Craigweil House Care Limited - Craigwell House

Transcription

1 Craigweil House Care Limited - Craigwell House 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 HealthShare 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: Premises audited: Services audited: Craigweil House Care Limited Craigweil House Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care); Dementia care Dates of audit: Start date: 29 September 2016 End date: 30 September 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: 53 Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 1 of 36

2 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 Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 2 of 36

3 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 Craigweil House can provide care for up to 68 residents. This certification audit was conducted against the Health and Disability Service Standards and the service contract with the District Health Board. The audit process included the review of policies, procedures and residents and staff files, observations and interviews with residents, family, management, staff and two medical officers. The facility manager is responsible for the overall management of the facility and is supported by the clinical manager. Service delivery is monitored. Improvements are required to the following: to advance directives; completion of incident forms; training for staff in the dementia unit; documentation of the time of entry in resident records; assessments and care planning; activity programme; the external environment in the dementia unit; and training for the infection control coordinator. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 3 of 36

4 Consumer rights Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Some standards applicable to this service partially attained and of low risk. Residents receive services in line with the Health and Disability Commissioner s Code of Health and Disability Services Consumers Rights (the Code). The systems protect their privacy and promote their independence. There is a documented Maori health plan in place which acknowledges the principles of the Treaty of Waitangi. Individual care plans include reference to residents values and beliefs. Management and staff communicate in an open manner and residents and relatives are kept up-to-date when changes occur. Systems are in place to ensure residents are provided with appropriate information to assist them to make informed choices and give informed consent. The rights of residents or their legal representatives to make a consumer complaint is understood, respected and upheld. An up-todate complaints register is maintained. Consents are documented by residents. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 4 of 36

5 Organisational management Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. There is an annual business plan in place which defines the scope, direction and objectives of the service and the monitoring and reporting processes. The service is managed by the facility manager who is a registered nurse with a current practising certificate. There is an established quality and risk management system in place. There are a range of policies and associated procedures and forms in use to guide practice. Quality outcomes data are collected and analysed to improve service delivery. An internal audit schedule is in place. Adverse events when documented, are reported to management and external agencies. The human resource management system is consistent with accepted practice. There is an annual training plan in place that includes mandatory training. There is a staff training programme in place. There is a clearly documented rationale for determining staff levels and staff mix in order to provide safe service delivery in the rest home, hospital and the dementia unit. An appropriate number of skilled and experienced staff are allocated each shift. Resident information is stored securely. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 5 of 36

6 Continuum of service delivery Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Entry into the service is facilitated in a competent, timely and respectful manner. The initial care plan is utilised as a guide for all staff while the long term care plan is developed over the first three weeks of admission. Care plans are expected to be reviewed every six months, and when completed, are individualised. Each resident has a current interrai assessment and care plan. Residents response to treatment is evaluated and documented. Relatives are notified regarding changes in a resident s health condition. An activities programme is documented and displayed in each area. The activities coordinators provide activities in the rest home/hospital area and in the dementia unit. Medicine management policies and procedures are documented and residents receive medicines in a timely manner. Medication competencies are completed annually for all staff that administer medications. The facility utilises four weekly rotating summer and winter menus, reviewed by a dietitian. Residents and family expressed satisfaction with food services. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 6 of 36

7 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. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. All building and plant comply with legislation with a current building warrant of fitness and New Zealand Fire Service evacuation scheme in place. A preventative and reactive maintenance programme includes equipment and electrical checks. Fixtures, fittings and floor and wall surfaces are made of accepted materials for this environment. Resident rooms are of an appropriate size to allow for care to be provided and for the safe use and manoeuvring of mobility aids. One room has been converted from an office to a room able to be used for respite services. The audit has confirmed appropriateness of the room for the purpose intended. There is a dementia unit that has specifically identified indoor and outdoor areas for residents. Essential emergency and security systems are in place with regular fire drills completed. Call bells allow residents to access help when needed in a timely manner. Restraint minimisation and safe practice Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service fully attained. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 7 of 36

8 The restraint minimisation programme defines the use of restraints and enablers. The restraint register is current. Policies and procedures comply with the standard for restraint minimisation and safe practice. Assessment, documentation and monitoring of care and reviews are recorded and implemented. Restraint risks are identified. Staff members receive annual training regarding restraint use. 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. Some standards applicable to this service partially attained and of low risk. The infection control programme is reviewed annually for its continuing effectiveness and appropriateness. Staff education in infection prevention and control is conducted according to the education and training programme and recorded in staff files. The infection control coordinator has had training around infection control in the past. The surveillance data is collected monthly for review and discussion at clinical meetings. Appropriate interventions are in place to address infections. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 8 of 36

