monthly infection data is collected for all infections based on signs and symptoms of infection. Monthly registered of types of infection are developed and analyses with results are provided to staff at the staff meetings. The clinical manager is the infection


programme. control nurse. Expert advice can be sought from the GP and/or laboratory clinical microbiologist or the infection control team at the DHB if needed. The contracted pharmacist to the service is also available for consultation.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The restraint policy includes the definitions of restraint and enablers. Interviews with the restraint coordinator (clinical manager) and staff confirmed their understanding of restraint minimisation.

The service had nine hospital level residents using restraints and one hospital level resident using bedrails as an enabler (link to finding 1.2.4.3) Enablers are assessed as required for maintaining safety and independence and are used voluntarily by the residents.


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

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

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

Criterion with desired outcome

Attainment Rating

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

Criterion 1.1.9.1

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

PA Low Staff are instructed to keep family/enduring power of attorney (EPOA) informed with any change in the health status of the resident or following an adverse event. Interviews with family indicated that they were kept informed.

The accident/incident form includes space for staff to document if family are kept informed following an adverse event. Family notification was missing in a selection of accident/incident reports reviewed and corresponding progress notes.

Evidence of open disclosure and notifying family after an adverse event through the incident/accident system was missing in seven of sixteen accident/incident forms and corresponding residents’ progress notes for January 2016.

Ensure documentation on the accident/incident form indicates the family/resident are being kept informed.

90 days

Criterion 1.2.3.8

A corrective action plan addressing areas requiring improvement in order to meet

PA Low Corrective action plans are developed where opportunities for improvement are identified although no corrective action plan was developed to address

The service currently has a high number of pressure injuries, but no corrective action plan has been developed to address this area of

Evidence

Ensure corrective actions are put into place where opportunities for


the specified Standard or requirements is developed and implemented.

a high incidence of pressure injuries concern improvements are identified (eg, pressure injuries).

90 days

Criterion 1.2.3.9

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

PA Moderate

Potential risks are identified on a risk management plan and on the hazard register. Processes are in place to ensure that the risk management plan and hazard register are regularly reviewed.

The 2015 annual review of the restraint programme identified two residents who were using bedrails as restraints are were at risk of climbing over the rails. These risks had not been mitigated. Instead, directives were provided by the families/enduring power of attorney (EPOA) to keep the bedrails in place.

Two residents using bedrails as a restraint have been identified at risk of climbing over the rails. The bedrails remain in place as per the family/EPOA requests, but no strategies documented to minimise the risk.

Ensure those residents with assessed risks when utilising restraint have strategies documented to minimise the risk.

30 days

Criterion 1.2.4.3

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

PA Low The adverse events reporting system is integrated into the quality and risk management programme. Hard copy accident/incident forms are completed by staff with follow-up by a registered nurse. Staff interviews confirmed their responsibility for completing accident/incident forms following any adverse event although accident/incident forms were missing

Two pressure injuries identified in December 2015 and two pressure injuries identified in January 2015 did not have corresponding accident/incident forms completed.

Ensure accident/incident forms are completed when a pressure injury is detected.

90 days


for a sample of pressure injuries.

Criterion 1.2.7.5

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

PA Low An annual education plan is implemented for staff, which includes job specific competencies. Training is linked to the monthly staff meetings. Individual staff training records are being maintained.

Only three staff (clinical manager, activities coordinator and maintenance staff (who drives the van)) hold current first aid/CPR certificates. The service is not currently able to provide roster cover of at least one trained first aider on each shift.

Ensure there is a minimum of one staff holding a current first aid/CPR certificate on the evening and night shifts and over the weekends.

90 days

Criterion 1.3.12.1

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

PA Moderate

All medications are stored in a locked room. Three of six bottles of opened eye drops had been dated when they were opened. Standing orders are not in use. Prescribed medications were accurately documented as administered. One resident’s administration record documented an enema that had been administered without prescription.

(i) Not all open eye drops had been dated when they were opened.

(ii) One resident was administered a microlax enema that was not on the doctor’s prescription chart.

(i) Ensure all eye drops are dated when they are opened.

(ii) Ensure only prescribed medications are administered.

30 days

Criterion 1.3.12.5

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

PA Low There is one respite resident who self-administers inhalers and nebulisers. The resident also does this at home. A competency assessment had not been completed.

The one resident who self-administers medication does not have a competency assessment completed.

Ensure a competency assessment is completed for all residents who self-administer medications.

90 days

Criterion 1.3.3.3

Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is

PA Low All residents files sampled had an initial assessment and care plan completed on the day of admission. The four long term resident files sampled had a suite of paper based

None of the three residents admitted since 1 July 2015 had an interRAI assessment completed within 21 days of admission.

Ensure all new residents have an interRAI assessment completed within 21 days of admission.


provided within time frames that safely meet the needs of the consumer.

assessments completed within 21 days of admission including continence, falls risk, nutrition, pressure injury risk and a nursing assessment. The interRAI assessment tool had been used for two of the four long term resident files sampled. The one of five files sampled had an interRAI assessment completed, but not within 21 days of admission. The sample was extended to include all admissions since 1 July 2015 around interRAI assessments. All had a completed interRAI assessment but none were completed within 21 days of admission.

90 days

Criterion 1.3.3.4

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

PA Low Healthcare assistants and registered nurses document progress notes at least every shift. Issues are comprehensively documented by healthcare assistants but follow up of issues by registered nurses is sometimes documented by healthcare assistants but not the registered nurse. Family members interviewed report that they sometimes have input into care planning. However this is not documented.

(i) Two of five files sampled (one hospital and one rest home) have issues identified in progress notes by healthcare assistants (rash and vomiting) that include that a registered nurse was informed but there is no documented follow up by the registered nurse.

(ii) Five of five care plans sampled do not have family or resident input documented.

(i) Ensure all issues identified are followed up by a registered nurse and that this is documented.

(ii) Ensure that family and/or the residents have input into care planning and that this is documented.

60 days

Criterion 1.3.6.1

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

PA High The caregivers interviewed are very familiar with the needs and care of residents. Comprehensive communication between caregivers and registered nurses was observed. Staff interviewed report that residents

(i) Two of three residents with interRAI assessments (both hospital) did not have all existing issues identified in the assessments, therefore, these did not inform the care plan.

(i) Ensure interRAI assessments identify all current needs and inform the care plan.

(ii) Ensure resident files reflect interventions for all


outcomes. are turned regularly; however, this is not documented. One resident did not have the air mattress documented as necessary in the care plan insitu. InterRAI assessments are in use (link 1.3.3.3) however for two resident files sampled these do not identify all issues to sufficiently inform the care plan. One of the four long term care plans sampled (one resident was on respite care) documented interventions for all identified areas of need. Three of four minor wounds had appropriate documentation to support best practice. Not all wounds (including pressure injuries) had an assessment for each wound, a documented wound management plan and reviews completed within the required timeframes. The newly appointed clinical manager (one week in role) had identified some of these issues, understood all issues and had plans to address these.

(ii) Three of five resident files sampled (one rest home and two hospital) did not document interventions for all identified needs (e.g. epilepsy and restraint). One hospital resident’s care plan had not been updated when health declined. One of these residents with a short term care plan around pressure injury management does not have pain management addressed in the short term care plan.

(iii) Two residents with a requirement for two hourly turns do not have these documented as occurring. One resident with an air mattress required in the care plan did not have one on the bed.

(iv) Wound documentation is lacking: (a)Three ‘sets’ of wound documentation for two residents with pressure injuries have more than one pressure injury on the same ‘set’ of documentation. (b) Eight wounds including seven pressure injuries do not have a documented wound assessment. (c) Ten of 13 wounds (including seven pressure injuries) did not have a timeframe for review documented. (d) Twelve of thirteen wounds (including none pressure injuries) did not have a management plan documented.

current identified needs.

(iii) Ensure required interventions are implemented and documented.

(iv) Ensure all wounds have individual documentation that includes a comprehensive assessment, a management plan and a timeframe for review documented.

30 days

Criterion 1.3.8.2

Evaluations are documented, consumer-focused, indicate

PA Low Short term care plans are documented for identified short term needs. These had been appropriately evaluated for some short term care

Two resident files sampled (both hospital) have short term care plans that have not been evaluated.

Ensure short term care plans are regularly evaluated.


the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.

plans sampled.

90 days


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

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

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

No data to display

End of the report.

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