the mclean institute · the mclean institute date of audit: 11 november 2014 page 2 of 22 executive...

The McLean Institute Date of Audit: 11 November 2014 of 22

The McLean Institute

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 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: The McLean Institute

Premises audited: Holly Lea

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 11 November 2014 End date: 11 November 2014

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 32

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

Holly Lea Village Limited (HLVL) is under the ownership of a charitable trust called The McLean Institute. An unannounced surveillance audit was undertaken for the Holly Lea rest home/retirement village in suburban Christchurch. Although a relationship restructure between The McLean Institute and HLVL is currently underway and is changing aspects of the governance of this service, this is not impacting on the services to its residents. Five levels of support are offered to residents, with the fifth one being for residents assessed as requiring rest home level care. On the day of audit five of the 32 residents have been assessed for this level of care.

There have been no other significant changes at Holly Lea since the certification audit when ten areas were identified as requiring improvement. Five of these areas still require further action to meet requirements and include the need for staff performance appraisals to be completed, residents’ records to meet requirements, rest home level residents to have admission agreements, the need for information obtained during assessments to be integrated into care plans and that the facility has a current building warrant of fitness.


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

Standards applicable to this service fully attained.

Open communication, including open disclosure, is occurring and residents report full satisfaction. There is access to interpreter services when required, although such services have not been required for many years.

A complaints process that meets the Code of Health and Disability Services Consumers’ Rights is in place and complaints forms are available. Residents inform they are currently satisfied with services, which is reflected in the complaints register, as there has not been an entry in the register since 2013.

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 low risk.

Holly Lea has well defined goals, a mission statement, a philosophy and detailed quality management goals and objectives. The manager is suitably qualified with previous management experience and is actively maintaining her knowledge and skills.

The service is demonstrating a commitment to quality improvement. Implementation of the quality and risk management system is ensuring that quality and risk management plans are being implemented as documented. Policies and procedures meet requirements and an area that required improvement has been addressed. The analysis of data for adverse events, infection


control, resident satisfaction, internal audits and health and safety, for example, is occurring and the information contributing to quality improvement. Staff are being provided with verbal and written updates on quality and risk systems following quality management meetings and reports. Risks and hazards have been identified, monitored and the information analysed.

Professional qualifications are validated, new staff are screened for suitability and recruitment processes include a comprehensive orientation and induction that is signed off. An in-service staff training schedule is being implemented alongside on-line staff training. An area that required improvement around the completion of staff annual performance appraisals has yet to be completed, although the required position descriptions are now in place.

Safe staff levels are being maintained with all shifts having a person with a current first aid certificate and a current medication competency on duty. A registered nurse is on morning shift seven days a week.

Records reviewed are complete and current but do not always include identifiable signatures and staff identification, leaving this previous required improvement open. Some records have been deleted using white out liquid paper. All current and archived records are secure.

Continuum of service delivery

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


The facility’s registered nurse (RN) completes a range of assessments within accepted timeframes addressing a previous required improvement. Assessments are used to develop detailed care plans or short term care plans for isolated issues, and guide care staff in service provision; however not all assessment information is transferred onto the care plan and this requires improvement, and some assessment tools are not always completed. The RN reviews care plans within recommended timeframes. Observation


of staff, review of integrated residents’ notes, and resident interviews, confirms that all staff provide individualised care that reflects desired goals and outcomes.

A general practitioner (GP) is interviewed during the audit and confirms the RNs’ assessments are accurate and appropriate, that he is notified in a timely manner of any issues, his recommendations and treatments are carried out, and he is happy with the RN input.

An activities programme is planned and implemented by the activities person and meets the identified activity wishes of the residents. An individual resident’s activity plan is developed that reflects the individual’s interests, and these are reviewed in line with care plans.

Policies and procedures are in place for all stages of medication management. A blister pack medication system is in place for the facility. The medication administration process was observed during the audit confirming safe practice occurs. Documented medication records are completed by the residents’ GPs.

A dietary profile is completed for each resident on admission and updated as required. Special dietary requirements are met and personal likes and dislikes are catered for. Kitchen processes, including food preparation, transport, storage and removal of kitchen waste is appropriately managed by the kitchen staff including the chef. A nutritional review of the menu has occurred this year, and observation of the meals provided reflects the facility’s menu. Food, fridge and freezer temperatures are recorded daily and are within recommended levels.