9 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 () 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 Criteria 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 Criteria Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 9 of 36

10 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 Standard 1.1.1: Consumer Rights During Service Delivery Consumers receive services in accordance with consumer rights legislation. Attainment Rating Audit Evidence Policies and procedures are in place to ensure consumer rights are respected by staff. Staff receive education during orientation and ongoing training on consumer rights is included in the staff annual training schedule. Staff interviewed are all able to articulate knowledge of the Health and Disability Commissioner s Health and Disability Services Consumers' Rights (the Code) and how to apply this as part of their everyday practice. Staff interviewed confirm they receive ongoing education on the Code. Visual observations during the audit and the review of clinical records and other documentation indicate that staff are respectful of residents and incorporate the principals of the Code into their practice. The service provides information on the Code to families and residents on admission. Residents and family interviewed state that they believe receive services as per the Code. Standard : Informed Consent Consumers and where appropriate their PA Low There is an informed consent policy in place. Consent is included in the admission agreement and sought for appropriate events. Staff mostly use verbal consents as part of daily service delivery. Staff interviewed demonstrate an understanding of informed consent Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 10 of 36

11 family/whānau of choice are provided with the information they need to make informed choices and give informed consent. processes. Residents and relatives confirmed that consent issues are discussed with the relatives and residents on admission and appropriate forms are shown to them at this time and thereafter as relevant. All residents' files reviewed demonstrated written consent. All residents have the choice to make an advanced directive. In records reviewed, all residents had advanced directives recorded however an improvement is required to signing of some advance directives. Standard : Advocacy And Support Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. There are policies in place regarding advocacy and/or support services. Advocates can also be accessed through the Nationwide Health and Disability Advocacy Service if required. The Nationwide Health and Disability Advocacy Service brochure is provided to the resident and their family/whanau on admission. These brochures are also displayed in the entrance foyer of the facility. Education on advocacy is provided to staff during orientation and in the ongoing in-service programme. Residents and relatives interviewed confirmed they are aware that advocacy services are available should they be needed. Standard : Links With Family/Whānau And Other Community Resources Consumers are able to maintain links with their family/whānau and their community. Residents have open access to visitors of their choice. There is a visitors' policy and guidelines available to ensure resident safety and well-being is not compromised by visitors to the service. Access to community support/interest groups is facilitated for residents as appropriate. The activities staff are available to take residents on community visits and staff are available to take people to appointments if family are not able to provide transport. Residents interviewed confirmed they can have access to visitors of their choice at any time and are supported to access services within the community. Standard : Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. The complaints management policy and procedure is documented and follows Right 10 of the Code. The complaints policy and procedure is explained by the staff as part of the admission process. There are complaint forms available at the main entrance to the building. Residents complaints are managed by the facility manager. An up-to-date resident complaints register is maintained. There have been two resident complaints in 2016 both of which were substantiated. Both complaints have been addressed to the satisfaction of the complainant. Staff, residents and Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 11 of 36

12 families interviewed have a good understanding of the complaints process. Standard 1.1.2: Consumer Rights During Service Delivery Consumers are informed of their rights. Information on the Code and the Nationwide Health and Disability Advocacy Service are displayed in the facility and included in the admission information pack. The Code and other rights and information in the information pack are discussed with residents and relatives on admission. Residents and relatives interviewed confirmed that the Code, the advocacy service and residents rights are explained on admission. 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. There are a range of policies and procedures in place to ensure residents are treated with respect Staff endeavour to maximise residents independence. There is respect for residents' spiritual, cultural and other personal needs. Residents are referred to by their preferred name. Residents and relatives interviewed stated that staff have regard for the dignity, privacy, and independence of residents. There are quiet, low stimulus areas that provide privacy for residents in the dementia unit. 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. There are policies and procedures covering cultural safety and cultural responsiveness. The documentation includes appropriate Māori protocols and provides guidelines for staff in care provision for Maori residents. The documentation is referenced to the Treaty of Waitangi and includes guidelines on partnership, protection, participation and equality with the inclusion of Te Whare Tapa Wha model of healthcare. Staff interviewed confirm an understanding of cultural safety in relation to care. Cultural safety education is provided in the orientation programme and thereafter through refresher training. On the days of audit there were residents who identify as Māori. The cultural needs for both Māori residents were reflected in their assessment and care planning documents. Access to Māori support and advocacy services are available if required. Systems are in place to allow for review processes including input from family/whanau as appropriate, for residents who identify as Māori. Links have been made with the Māori community including local marae and Te Ha Oranga Ngati Whatua. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 12 of 36

13 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. There are policies and procedures in place to guide staff on cultural safety and cultural responsiveness. Cultural preferences are included in the assessment process on admission and individual values and beliefs are then documented in the care plan. Staff interviewed confirm their understanding of cultural safety in relation to care. Residents and family members interviewed confirmed that values and beliefs are respected by staff. Standard 1.1.7: Discrimination Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. There are policies and procedures in place to protect residents from abuse, including discrimination, coercion, harassment, and exploitation, along with actions to be taken if there is inappropriate or unlawful conduct. Expected staff practice is outlined in job descriptions. Staff interviewed demonstrated an awareness of the importance of maintaining boundaries with residents. Residents and relatives interviewed reported that staff maintain appropriate professional boundaries. Standard 1.1.8: Good Practice Consumers receive services of an appropriate standard. Policies and procedures are reflective of evidence-based practice. Management and staff have access to, and demonstrate knowledge of, relevant legislation and approved service standards. Evidence based guidelines, treatment protocols, reference material and resources are available and utilised by staff. Clinical staff have access to the internet and external expertise if they need to consult and/or gain further clinical knowledge or advice. The education programme includes mandatory training requirements for staff and other significant clinical aspects of care delivery. Demonstrated competencies are recorded. Staff interviewed confirmed that the facility provides a resourceful, learning and supportive environment. Family members interviewed confirm they are very happy and satisfied with the care provided to their relatives living in the dementia unit. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment The service provider has policies covering communication, access to interpreters and maintains an open door policy. Information is provided in a manner that the resident can understand. Relatives and residents can discuss issues at any time with staff. Resident meetings are conducted. The incident and accident forms include an area to document if the Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 13 of 36

14 conducive to effective communication. relatives have been contacted. Open disclosure is practised and documented when family are contacted. Residents and relatives interviewed confirmed that they are kept well informed, and that management and staff communicate in an open manner. Relatives confirmed that they are advised if there is a change in their family member's health status. The general practitioners interviewed reported satisfaction with communication by staff. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. The organisation is privately owned and governed by a board of directors. The business has agreements in place with Waitemata District Health Board for the provision of aged residential care, the provision of Long Term Supports-Chronic Health Conditions, and an agreement with the Ministry of Health for Residential-Non Aged care. There were no residents on the days of audit admitted under the Ministry of Health Agreement. The purpose, values, priorities and goals are documented in the annual business plan for These goals are then included in the quality and risk management programme. Organisational performance is closely monitored by the board through six weekly executive meetings and weekly management reports. The facility manager is in frequent telephone contact with the managing director. The board reviews the performance of the facility manager annually. The facility manager is responsible for ensuring services are planned, coordinated and appropriate to meet the needs of the residents. The facility manager is a registered nurse with a current practising certificate and has been in the current role since May Prior to this she was employed by the facility as the clinical nurse manager and prior to that as a registered nurse. The facility manager is supported by the clinical manager who is a registered nurse with a current practising certificate. The clinical manager is employed full-time and has been in the role since September 2015 following an internal promotion. The clinical manager is an experienced registered nurse who has worked extensively in the aged care sector in rest home, dementia and hospital level care. Both the facility manager and the clinical manager have competed at least eight hours of education in the last year to maintain their practising certificates. Standard 1.2.2: Service Management During the temporary absence of the facility manager, the clinical manager is available and Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 14 of 36

15 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. 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. experienced to cover the service. If the facility manager was unable to perform the role for an extended period, then the board would reconsider other options. The quality and risk management programme identifies objectives for the service. Activities within the programme are closely linked with health and safety, adverse event reporting, the infection prevention and control programme, restraint minimisation, and the resident complaints process. Quality related data and outcomes are collated, analysed and shared with staff at regular staff meetings. Policies are reviewed two yearly as defined by policy. The service uses an external quality and risk management consultant to provide advice on policies, procedures and forms. Policies sighted reflect current good practice, legislation and compliance requirements. All documents sampled are controlled and obsolete documents removed from circulation. Policies and procedures and the internal audit schedule include reference to interrai and care planning processes. Internal audits are planned and corrective actions are documented and implemented where a variance is identified. Corrective actions are discussed at both management and staff meetings and linked to the quality and risk management system. There is a process to measure achievement against the quality and risk management plan. The plan is reviewed annually. The quality system is managed by the facility coordinator. A risk management plan is included in the quality and risk management plan. The risk register is maintained by the facility coordinator for the facility manager. Health and safety requirements are being met, including hazard identification. Health and safety systems have been reviewed since the introduction of the Health and Safety at Work (General Risk and Workplace Management) Regulations Policies have been updated in August The facility coordinator who is the health and safety representative has attended training on the new legislation on 17 May 2016 and the legislation has been discussed at board level. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service PA Moderate There is an established system in place for managing adverse events (both clinical and nonclinical). A review of the adverse event reporting system confirmed that incidents and accidents are being reported, although an in-depth review of one resident recently discharged confirmed that not all incidents were documented on incident and accident forms as is policy Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 15 of 36

16 and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. (refer 1.3.3). The incident forms that have been completed show evidence of immediate responses, investigations and remedial actions being implemented as required. This includes reporting to family members and informing the general practitioner. The review confirmed that documented incidents and accidents were closed in a timely manner and linked to the quality system, including remedial actions. Monthly statistics on all documented adverse events are collated, analysed and reported at nurse meetings, quality meetings and board report. The facility manager and clinical manager understand their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. 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 Moderate There is an established system in place for human resource management. All staff records reviewed include an employment agreement and a position description. Staff have criminal vetting prior to appointment and professional qualifications are validated. All staff receive an orientation and participate in ongoing refresher education. Performance appraisals are completed for all staff who have been employed for 12 months or more. There is a registered nurse in charge on each shift. Files of registered nurses reviewed hold current first aid certificates. Three registered nurses are interrai competent including the facility manager, the clinical manager and another registered nurse. Medicines are given by registered nurses and healthcare assistants who have been assessed as competent in the rest home and dementia unit. Only competent registered nurses give medicines in the hospital unit. Staff administering medicines maintain competency which is assessed annually by a registered nurse who has been assessed as competent. Staff participate in staff meetings. Staff interviewed confirm they are kept up-to-date on changes occurring within the service or matters of concern. One healthcare assistant who is the senior caregiver working in the dementia unit has completed the unit standards for providing care to residents in a dementia unit (sighted). The dementia unit was opened in Other staff currently working in the dementia unit have yet to complete training related to their work in the dementia unit. Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and The process for determining provider levels and skill mix is defined in policy and takes into account the layout of the facility and levels of care provided. Staff rosters are developed by the clinical manager and the facility manager. Rosters and staff interviewed and observation Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 16 of 36

17 safe service from suitably qualified/skilled and/or experienced service providers. on the days of audit confirmed there were sufficient numbers of staff in each area to meet minimum requirements as specified in the Aged Residential Care Agreement. Registered nurses are on duty each shift and are supported by health care assistants. The clinical manager is on site Monday to Friday and on call for clinical emergencies/concerns. There is a staff member on duty with a current first aid certificate on each shift. The facility requires that all registered nurses hold valid first aid certificates and copies are in place on staff files. Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. PA Low Electronic and paper-based clinical records are maintained for each resident. All records are maintained confidentially. The resident records are stored in a locked cupboard in the nurse`s station or stored electronically with appropriate back-up systems in place. The detail is adequate and records information important for ongoing care and support being provided. A record of past and present residents is maintained electronically. InterRAI assessments are completed by the registered nurses and inform the development of the resident s plan of care (refer 1.3.4). Progress records are clearly documented by the clinical staff in the paperbased record. The date, time, signatures and designation of those entering into the records is legible, however shift rather than time is being recorded by some staff in some progress records. 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. The residents entry into the service is facilitated in a competent, equitable, timely, and respectful manner as described by residents interviewed. Information packs are provided for families and residents to the hospital, rest home and the dementia unit, prior to admission. The facility requires all residents to have needs assessment service coordinator (NASC) assessments via an interrai assessment, prior to admission, to ensure they are able to meet the resident s needs. All but one file reviewed as part of the selected sample had a needs assessment completed prior to admission with an additional needs assessment required for another resident in an extra file sampled (refer 1.3.4). Interviews confirm that the registered nurses, clinical manager or facility manager (registered nurse) admit new residents into the facility. Evidence of completed admission records was sighted. The registered nurse receives hand-over from the transferring agency, for example, the hospital at the district health board, and utilises this information in the development of the care plan for the resident. Family are encouraged to be a part of the admission and entry process with this confirmed by family interviewed. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 17 of 36

18 Standard : Transition, Exit, Discharge, Or Transfer Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. Planned exits, discharges or transfers are coordinated in collaboration with the resident and family. There are documented policies and procedures to ensure exit, discharge, or transfer of residents are undertaken in a timely and safe manner (refer 1.3.4). The clinical manager reports that they include copies of the resident s records including: general practitioner visits; medication charts; current long term care plans; upcoming hospital appointments; and other medical alerts, when a resident is transferred to another health provider. Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. Medicine management policies and procedures are in place and implemented, including processes for safe and appropriate prescribing, dispensing and administration of medicines. Standing orders are documented as per Ministry of Health guidelines with annual review completed. The medication areas are free from heat, moisture and light, with medicines stored in original dispensed packs, in a secure manner. Medicine charts list all medications the resident is taking, including name, dose, frequency and route to be given. All entries are dated and allergies recorded. All residents have photo identification with confirmation that the photograph is a true likeness. Discontinued medicines are identified. The three monthly general practitioner reviews are all completed within the three monthly timeframe. Medication reconciliation policies and procedures are implemented. Medication fridge temperatures are monitored daily. Controlled drugs are kept inside a locked cupboard and the controlled drugs register is current and correct. One elixir was slightly under the amount documented in the controlled drug register however the resident was having small amounts at very regular intervals. The clinical manager acknowledged the difficulties of maintaining an absolutely correct total as some is lost when checked. Sharps bins were sighted. Unwanted or expired medications are collected by the pharmacy. Medication administration was observed during lunch time in the rest home, hospital and the dementia unit. The staff members checked the identification of the residents, completed cross checks of the medicines against the script, administered the medicines, and then signed off after the resident took the medicines. Staff are authorised to administer medications with competencies completed annually. All staff members responsible for medicines management complete annual competencies. There are residents who self-administer medicines with a competency completed. Each resident is confirmed as having a safe secure place to store medications if they self-administer. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 18 of 36

19 Standard : 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. PA Low The food service policies and procedures are appropriate to the service setting, with seasonal menus reviewed by a dietitian. Residents dietary profiles are developed on admission with a current list of likes, dislikes and allergies maintained on a white board in the kitchen. Dietary profiles are not updated. Interviews with kitchen staff confirm their awareness of the residents dietary requirements. Kitchen staff are trained in safe food handling processes. Food safety procedures are adhered to. Residents who require special dining aids are provided for, to promote independence. The residents' files demonstrated monthly monitoring of individual resident's weight with any weight loss reported and measurement of weight increased to weekly. Supplements are provided to residents with identified weight loss. Residents stated they are satisfied with the food service and family for residents in the dementia unit state that they are happy with meals and service provided. Residents reported their individual preferences are met and adequate food and fluids are provided. Food on the days of audit as hot and met assessed resident needs. The service provides additional food over a 24-hour period for residents with dementia and for others in the service if they require snacks outside of meals and morning/afternoon tea times. All aspects of food procurement, production, preparation, storage, transportation, delivery and disposal comply with current legislation and guidelines. 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. The service has a documented process for the management of declining resident s entry into their care. Records of enquiry are maintained and in the event of decline, information is given regarding alternative services and the reason for declining services. The scope of services provided is identified in the NASC assessment (refer 1.3.4) and communicated to prospective residents and their families. The clinical manager assesses the suitability of residents with support and input from the facility manager. When residents are not suitable for placement at the service, the family and / or the resident are referred to other services, depending on their level of needs with NASC services informed. Standard 1.3.4: Assessment PA Low The registered nurse, facility manager or the clinical leader completes a variety of risk assessment tools on admission and as required. The dietary profiles are not kept up to date. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 19 of 36

20 Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. The service completes interai assessments for new residents with all bar one file reviewed confirming that these were completed in a timely manner. A medical assessment is completed by the general practitioner and recreational assessment completed by the activities coordinator. Baseline recordings are recorded for weight management and vital signs with at least monthly monitoring. The needs, support requirements, and preferences are collected and recorded for most residents however the interrai assessments do not always align with the documentation of the long term care plan. Staff interviews confirm that the families are involved in the assessment and review processes with family signing on the assessment and/or care plan to indicate their involvement. The outcomes of the assessments are used in creating an initial care plan and in the long term care plan. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. The care plans are resident focused for residents in the hospital and rest home and describe in depth strategies for most goals in the dementia unit (refer 1.3.6). and integrated. The residents files have sections for the resident s profile, details, observations, care plans, monitoring and risk assessments. Interventions sighted were consistent with the assessed needs and best practice (refer 1.3.4). Goals are realistic, achievable and clearly documented. The service records interventions for the achievement of the goals (refer 1.3.6). Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Moderate Residents state that they receive adequate and appropriate services meeting their assessed needs and desired outcomes. Interventions are documented for each goal in the care plan documented for each individual resident. Residents files reflect residents and family involvement in the development of goals and review of care plans. Interview with the general practitioners confirmed clinical interventions are effective and appropriate. Interventions from allied health providers are included in the long term care plans such as discussions with the needs assessment service coordinators (NASC), podiatrist and the physiotherapist. