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Rose Lodge Rest Home 2006 Limited - Rose Lodge 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 The DAA Group 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: Rose Lodge Rest Home 2006 Limited

Premises audited: Rose Lodge Rest Home

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 14 March 2016 End date: 15 March 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: 28

Rose Lodge Rest Home 2006 Limited - Rose Lodge Rest Home Date of Audit: 14 March 2016 of 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

Rose Lodge is a 30 bed rest home in suburban Invercargill in Southland. Twenty-eight beds were occupied on the day of this certification audit, one of which was a person receiving respite care and another was occupied through carer support funding. The regional manager and owner have not changed since the previous certification and the facility manager has been in her role for approximately seven months.

This audit against the Health and Disability Services Standards included sampling processes, interviews, reviews of documents and observations of the environment and practices. Managers, staff, residents, family members and external health professional were involved. Policy documents, service delivery plans, staff competency and training processes and quality and risk system documentation were reviewed.

The resultant information confirmed that the systems and processes in place at Rose Lodge are meeting the requirements of the standard and the needs of the residents are being met with high levels of satisfaction. There were no corrective actions identified. Three areas of quality improvement within implementation of the quality and risk management system were evident. An increased number of internally generated corrective actions have resulted in positive changes. There has been a significant increase in the number of quality improvement projects.


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.

The admission process for residents into the facility is planned and timely. Information is provided prior to admission to ensure residents and families have time to consult with others and are fully informed. Time and privacy for discussion to occur is provided.

Completed incident/accident reports showed that open disclosure is occurring and this was confirmed by relatives and residents who talk of being fully informed and say the manager and staff maintain open dialogue with them at all times. An interpreter policy with contact details is in place, however there has not been any requirement for such services.

During the audit staff were observed to respect residents’ rights during service delivery, allowing for personal choices, acknowledging and supporting cultural, spiritual, emotional, individual rights and beliefs and encouraging independence.

Residents and family members interviewed reported that staff are very respectful of their needs, that communication is consistent and appropriate and they are given time for discussions to take place with staff and family/whanau. They have a clear understanding of their rights and the facility’s processes if these are not met.

Information about the Health and Disability Commissioner’s Code of Health and Disability Services Consumer Rights (the Code), including the facility’s complaints process and the Nationwide Health and Disability Advocacy Service, was on display at the entrance to the facility and is available in admission packs and on request.

Information about the complaints process and a complaints and suggestion form is available. Complaints are being investigated and followed up until resolution. A register of complaints is in place and shows that verbal expressions of dissatisfaction are also being registered.


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.

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

The purpose, scope and values of the organisation are available and are relevant. Goals and objectives sit within an updated business plan. Both the facility and regional managers are suitably qualified and experienced and continue to update their skills.

Organisational policies and procedures are document controlled and have been reviewed and updated as required. Comprehensive quality and risk management plans align with the organisational policy documents. These plans are being implemented at a level of continuous improvement as a wide range of staff, including care assistants, have been trained and involved in different aspects of quality management, internal audits and review processes. This has resulted in a culture shift around attitudes about quality and risk systems and there were multiple examples of quality improvement projects in place, many of which have resulted from corrective actions identified by staff, other than managers. Data is being analysed and corrective action plans developed from all expected components of a quality and risk system including internal audits, the management of complaints and incidents, reviews of restraint and infection control and health and safety reviews, for example.

Professional qualifications have been validated. Safe and accountable recruitment processes are ensuring suitable staff are being employed. A comprehensive orientation programme for new staff is being implemented and a diverse internal training programme is being maintained. Staff are encouraged to undertake suitable external training opportunities.

Staff are being rostered at safe levels according to a master that has been created according to a staffing policy. Rostering takes staff competencies into account. Additional rostered hours of staff are added or reduced according to changes in acuity levels.

Residents records are being entered in a timely manner and meet the requirements of the standard and the contract. Archived records were stored securely.


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.


Services are being delivered according to service delivery plans that are developed and reviewed by a registered nurse (RN). Assessment tools are used and residents and relatives are consulted. This facility has commenced using the interRAI assessment programme. The RN completes the assessment from which an individualised, detailed care plan is developed. Regular review occurs to reflect the resident’s assessed needs. There has been a comprehensive implementation and review of care planning and evaluation process with input from residents, families/whanau, allied health professionals and the wider community.

Short term care plans are developed when issues arise within the review time frame. Staff were observed providing services in a respectful and dignified manner, reflecting the care plan content. This was also confirmed in resident and family/whanau interviews.

Planned activities occur that are meaningful to the consumer as part of the service delivery plan and are appropriate to their needs, age, culture and the setting of the service.

Medicines are being managed according to policies, procedures and guidelines for safe practice. Those administering medicines have been assessed as competent to do so.

Two general practitioners (GPs) were interviewed during the audit and confirmed the facility provides a good standard of care and that assessments and service delivery is appropriate, timely and in line with treatment recommendations.

Whole foods and home prepared cooking contribute to ensuring the nutritional needs of residents are met. A rotating menu has been reviewed by a dietitian, and for any resident with special dietary needs, these have been accommodated. Food is stored safely, twice daily temperature monitoring is occurring and stock rotation is occurring in the fridges, freezers and pantry.


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.


Waste is being managed through the use of private contractors and council collections. Personal protective equipment is available for staff and its use is monitored by the infection control officer.

A maintenance person is responsible for the management of the buildings and equipment. The facility has a current building warrant of fitness, a maintenance schedule is being adhered to and repairs are undertaken as required. Electrical checks have been completed, equipment is being calibrated and water temperatures are monitored. The external areas are safe and gardens are well maintained.

There are adequate communal toilets and showers as well as a shared ensuite between two rooms. All rooms have a wash basin. Residents, including those with walking aids, are able to easily mobilise around their bedrooms the communal lounge and the dining room.

Cleaning and laundry is undertaken according to schedules. Chemicals are locked away and staff have been trained on their use.

A fire evacuation plan is in place, fire drills occur every six months, fire safety systems and equipment are being checked and emergency management training provided. The contents of an emergency kit are being checked annually and emergency management and security systems are in place. A call bell system is operational.

Night store heating units are in all residents’ rooms and throughout the facility. A heat pump and bathroom fan heaters are in place. Room temperatures are checked monthly. Windows in all resident-designated areas have security latches and are openable.


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.


Policies and procedures on restraint minimisation and safe practice are accessible to staff. These include a definition of enablers and descriptions of any use of them at this facility. Staff undertake related training at orientation and biennially. The facility manager is the restraint coordinator and is responsible for reporting on restraint and enabler use at quality and risk meetings. There were no restraints or enablers in use at the time of audit.

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.


There is a documented infection prevention and control (IPC) programme which contains all requirements of the Standards. The infection control officer is supported by the facility manager and registered nurse (RN). The infection control officer reports to the manager and at the monthly quality meeting. Feedback is also provided to staff at their monthly meeting.

Records sighted and interviews demonstrated that staff have a clear understanding of what is required to implement the documented infection prevention and control programme (IPC) and reporting requirements. The staff are able to gain advice from a variety of external sources if required, including the Public Officer of Health in Invercargill. The GPs are also consulted regarding individual resident’s infections.


Infection control surveillance is occurring. The incidence and range of infections is low. The numbers and type of infections are analysed at the organisational level and at the individual resident level with the aim of minimising infections.

All staff receive IPC education as part of orientation and at least annually. There is a focus on education and prevention. Residents and family/whanau are educated in IPC practices as required for specific practices and when visiting 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 1 44 0 0 0 0 0

Criteria 3 89 0 0 0 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 Interviews with residents and family/whanau members and a review of seven rest home care records and observation during the audit verified that staff have knowledge and understanding of consumer rights and integrate them into every day practice. Records reviewed confirmed staff training occurs initially, during orientation and annually.

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 appropriate informed consent policy and procedures. These were reflected in documentation reviewed and included signed admission agreements and advance directives, written consents for transport, influenza vaccination, outings, photographs, names on doors and care provisions. Where applicable, power of attorney documentation was provided and accompanying signatures.

Staff during interview demonstrated knowledge of informed consent practices. Residents and family/whanau confirmed and provided examples that staff gain consent on a daily basis.

Standard 1.1.11: Advocacy And FA There are policies that include the right of residents to have an advocate or support person of their


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

Support

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

choice. Residents and family/whanau interviewed confirmed that family/whanau and support persons are included in discussions relating to care provision. Staff interviewed were aware of the residents’ rights to have a support person of their choice at any time.

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 All residents and family/whanau interviewed verified that family and visitors of their choice are able to visit at any time and there are no restrictions.

External community links are encouraged and enabled to continue, with examples of this provided.

Care plans, activity plans and progress notes reviewed confirmed regular outings, activities and appointments where transport can be organised to enable attendance.

Standard 1.1.13: Complaints Management

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

FA A complaints policy defines a complaint with reference to a complaints, concerns, compliments and suggestions form. The policy details timeframes that are consistent with the Code, refers to the use of a disputes committee, describes how to access advocacy services and notes that verbal issues will also be addressed.

The complaints register includes evidence of verbal issues, including those raised at residents’ meetings, being investigated and resolved. The manager reviews all concerns and complaints, retains all related correspondence and raises these for discussion in quality and risk management meetings. Minutes of these meetings show that complaints are used to help identify quality improvement opportunities. The complaints register notes the nature of the complaint, identifies the complainant, describes the resolution process and notes the dates of each stage of investigation and resolution.

Staff and residents interviewed are aware of the complaints process and complaints forms are accessible.

Standard 1.1.2: Consumer Rights During Service Delivery

Consumers are informed of their rights.

FA Residents and family/whanau in the facility confirmed that they are provided with information regarding the Code of Health and Disability Services Consumers’ Rights (the Code) and the Nationwide Health and Disability Advocacy Service. They verified that explanations regarding their rights occur initially and on an ongoing basis if they have any concerns. They were aware an advocate can be appointed if required. None of those interviewed had required the service.

Consumer rights posters, consumer rights brochures and information on the Advocacy Service were available at the entrance to the facility and include information on providing feedback, complaints and


compliments.

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 Care plan documents reviewed included preserving independence, values, beliefs and cultural, social, and/or ethnic needs of residents, with further examples observed and provided during interviews with staff.

Residents and their family/whanau members interviewed have not been subject to, or witnessed, any signs of abuse or neglect. Those interviewed maintained all staff show respect at all times, by knocking before entering rooms, ensuring conversations are private, respecting and understanding the individual resident’s values and beliefs and maintaining independence. These practices were observed during the audit and confirmed in the review of residents’ files.

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 Currently there is one Maori resident in the facility. Interview with the resident confirmed his spiritual, mental, physical and extended family care was commensurate with his and his whanau needs.

Policies on cultural safety and Maori health provide guidelines for the provision of culturally safe services for Maori residents. There is ongoing education in line with the Treaty of Waitangi expectations for staff. At initial assessment an appropriate care plan is developed in consultation with the resident and whanau and regularly re-evaluated to ensure it meets the residents’ required goals and outcomes. The care plan document reviewed and interviews with staff and the resident confirmed this.

Staff practice the ‘whare tapa wha’ model of health care combining the spiritual, mental, physical and extended family in assessment, ongoing care planning and re-evaluations.

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 Alongside the policies and procedures to address the needs of Maori residents in the cultural safety policy, there is a section on cultural needs of all persons within the facility. Residents and family/whanau members interviewed verified that the facility continually ensures their individual values and beliefs are met. Examples were provided that staff ensure residents receive services that respect their individual values and beliefs. This was also observed during the audit.

Standard 1.1.7: Discrimination FA Policy documents reviewed including the elderly abuse and neglect prevention policy, include guidelines to ensure residents are free from any discrimination, coercion, harassment, sexual, financial, or other


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

exploitation. Staff interviewed demonstrated an awareness of the residents’ rights in relation to these areas. Residents and family/whanau interviewed verified there have been no issues relating to coercion or exploitation.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

FA Induction and orientation for staff aligns to best practice processes. Records reviewed and interviews with staff verified that in-service education and ongoing professional development is provided and supported by the organisation. Policies and procedures are current and reflect best practice guidelines. The facility has commenced and completed the interRAI assessment for every resident and every new resident will be interRAI assessed.

Standard 1.1.9: Communication

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

FA The facility’s Open Disclosure policy describes key principles and explains expectations for this service. Residents and family/whanau members interviewed confirmed that communication is appropriate and delivered in a manner the resident and family/whanau can understand. Staff were observed taking time to ensure when communicating with residents that they are understood and residents have time to answer.

The facility’s RN has verified the facility has not needed to access interpreter services, although she could explain the processes in place should these be 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 A business plan reviewed 2016, describes a purpose and the scope of services to be delivered. A strengths, weaknesses, opportunities and threats (SWOT) analysis has been undertaken and contributes to the plan. The plan includes six goals and objectives, an executive summary and a description of the future direction for Rose Lodge. Each section focuses on the residents, their care, safety and support, as well as the need for good management and financial planning.

A philosophy of care notes that the management and staff are committed to new challenges that extend the boundaries of care. The facility aims to provide residents the opportunity for self-identity, having a personal powerbase, privacy, security and a sense of belonging.

The facility’s manager is a registered nurse with 20 years’ experience. She has been a tutor for programmes on care of the older person and previously worked at Rose Lodge. This person undertook a management of aged care facilities training day in October 2015 and is accepting responsibility for her own professional development with examples being the completion of on-line dementia training and becoming an Aged Care Association assessor.


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 A regional manager covers Rose Lodge and one other aged care facility in Invercargill. The regional manager who works from Rose Lodge for two full days each week relieves during any temporary absence of the facility manager. The regional manager has a Bachelor of Health Science with a major in Therapeutic Recreation and has been in a management role at Rose Lodge for seven years, three of which have been in her current role. Clinical oversight is maintained by another registered nurse who works four days a week and by an enrolled nurse. They have access to additional management and clinical support from another rest home and hospital facility if required.

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.

CI An organisational quality and risk management policy and procedure describes the organisation’s quality and risk management system. These include quality management and risk management objectives and detailed action plans for implementation. A range of different approaches for quality improvement are specified. Flow diagrams enable staff with different levels of experience to more easily understand the quality and risk management system. These comprehensive plans form the backbone of a system that is overall operating at a level of continuous improvement. Ongoing reviews and evaluations of the different aspects of quality and risk management are consistently occurring, staff at all levels of the organisation are upskilling and getting involved and all staff interviewed were familiar with language associated with quality improvement and with the initiatives supporting it.

Organisational policies and procedures are available in a set of manuals on different aspects varying from service delivery to human resources. A document control policy and procedure describes the expectations of managers and staff around managing organisational documents. This includes how such documents will be developed, controlled, reviewed and distributed. Organisational documents are reviewed at least annually and as needed. All sighted were current. Any new or amended document is approved by the quality assurance committee monthly meeting before it is circulated. Each quality manual has a specific month for review. These processes were also described by the regional manager.

Key components of quality and risk were evident in conversation with staff and managers and in quality and risk management meeting minutes. The health and safety policy states a health and safety programme will be developed and a health and safety officer appointed. A caregiver has accepted this role and attends relevant seminars and external monthly meetings. Information is subsequently fed into the monthly quality and risk (also known as quality assurance) committee meetings. The infection control officer provides reports on the surveillance of infections and is especially pro-active in the internal audit system. Quality assurance meeting minutes show that topics discussed and reports presented also cover hazard identification and reviews of the hazard register, staffing levels,


occupational health and safety, restraint, maintenance, activities, cleaning, kitchen complaints and internal audits. The analysis of data generated from incident reporting, complaints and infection reports for example is raising quality improvement opportunities that are being followed through.

The internal audit system is operating exceptionally well. With staff other than quality assurance committee members being allocated audits an increase in the number of corrective actions has occurred. This has resulted in new and more changes and an increase in quality improvement initiatives being developed.

The comprehensive risk management plan is reviewed through the usual quality management processes as well as a reporting system. A review of risks identified one for residents’ outing\s and the use of company vehicles. A comprehensive safety action plan was developed. The facility manager reports to the regional manager on a weekly basis covering risk related topics such as occupancy, vacancies, deaths, residents, issues, appointments, staff, issues, meetings/appointment and general issues. Monthly reports cover key activities over the past month, financials, occupancy, staffing, complaints/concerns, maintenance, suppliers/creditors and targets for next month. The regional manager provides monthly and quarterly reports that include aspects of the risk management plan to the owner.

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 regional and facility managers verbalised their awareness of different statutory and/or regulatory obligations. Although they have not had any such incidents, they noted their routine reporting obligations, their quarterly meetings with the portfolio manager and provided examples of significant adverse event reporting requirements.

An incident/accident policy defines an incident and categorises them into: a) Minor Incident/Accident; b) Serious Incident; and c) Serious Harm/Accident. Reference to an incident form is made and a copy sighted. Follow-up, reporting and analysis processes are all described and this process is being implemented. Staff are completing incident reports, the registered nurse facility manager is reviewing each and prevention opportunities for individuals are being developed and included in care plans. These are reviewed in the next timeframe. Incidents are being categorised for reporting purposes, graphs of different types being developed and analyses made. The data shows which residents or staff dominate, where most resident related incidents are occurring and what time of day. All incidents are reported and discussed at quality and risk meetings. The clarity of the data and graphs facilitates the analysis of it and is enabling corrective action/quality improvement opportunities to be identified and implemented.

Standard 1.2.7: Human Resource FA Records of annual practising certificates for registered nurses, the enrolled nurse, the visiting podiatrist,


Management

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

the pharmacist and the local GPs were sighted. All were current. A recruitment and employment policy and procedure details employment processes and an interview with the manager confirmed these are being followed. Staff files contain records of employment processes including application forms, interview records, reference and police checks and signed contracts and position descriptions.

In addition to policy documents on orientation processes for new staff, there is an orientation package, which is placed in staff files once signed off. Staff and managers described the process and staff are comfortable with the contents and length of orientation. The induction and orientation processes are comprehensive. They cover the essential components of the service including a range of human resource issues, a variety of training topics and competencies to be completed before full sign off. At their three month anniversary a performance review of all new staff is undertaken by the facility manager.

Monthly paid staff education sessions are separate from the two monthly staff meetings. A staff education calendar for 2016 details topics to be covered in the internal training programme. Records of completion of training are in staff files as well as in a master list of all staff and the training they have attended. As per the training policy, some topics are compulsory and non-attendees are required to complete a related questionnaire, which is then filed. Staff reported they get opportunities to undertake external training provided by the local district health board, or other training agencies such as the community college. Care assistants are being registered to undertake the National Certificate in Health, Disability and Aged Support. Registered nurses, senior care assistants and kitchen staff have up to date first aid certificates. Records show that staff are demonstrating competence, most of which are reviewed annually, in medication administration, moving and handling, hand hygiene, restraint minimisation and wound management.

Standard 1.2.8: Service Provider Availability

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

FA A staffing rationale policy notes that the allocation is 2.5-2.6 hours per resident per day, with a minimum of 2 staff on duty at all times and access to a registered nurse 24 hours a day on 7 days a week. The skill mix is determined by management and defined on the rosters. Factors to be considered include the ability of Rose Lodge to meet its organisational goals and objectives, the acuity and fluctuating needs of residents, clinical indicators, the safety and security needs of residents and staff and the skill level of staff.

Three care assistants work morning shifts. A minimum of two care assistants are on duty later in the afternoon shift and on night shift. Weekends have the same numbers of care assistants rostered on duty as during the week. Staff report that illness is covered by a relief staff person and there are open relationships with the facility manager to talk about acuity. The regional manager is responsible for roster development, which rotates on a fortnightly basis. The roster is coded to demonstrate who has up to date first aid and medication administration competencies, who the senior person is and which


registered or enrolled nurse is on duty after hours. Time for handovers is built in and the manager described examples of when additional staff may be used and how shifts are extended when acuity increases. Roster print offs covering four weeks over the audit period demonstrate that the policy is being implemented and safe service provider levels are in place.

Standard 1.2.9: Consumer Information Management Systems

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

FA A review of Rose Lodge Rest Home’s records, interview with the facility manager, RN, and documentation reviewed confirmed that information was entered into each resident’s integrated file in a timely manner. Records reviewed were current, accurately recorded, legible, and stored in a locked room.

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 Entry to service documents detail all requirements for both parties on admission to the facility. Records reviewed showed a needs assessment and service coordination (NASC) assessment occurs prior to all admissions to ensure admission is appropriate. The facility’s service agreement requirements have all been met in the files reviewed.

Residents and family/whanau interviewed verified the facility ensured the admission was timely and carried out with dignity and respect, taking into account the resident’s and family/whanau’s identified needs.

Standard 1.3.10: Transition, Exit, Discharge, Or Transfer

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

FA One file of a transferred resident was reviewed. The RN confirmed all transfers and discharges included the involvement of the facility manager, resident, family and GP. The file reviewed was completed with evidence of family and GP involvement prior to the transfer occurring. Policy reflects the process.

Standard 1.3.12: Medicine Management

Consumers receive medicines in a safe and timely manner that complies with current legislative

FA A medicines management system is well documented in the policies and procedures and details, which meet legislative requirements and recommended guidelines. Medicine management is overseen by the RN, who is responsible for the reconciliation of medicines into the facility and for the return of unused medicines to the pharmacist who uplifts the medicines from the rest home fortnightly. The rest home uses a two weekly Robotic system whereby the pharmacist delivers the medication to the RN and


requirements and safe practice guidelines.

medications are locked away in a cupboard. There is a medication check sheet completed by the RN for all residents when checking medication in from pharmacy as evidenced. All medicines and the folder holding the medicine record sheets are locked in a mobile trolley.

There is currently two controlled medicines in use. The controlled drug register was sighted as was the locked metal safe used for storage of the medicine. Recordings and checks of controlled medicines have been undertaken according to requirements. A medicine round undertaken by the RN, wearing a red vest indicating giving out medication and not to be disturbed, was observed and administration protocols were upheld with safe practices in use. The RN informed that medicine related errors are managed through the adverse event reporting system and there is evidence of this in these reports.

There is a master list of staff who are competent to administer medicines and these staff have evidence of a current medicine competency in place which aligns to the master list.

There are not currently any residents who self-administer their medicines, although there are related policies and documentation required if a resident chooses to self-administer. The RN informs that self-administration is discouraged due to the associated risks with respite care residents.

Fourteen medicine records were reviewed. All medicines are signed individually by the GP, all records have an allergy status recorded and a photograph of the resident. All medicines are being signed when administered and staff have sample signatures at the front of the medicines file. Pro re nata (as required) medicines and short term medicines are being administered as prescribed and their uses are monitored.

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 A copy of the report on the review of the five week rotational menu (17 February 2016) by a registered dietitian is in place. Food and nutritional assessments are completed for new residents when they are admitted. An additional dietary check list is completed to ensure any feeding aid and preferences about nutrition and fluids, or where a resident may prefer to eat, are covered.

There are currently two residents who have diabetes and their dietary needs are met. Residents are regularly weighed and where necessary, high protein drinks and food supplements are introduced in conjunction with relevant health checks being undertaken. Re-evaluation occurs on a regular basis as viewed in documentation provided.

The kitchen works with an external provider in maintaining kitchen hygiene and infection control prevention. It was observed that both staff members who participate in food preparation have completed their certificates in food hygiene. Areas inspected were clean and in good repair. Staff were knowledgeable. Food stores inspected were all current, dated and stock rotation is undertaken and a hard copy of this process is sighted. Prepared food is sealed and dated. Fridges and freezers are


temperature monitored twice daily and hot food temperatures are checked and recorded both at lunch and tea as per schedule. Staff are aware of the expected temperatures and know to report any deviation from these.

The senior cook informed that every effort is made to use natural and whole foods which is confirmed by a senior caregiver, who also does a number of kitchen duty shifts. Homemade preserves and jams are available, baking of biscuits and slices are undertaken on site and vegetables are frozen in season and used to supplement foods that are ordered and purchased from Bidvest. Items are uplifted by the senior cook and stored on arrival appropriately as evidenced on audit.

Residents are surveyed as to dietary preferences and copies of notes and meal adjustments were sighted as part of the routine practice in the kitchen.

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 the organisation, where appropriate.

FA Interview with the facility manager and RN and a review of records confirmed the facility follows current policy in admitting residents into rest home care. The facility manager maintains a record of prospective residents and a NASC assessment from the Care Coordination Centre occurs prior to admission to ensure the appropriate placement.

Standard 1.3.4: Assessment

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

FA The RN confirmed during interview that prior to admission, the Care Coordination Centre (CCC) completes an interRAI assessment to ensure the placement is appropriate, and the manager makes the final decision based on the assessment. The RN completes an appropriate assessment on admission to the facility. The assessment includes a pressure area risk assessment, falls risk assessment, continence assessment, nutritional assessment and, if required, a wound assessment.

An interRAI assessment is now being completed on all new admissions as verified in records reviewed and an updated care plan is completed based on the completed assessment. Resident, family/whanau input and appropriate allied health and community feedback is incorporated into the assessment. Reviews occur in a timely manner by the RN. If an issue arises within the evaluation period, an appropriate assessment tool is completed prior to the development of a short term care plan. Examples reviewed showed a consistent assessment and care planning process.

Standard 1.3.5: Planning FA The facility’s RN develops the initial care plan following the interRAI assessment and within time frames to safely meet the resident’s needs. Residents’ files reviewed verified the long term plan is completed


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

within three weeks of admission. During interview, the RN explained that when progress alters the RN will develop a short term care plan, using appropriate assessment tools. Care staff during interview demonstrated knowledge of the care plan content. Each care plan was complete, comprehensive and included interventions that reflected the resident’s outcomes goals following the interRAI assessment. Residents and family confirmed their involvement in care planning and the review process. There was evidence of allied health interventions and this was confirmed during GP interviews.

Standard 1.3.6: Service Delivery/Interventions

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

FA Policies are in place for continence management, management of challenging behaviours, pain management, pressure injury prevention management, personal cares, skin management, wound care, death of a resident and falls prevention. Links with other services were demonstrated through policies and assessment processes.

The facility’s RN documents appropriate interventions on the resident’s short term or long term care plan, based on completed prior assessments and the interRAI assessment tool. A daily handover sheet for carers has improved safety and outcomes for residents in this facility with clinical detail recorded in the residents individual progress notes and those sighted confirmed residents’ needs were met and service delivery was provided in a timely manner. This was verified during interviews with residents, family/whanau and staff.

GP assessments sighted were detailed on the medical clinical forms in the integrated resident’s files and the subsequent intervention included on the resident’s short term care plans. Both GPs interviewed confirmed interventions were timely and always completed by the facility staff.

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 A social activity profile, including resident’s personal history and interests, was developed by the two activity coordinators in the rest home following admission to the facility in files reviewed. An activity plan was developed following completion of the resident’s long term care plan in the rest home. Progress notes were observed to be completed weekly, and report on progress relevant to the resident’s individual activity programme and social interactions. A daily activities attendance is recorded. The general activity programme includes the local shopping run, church services, newspaper reading, arts and crafts, outings, singing group visits, entertainers, sing a longs, exercises, word games and individual birthday celebrations as observed at audit. Residents and family/whanau interviewed were happy with the content and variety of activities provided.

Encouragement has been given from both the regional and facility manager for both activities coordinators to undertake the diversional therapy course with financial support from the facility.


Standard 1.3.8: Evaluation

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

FA Care plan reviews are the responsibility of the RN. During interview the RN reported that when progress is less than expected a short term care plan is developed and implemented. Evidence in files confirmed this occurs, including re-evaluation and if required transferring the issue to the long term care plan. Examples were sighted where this had occurred. Files reviewed verified care plans were completed at least six monthly and often three monthly.

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 consumer choice/needs.

FA A review of integrated files, resident and family/whanau interviews, and two GP interviews provided evidence of referral to other health and disability services. During interview with the RN, examples were discussed and documentation reviewed of referrals to allied health services.

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 A waste management policy that listed the different types of waste states how these are disposed of at Rose Lodge. Rubbish is stored in containers at the rear of the facility. A skip for general and food rubbish facility is collected by a private contractor weekly, recyclables are collected weekly through the local council collection system, recyclable cardboard is collected by a private contractor as needed, as is green waste. New sharps containers are obtained from a local laboratory, however when fill the service provider needs to contact a Dunedin person to remove it. There are no other identified hazardous chemicals on site, other than cleaners. These are stored in a cleaner’s room that has a key pad lock on it.

Personal protective equipment of plastic aprons, gloves, foot coverings (for use inside gumboots if a staff person has bare feet), a face shield and masks are available. Staff were aware of their purpose and use, which is monitored by the infection control officer. The cleaner described actions to take in the event of a spill of a cleaner and showed the auditor where the instruction sheets are for such an event.

Standard 1.4.2: Facility Specifications

FA The building warrant of fitness with an expiry date of 17 February 2017 was on display at the front entrance. Electrical checks have been completed (November 2015), as per the maintenance schedule. Records sighted show that the calibration of medical equipment and weighing scales is up to date (11


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

December 2015). A maintenance person is responsible for attending to any repairs needed and for ongoing monitoring of the temperature of the internal environment, hot water checks and equipment maintenance. A lifting hoist has been checked within the past year and records sighted show that required checks of fire equipment are being upheld by a contractor. Repair records are placed in a maintenance book and folder and a maintenance report is provided to the owner on a monthly basis. Qualified tradespeople are called in when such expertise is needed.

A gardener is contracted to attend to the external environment, where attention to detail was evident. All external areas including an enclosed patio were tidy and safe. Residents are not given access to the area at the rear where rubbish bins are stored.

Standard 1.4.3: Toilet, Shower, And Bathing 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.

FA Residents confirmed that there are sufficient toilets and bathrooms around the facility. There are four showers and five bathrooms counting the ones in an ensuite that adjoins two residents’ rooms. All residents have a wash basin in their rooms.

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 residents have their own room, which is of sufficient size to enable them to have their own belongings and to negotiate around them with a walking aid safely. There are not currently any residents who use a wheelchair and the manager reported that if this was required the person would need to be reassessed.

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

FA A communal dining room is of adequate size to enable all residents to have their meals in one sitting. A communal lounge is available and there are sitting areas throughout the facility that residents use to relax in. Activity sessions are held in the lounge or in the dining area depending on the nature of the planned activity.


dining needs.

Standard 1.4.6: Cleaning And Laundry Services

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

FA A cleaning, disinfection and sterilisation policy and procedure was sighted. Laundry is primarily undertaken on site during the night shift. All instructions are available. Personal clothing is laundered during the day shift and wherever possible relatives are asked to launder woollens. All laundry and cleaning chemicals are stored in the laundry and cleaners’ room, which are locked with a number key pad.

During interview, the cleaner spoke of her role and responsibilities, which were also described on a housekeeper’s schedule. Staff have received training on the use and storage of cleaning and laundry products.

Internal audits are used to monitor the effectiveness of laundry and cleaning processes. Examples of corrective actions having been raised at the most recent housekeeping internal audit were sighted in the quality and risk meeting minutes and were discussed during the audit. Other monitoring systems being used for laundry and cleaning processes were the complaints system and resident and relative surveys.

Standard 1.4.7: Essential, Emergency, And Security Systems

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

FA Staff reported they undertake emergency management training at orientation and every year. This was verified in the training plan and in staff files. Fire drills are occurring six monthly and reports are being sent to the fire service with the most recent being February 2016. Checks on the range of different fire equipment and fire safety systems are being consistently undertaken and recording. An approved fire evacuation plan was sighted.

The regional manager explained that as cooking facilities use bottled gas these would be used should the power fail, otherwise a gas barbecue is available. Bottled water was dated and was in a store room with additional food and continence products. An emergency kit was on a shelf in the nurses’ station and records showed its contents are checked annually and renewed as needed. A call bell system that brings up a light and a digital read out above the door of the resident’s room, bathroom or communal area where it was rung was in working order when tested.

A security policy is in place. Residents expressed that they feel secure in this facility. Doors are locked around evening meal time as they are not visible from the dining area. Curtains are reportedly to be drawn at nightfall. External doors are alarmed once locked and will alert staff if a person tries to go outside. Security latches are on residents’ windows, sensor mats are used for new residents if there is a concern they may wander and a sign in and out process is in place. Staff reported that although they have had concerns with people going outside, there have not been any security concerns.


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 residents’ bedrooms, communal dining and living rooms and the hallways have windows of reasonable proportions that enable natural light to filter in. Windows are able to be opened for ventilation purposes, despite having security latches. Extraction fans are in bathroom areas.

The facility is heated by night store heaters throughout and all residents have a unit to release heat in their room. A heat pump boosts the temperature in the communal lounge and may be used in reverse to assist with reducing temperatures on warmer days. Bathrooms have electric fan heaters. Temperatures of residents’ rooms and internal communal areas are checked and recorded every month with actions taken if required.

Two designated smoking areas that are used depending on the predominant weather are in place for residents. A separate one is designated for staff. Non-smoking residents are not adversely affected by cigarette smoke.

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 scope of the service.

FA A comprehensive package of policies and procedures and guidelines appropriate to the service are in place. The facility manager, RN and infection control officer take responsibility for infection control in consultation with an infection control consultant. All staff attend a yearly infection control training programme to refresh and further their infection prevention and control knowledge. The infection control officer attends a two yearly infection prevention update, next scheduled for April 2016. This is evidenced by training records and supported by interviews with staff. The facility manager, RN and infection control officer are accountable and oversee infection prevention and control.

Surveillance occurs, infections are reported on the appropriate form, an infection report and feedback occurs at the monthly quality and staff meeting. Reports are graphed, re-evaluated and benchmarked against another local rest home by the infection control officer. The infection rate in the facility has slightly decreased in the previous three years.

The infection control programme is reviewed annually and signed off by the Board. The facility and regional manager report quarterly to the Board. Use of antibiotics is documented for surveillance and the monthly report demonstrates trending, analysis and benchmarking. Areas for improvement are targeted via the corrective actions process and addressed via the monthly meeting or sooner if required, with input from the infection control consultant as required.

Residents with colds or other illnesses are encouraged to stay in their rooms. Signage is at the front entrance indicating unwell visitors should not enter the rest home. Unwell staff are sent home. Strategies are in place to deal with infectious outbreak should this occur in conjunction with established processes.


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 facility manager and all staff receive annual infection control training including hand hygiene, cleaning and standard precautions. The infection control officer receives bi-annual in-depth training; the next training is booked for April 2016.

The Infection Control Programme is audited annually and any recommendations from the infection control officer are implemented.

The facility manager, RN and infection control officer were confident in their knowledge of infection control. Other staff interviewed were confident in their knowledge of application of infection control practices.

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 There are appropriate documented policies and procedures in place for the prevention and control of infection which reflect current accepted good practice and relevant legislative requirements. These procedures were evidenced and followed appropriately in documentation reviewed.

Standard 3.4: Education

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

FA The infection control officer provides annual training to all staff, including those staff whose training was already current. Records sighted show that there was nearly 100% attendance of staff. All new staff complete basic infection control training as part of their orientation training as evidenced at audit. Infection control education occurs at least annually.

Standard 3.5: Surveillance

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

FA Caregivers were able to describe their education on infection control and their responsibilities around reporting symptoms of potential infections. Monthly records of the incidence of infections were sighted. These include records of the date of each infection, the resident’s name, the area in the facility, how the infection was identified, infection type, whether the initial treatment was effective, the identified organism and the treatment prescribed, outcome and evaluation. Infections in the surveillance programme include


in the infection control programme.

eye, skin (cellulitis and fungal), influenza, urinary tract and upper and lower respiratory tract and any other infection. Rates are calculated according to occupancy, a summary of infection rates and types for the year is created, as are monthly/annual records of comparisons for each. Individual client’s files also have a record in their file with monthly and annual totals and the RN informs these are considered when reviewing and re-evaluating residents’ care plans.

Monthly and annual analyses of infections are occurring and being reported at monthly staff/quality meetings. Infection surveillance records are showing a slight decrease in the incidence of infections over the past three years, which is also noted during conversation with the facility manager, RN and infection control officer. The facility manager and RN attribute this to the good care being provided, strict toileting regimes, increased hygiene, increased showering, increasing the availability of extra fluids throughout the day. The infection control officer has been in the role for many years and is highly motivated in preventing infections in the rest home and is diligent in continuing to educate staff in the prevention of infections. They also state that staff education on infection control has contributed to an increased awareness about infection related risks and prevention.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA Restraint minimisation and safe practices policies and procedures were sighted and are easy to follow. The definitions of different types of restraints and of enablers are accurate and the procedures cover the different aspects of this standard should a restraint be required. An approved restraint use guide specific to the facility is appended to the policy. Approved restraints in this facility are a lap belt harness, bed rails and lazy boy chairs. The appendix details monitoring and observation requirements and evaluation and review.

The facility manager is the restraint coordinator and a restraint report is an agenda item for quality and risk meetings. Staff and managers informed there were no restraints or enablers being used in this facility at the time of audit. There was no evidence of any restraints or enablers being used in the facility and the quality and risk meeting minutes sighted stated none were in use. The last entry in the restraint register of was in 2009.

Staff undertake training on restraint use during their orientation and receive updates every two years.


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.

No data to display


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.

Criterion with desired outcome

Attainment Rating

Audit Evidence Audit Finding

Criterion 1.2.3.6

Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

CI A wide range of quality improvement projects were reported and documented. These originated from a range of quality and risk management processes, which varied from internal audit results, satisfaction surveys, concerns raised by residents at their meetings, the complaints system, infection control surveillance processes and staffing reports. The projects were all planned, implemented and reviewed or evaluated depending on the stage the project was at. A common element was that if the ideas did not develop from the analysis of data, then an effort had been made to obtain sufficient data to analyse and justify making changes. Examples of such projects included that through collective efforts nine issues identified on a hazard register had progressively been eliminated, and the involvement of residents in discussions on menus has resulted in a decrease in the number of food related complaints going through the complaints system.

Multiple examples of quality improvement projects have resulted from the collection, analysis and evaluation of quality improvement data. Each quality improvement project is being evaluated to measure the level of improvement, or satisfaction with the changes implemented. Positive changes are being made in response to the implementation of projects with additional modifications occurring as a result of evaluation and review processes. Continuous improvement is evident in the manner in which quality improvement data is collected, analysed and evaluated for quality improvement purposes.


Criterion 1.2.3.7

A process to measure achievement against the quality and risk management plan is implemented.

CI Monthly quality and two monthly staff meetings minutes provide opportunities to measure achievement against the quality and risk management plan. Management have attempted to create an environment where improvement was part of culture. They have encouraged staff to be directly involved in quality and risk management, in particular the internal audit system and solutions to address patterns emerging from the analysis of incident reports for example. A review of this process shows that the enrolled nurse and several care assistants have now taken ownership for internal audit processes, infection control surveillance and reviews of hazards for example. There is an organisational wide commitment to address shortcomings and staff overall have more familiarity with quality and risk management language.

An enrolled nurse and care assistants are now pro-actively involved in the internal audit system, infection control surveillance, health and safety and hazard identification and review. Increased responsibilities have resulted in increased co-operation from a wider cross section of staff for implementation and review of components of the quality and risk management plan. There is evidence of continuous improvement in the processes that underpin implementation of the monitoring and measurements of the objectives in the quality and risk management plan.

Criterion 1.2.3.8

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

CI Corrective actions are being raised across all components of the quality and risk management system. The managers provided evidence of an increase in the number of corrective actions being raised, more staff attending quality assurance meetings and more attention being paid to detail. This was attributed to the proactivity of an enrolled nurse and several care assistants in the internal audit, infection control, health and safety and hazard management processes. Staff have since taken increasing ownership of this process for themselves and they claim they feel more part of the team. More positive changes are occurring because of the additional corrective actions raised and the evaluation processes are stimulating the initiation of quality improvement projects. An example is that following the safety audit a project around the purchase and use of wet floor signs, as well as staff education ensued. Re-audits occurred until full compliance was attained. Not all staff had undertaken restraint training and not only was this provided but a package was developed for ongoing use that included orientation. It was found that not all care plans included details about residents’ hygiene needs and not only was this remediated but there was progressive auditing and ongoing education about nail care and shaving, for example. A final re-audit of random checks showed

The management group have reviewed their quality improvement project related to more staff being actively involved with implementation of the quality and risk management system. Results show that peer review processes have resulted in more attention being paid to detail. More corrective actions have been raised and therefore more improvements have been made. Corrective actions are not just being addressed but there are many examples of quality improvement projects developing from the review processes of corrective actions. There is evidence of continuous improvement, not only for some of the corrective actions raised, but also in the process of the identification of areas requiring improvement, the


full compliance and generated positive comments from relatives and residents. development of corrective action plans and the implementation of the projects.

End of the report.


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