Safe and appropriate environment

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



The facility has a current building warrant of fitness. A certificate of public use is on display and confirms the building is safe, however the authorities are not able to provide a full Code of Compliance from recent building work undertaken until all repairs to the damage incurred during the 2011 Christchurch earthquake are completed.

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 in place and reflect the need for enabler use to be voluntary. There is no evidence of restraints or enablers currently being used, therefore an issue identified as requiring improvement in the previous audit is no longer relevant.

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.


A documented and implemented infection control programme which meets the infection control standards includes policies and procedures to guide all staff. Records sighted, observation and interviews with care staff provides evidence that all staff have a clear understanding of what is required for prevention of infections.


The registered nurse and general manager ensure the programme is implemented, collate and analyse infection control data, and report findings to the quality committee and staff meetings.

Summary of attainment

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

Attainment Rating

Continuous Improvement

(CI)

Fully Attained(FA)

Partially Attained

Negligible Risk(PA Negligible)

Partially Attained Low

Risk(PA Low)

Partially Attained

Moderate Risk(PA Moderate)

Partially Attained High

Risk(PA High)

Partially Attained Critical

Risk(PA Critical)

Standards 0 14 1 4 0 0 0

Criteria 0 40 1 4 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 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 process is described in the organisational policy and procedures and meets requirements. Complaints forms are accessible to residents, however residents spoken with are satisfied with the services provided and do not have any complaints to make. There have not been any complaints entered into the complaints register since October 2013. All complaints in the register provide details of follow-up and copies of e-mail and written correspondence are also on file alongside the relevant complaints form.

Standard 1.1.9: Communication

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

FA The right to full and frank information and open disclosure is noted in a policy on open disclosure. Completed incident forms show that open disclosure is occurring and residents state they are kept fully informed and can always ask questions. A policy document on interpreter services provides staff with ways in which they can access these services as required and includes managing those who are hearing and/or sight impaired. Management and staff advise there has not been any requirement to implement this policy over recent times.

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


Standard 1.2.1: Governance

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

FA The mission of Holly Lea states that their aim is ‘to provide exceptional individualised care in unique and gracious surroundings’. Organisational goals refer to key concepts of partnership, the maximising of independence, quality and holistic care, a peaceful, homelike and safe environment, the inclusion of family/whanau and qualified staff with access to ongoing education. There are six bullet points associated with the philosophy of care, all of which make reference to quality, such as a high quality of life, a stimulating environment or improving self-esteem.

The quality and risk management plan further describes goals and objectives intended to ensure the organisation’s mission, goals and philosophy of care are upheld.

Holly Lea is being managed by a suitably qualified and experienced person who has been in the position for approximately two years. She is a registered physiotherapist who was previously chief executive officer of a large organisation for people with disabilities, is a qualified auditor, and has had several roles in quality management/facilitation. Ongoing education and upskilling is occurring with attendance at relevant conferences, regular meetings within the aged care industry and at training on management topics, such as employment law. There are an updated curriculum vitae and a current performance appraisal on file. A recently reviewed position description describes the authority, accountability and responsibility of her role.

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.

FA A quality policy includes a quality philosophy (June 2013), quality objectives and information about the document control system. A risk management policy provides risk related definitions and informs about the identification of risks. Quality and risk management review includes which reports will be provided monthly, bi-monthly and annually, lists contracts, legislation and regulations that impact on the service and the documentation, provides risk management guidelines and describes the quality improvement process.

Policy and procedure manuals cover all aspects of organisational management and of service delivery and are being managed according to a policy document titled ‘Control of Quality Documents and Records’. These are being reviewed and updated every two years, as any new information becomes available and when organisational changes occur. All pages are document controlled and show the version and the manual. A front page in each manual serves as a document review and amendment log. The areas requiring improvement that were identified as requiring improvement


at the certification audit have been addressed, as examples of documents having been changed to more accurately reflect the transition to electronic monitoring are sighted and there is no evidence of documents being over written or obsolete documents being in place. The quality team are responsible for the review of organisational documents and the manager has sign off authority.

One to two monthly quality meeting minutes, staff meeting minutes and the manager’s monthly report to the board of Holly Lea Village Limited are sighted, as is the annual quality report for the end of 2013. These documents reflect quality improvement processes in place as well as summaries of resident numbers and their health status and staffing issues and education. They also cover complaints, health and safety, food and activities, exception reporting, infection control, restraint minimisation, audit results and planning and review processes. An annual resident satisfaction survey has been fully analysed and reported. A health and safety committee reports to the main quality meeting, as does the infection control team, and these are minuted. The manager and quality manager work together to address restraint requirements.

A comprehensive system and schedule for internal audits is in place with corrective action and review processes occurring. Data from incident reports and internal audits, for example, is being analysed. Resulting trends and patterns are being used to help identify changes that will contribute to quality improvement purposes.

Identified risks are being monitored and reviewed in a consistent manner and the hazard register is also reviewed monthly with additions and updates added as needed. An annual analysis of hazards for 2013 is sighted.

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 managers are aware of essential notification reporting. Examples are provided of reporting that has been undertaken, such as the reporting of a noro virus outbreak, as are examples of other possibilities that may arise, such as emergencies and change of manager.

The incident reporting system is detailed in the organisational policies and procedures. Staff are using incident report forms to report any adverse events and when interviewed all seven staff are able to inform of examples. The quality manager collects monthly data around the incident reports for falls, skin tears, medication errors, staff incidents/accidents, maintenance, building issues, other. Every three months a more comprehensive report is develop, the data is graphed and trends and variances identified. Corrective actions are being implemented, such as the


registered nurse going through medication education with staff on a one to one basis to address an exceptionally high number of medication errors. A review noted an ongoing reduction since. Likewise an increase in falls was investigated and contributed to a person being re-assessed.

An annual adverse event report is developed at the end of the year (sighted one for January to December 2013).

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 Evidence of professional qualifications is in two of the staff files sighted and copies of annual practising certificates are sighted. These are current for the three registered nurses, the pharmacists, the visiting podiatrist, physiotherapist and the three GPs who attend the rest home level residents.

Recruitment processes are undertaken according to the policy and procedure documentation. Records of staff interviews are in all seven staff files that were reviewed, as is evidence of referee checks and confirmation that police checks are undertaken when staff commence employment. Position descriptions are sighted, including for the registered nurse. These now include all necessary details and fulfil the required improvements identified at the certification audit. An annual staff performance appraisal process is in place; however staff files show that these have not been kept current. An effort to remedy this has been made and some staff have completed versions on file. Caregivers have completed the self-assessment section; however there is still no evidence that a member of the management team has discussed their performance. Completion of annual performance appraisals in a timely manner is an area that was identified as requiring improvement during the certification audit and continues as an area requiring improvement.

A comprehensive orientation programme has an accompanying handbook and sets of checklists. Sign off of these is evident in staff files and staff inform during interview that everyone commences employment by ‘buddying’ with an experienced staff person for as many shifts as are required.

There is an in-service staff education schedule for 2014 and a partially developed one for 2015 is sighted. Monthly staff education sessions are complemented by the use of an on-line training package for caregivers. Worksheets from these packages are in staff files. The education programme includes core topics of consumer rights, medication competencies, emergency management, restraint, infection control and first aid. All staff who may be in the position to administer medicines have a current medicine administration competency and all staff have a current first aid certificate.


Attendance records for each training session and records of training attended by individual staff are viewed.

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 service provider level and skill mix policy describes factors that impact on matching staffing resources with residents’ needs as well as the staffing structure that forms the foundation for the roster. The manager confirms she is responsible for the staff roster and provides a copy of the human resources plan.

A person with a current first aid certificate is always on duty as all caregivers and registered nurses have a current first aid certificate. Similarly there is always a staff person with a medicine competency on duty.

Rosters for the two weeks prior to the audit and two weeks following the audit are sighted. Any sickness and annual leave has been replaced and there is an example in October of ten days when a one on one special was allocated to a person requiring additional care.

A registered nurse is rostered on a seven and a half hour shift on seven days a week and provides supervision to the caregivers. This person is also on call for the balance of the 24 hour period.

One caregiver works morning shift 6.30 am to 2.30 pm and another 7 am to 3 pm. Afternoon shifts for caregivers are 2.30 pm to 10.30 pm and 2.45 pm to 11 pm. Two caregivers work nightshift 10.45 pm to 6.45 am. An additional shift is in place for a caregiver on Sundays between 4.30 pm to 8.30 pm and is used for other days of the week depending on requirements.

An activities coordinator works 15 hours a week on Monday, Wednesday and Thursday, one cleaner works three days a week and another five days a week (both between Monday and Friday) and there is a cook on duty each day between 9 am and 6.30 pm and a kitchen assistant 7.45 am to 1 pm.

Staff confirm during interview that there is adequate staff available on all shifts and that agency nurses may be used but only as a last resort.

Standard 1.2.9: Consumer Information Management Systems

Consumer information is uniquely identifiable,

PA Low Five resident records files are reviewed. The RN and care staff make entries at least every shift. RN’s complete assessment forms and develop care plans. In those reviewed there are assessment form and care plan entries that have not been signed,


accurately recorded, current, confidential, and accessible when required.

dated or designation of the service provider included. One file reviewed has information deleted by ‘white out’ liquid paper. A personal care form sits in front of the notes (four of four files reviewed), is dated but not signed or the designation included. This previous area of required improvement remains open. There is a register of staff signatures and designation to verify staff initials and signatures, including general practitioners.

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.

PA Low There are five residents assessed as requiring rest home level care. All reviewed have an assessment completed from needs assessment and service co-ordination (NASC) to determine the level of care is rest home. There are other entry screening processes sighted that include GP and RN initial assessments. The RN is interviewed and reports that the initial entry assessment and care plan serve as the initial guide for care staff. This is confirmed by care staff interviewed. The facility has no residents who have been assessed at hospital level care, addressing a previous required improvement. Two residents have completed resident’s agreements, but do not have all the statements as required in the provider’s agreement with the district health board. (Clause D13). Three other residents do not have a signed resident’s agreement. This previous required improvement has yet to be addressed.

Standard 1.3.12: Medicine Management

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

FA Within the clinical policies there is a suite of medication related documents. Policies and procedures for medication management include each health professional’s responsibility in relation to medicine prescribing, administration, reconciliation, dispensing, storage and disposal.

The facility has a blister pack medication system in place for all residents requiring medication assistance. The blister packs are reconciled into the facility by the RN monthly. Discontinued medications are returned to the pharmacy at least daily if required, including controlled medications, as sighted in records signed by the RN and the pharmacist. There are no stock medications retained at the facility addressing a previous required improvement.

The resident's prescription medication record is completed, and now updated by the resident's GP and administered by the facility care staff or the RN. The initial record is legible and each record signed individually by the GPs and there are no faxed records, addressing previous required improvements.

One RN is observed administering medications on the day of the audit, with a current


medication competency (sighted). The medication trolley holds all current medication, blister packs and medication records and is observed to be locked and securely stored when not in use.

Controlled drugs are reviewed and storage is in line with guidelines. There is a separate medication fridge and temperatures are recorded (observed) and within recommended guidelines.

Eight pro re nata (prn) medication records are sighted and records verify these are recorded to the level of detail required, for example for pain, nausea and constipation.

There are no assessed residents who self-medicate; however there are policies and procedures in place should this occur.

Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

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

FA There are policies and procedures in place for all aspects of food service, delivery, preparation, service, storage and disposal and cleaning.

A nutritional audit of the menus has been undertaken by a dietitian on the 15 April 2014 (sighted). The menu content on the day of the audit reflects the summer menu version. The cook, who was interviewed, manages the kitchen. She has been in the position for over 10 years and is supported in her role by a kitchen assistant. Kitchen duties are shared among the cook and the kitchen assistant.

Dietary profiles are written on admission. These are sighted and include likes and dislikes, preferences for beverages, and any other special dietary instructions. The RN or general manager will usually inform the kitchen if there are any changes in dietary requirements. Residents' preferences are listed and catered for and sighted on the kitchen notice board. This is verified by residents interviewed who confirm there is variety in the food provided and that food meets their needs, and preferences met.

The facility has a large spacious dining room, but also manages to cater for residents who prefer to eat in their own room.

A resident with a weight related issue is being managed appropriately with supplements, GP and dietitian intervention, as sighted in the resident’s integrated notes.

Observation of the meal service confirms that residents enjoy the meals provided. A review of residents’ meetings minutes and survey results verifies that residents are


complimentary about the food.

Food and fridge temperatures are recorded and those reviewed are within recommended guidelines. Storage in the spacious pantry is dated and stock rotation occurs, particularly regarding decanted stock, addressing a previous required improvement.

Standard 1.3.4: Assessment

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

PA Low The RN is interviewed and she reports that the RN completes assessments for all residents. These are completed prior to updating the resident’s care plan. Five residents’ files reviewed have assessment tools completed six monthly, and these include falls risk, pain, continence and pressure area risk assessments, addressing a previous required improvement; however the information gathered on the assessment is not always reflected in the updated care plans which needs addressing, and one file reviewed does not have a pain assessment completed for a resident receiving prescribed medication for pain, and this also needs addressing.

Standard 1.3.6: Service Delivery/Interventions

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

FA The facility’s RN in most instances documents appropriate interventions on the resident's short term or long term care plan, based on prior assessments (refer to criterion 1.3.4.2). Care plans reviewed are usually consistent with meeting the resident’s identified needs and outcomes are evaluated regularly, and the care plan is either updated or a short term care plan is developed. Progress notes are written by care staff and those sighted confirm residents' needs are met and service delivery is provided in a timely manner. Staff are observed providing care to residents based on the care plan intervention. For example, one resident has strategies to manage decreased mobility, and this is observed occurring during the audit.

GP assessments sighted are detailed on the medical clinical forms in the integrated residents’ files and the subsequent interventions are included on the residents’ short term care plans (sighted). For example, GP recommendations and interventions to treat a wound are included on a resident’s short term care plan.

Residents’ interviewed and family communication forms reviewed confirm service delivery is consistent with meeting desired outcomes and they are involved in the review process, as evidenced in the family communication form.

There are no residents who are at hospital level of care addressing a previous required improvement.


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 Five residents’ files are reviewed and the activities person is interviewed. The activities person develops the activity programme each month following an activities meeting. The minutes of these meetings are sighted. The activities person implements activities for residents Monday to Saturday.

A social activity profile is developed on admission to the facility in all those files that are reviewed. An activity plan is developed following the completion of the resident’s long term care plan. Activity plans are reviewed six monthly in line with the care plan, identifying progresses and attendance at either group or individual activities. Care plans reviewed are detailed, individualised and specific to the resident’s interests from their social profile.

The general activity programme includes local shopping, church services, bowls, singing group visits, reading, quizzes, puzzles, housie, entertainers, movies, outings, sing a longs, exercises, stories and word games. Residents interviewed are happy with the content and variety of activities provided.

Standard 1.3.8: Evaluation

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

FA There are evaluations completed on all files reviewed at least six monthly. The RN during interview reports that she reviews care plans if progress is less than expected, and either updates the care plan or develops a short term care plan. An example sighted for a small skin tear, this prompts a care plan review and a short term care plan developed. Care staff are observed referring to short term care plans for changes in service provision.

Standard 1.4.2: Facility Specifications

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

PA Negligible

Although building repairs have been undertaken during the last twelve months, especially in one apartment, there has not been any modification or restructure of the building.

A certificate of pubic use and a building warrant of fitness are on display near the main entrance to the facility. The certificate of public use is dated 30 October 2014 and expires 1 November 2015 confirming the safety of the facility. The building warrant of fitness is dated 24 October 2014 and expires 1 November 2015.

A Code Compliance is still not available as repairs for damage sustained in the 2011 Christchurch earthquake have not yet been completed. Consequently, the required


improvement for the issue of full Code Compliance remains open.

The testing of electrical equipment has been undertaken and tagging has occurred. Scales and medical equipment have been calibrated. There are not currently any hoists in use in this facility. The required improvement that related to this from the last audit has been addressed.

Standard 3.5: Surveillance

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

FA A form sighted for the purpose of collecting monthly data on all infections is maintained by the RN. The general manger was interviewed and collects the monthly report sheets. The information is then transferred to a data analyses sheet (as sighted), listing specific infections of urinary tract, eye, respiratory tract, skin and wound and gastro-enteritis infections. This gives an up to date analyses of trends and patterns.

Documentation sighted includes the collection, collation and analysis of information on infections and the measurement of incidence and recommendations for minimising infections.

Evidence in the last two quality meeting minutes and staff meeting minutes reviewed verify that infection control surveillance, analyses, conclusions and specific recommendations to minimise reduction in infection have been documented and reported to the organisation. There is evidence that hand hygiene audits are occurring on a regular basis.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The restraint minimisation and safe practice policy and procedure is reviewed. This defines restraint and enabler use, describes the purpose of each and notes the different types of restraint. The manager informs there are not currently any restraints or enablers in use in this facility and this is confirmed during an interview with six staff of which four work directly with the residents. There is no evidence of any resident using any device that might constitute an enabler or a restraint. The person who was identified as having inadequate documentation around assessment of the use of items that were supporting their comfort and safety, during the last audit, is no longer receiving services in this facility.


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

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

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

Criterion with desired outcome

Attainment Rating

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

Criterion 1.2.7.3

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

PA Low An annual staff performance appraisal process is in place, as per organisational policy and contractual requirements; however staff files show that these have not been kept current. An effort to remedy this has been made and some staff have completed versions on file. Caregivers have completed the self-assessment section; however there is still no evidence that a member of the management team has discussed their performance. Completion of annual performance appraisals in a timely manner is an area that was identified as requiring improvement during the certification audit and continues as an area requiring improvement.

The annual performance appraisal system is not being implemented according to policy. Staff files have performance appraisals dating back to 2011. Although some appraisals have been completed for 2014, those for caregiver staff are incomplete as only the self-assessment sections have been filled in.

Annual performance appraisals are implemented according to policy and contractual requirements.Click here to enter text

180 days


Criterion 1.2.9.9

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

PA Low Five resident files are reviewed. In resident files reviewed there are assessment form and care plan entries that have not been signed, dated or designation of the service provider included. One file reviewed has information deleted by ‘white out’ liquid paper. A personal care form sits in front of the notes (four of four files reviewed), is dated but not signed or the designation included. This previous area of required improvement remains open.

Resident assessment form and care plan entries do not always have the name and designation of the service provider included.

All records include the name and designation of the service provider included.

180 days

Criterion 1.3.1.4

Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.

PA Low There are five residents assessed as requiring rest home level care. Two have completed resident’s agreements, but do not have all the statements as required in ARRC D13. Three other residents do not have a signed resident’s agreement.

The facility has five residents assessed as requiring rest home level care. Two subsidised residents do have a signed resident agreement, but do not have included the resident’s rights under the Social Security Act to apply for a review of the subsidised resident’s means assessment. Three assessed residents who are privately funding their care do not have a signed resident’s agreement that meets the requirements of the provider’s agreement with the district health board (Clause D13).

Entry agreements are documented and meet the requirements of ARRC D13.

180 days

Criterion 1.3.4.2

The needs, outcomes, and/or goals of consumers are identified via the assessment process and are

PA Low Five residents’ files are reviewed and assessments are completed six monthly for continence, pain, falls risk and mobility. However, the information gathered on the assessment is not always reflected in the updated care

The information gathered on the six monthly assessments is not always accurate or reflected in the updated care plans.

The needs and outcomes for residents are identified via the assessment process and used to update the care plan.


documented to serve as the basis for service delivery planning.

plans. For example, a resident with marked incontinence issues at night, has an assessment showing she is independent in toileting, and the continence products used as indicated on the assessment form are different to those on the care plan. Another resident who takes prescribed medication for pain has two blank pain assessment forms in her file.

180 days

Criterion 1.4.2.1

All buildings, plant, and equipment comply with legislation.

PA Negligible

A certificate of public use that is valid until 1 November 2015 is on display near the main entrance. A building warrant of fitness is still not available for this facility as repairs for damage sustained in the 2011 Christchurch earthquake have not yet been completed. Consequently, the required improvement of the need for a current building of fitness remains open.

A current Certificate of Public Use is on display. The facility does not have full Code Compliance.

That full Code Compliance is obtained.

365 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.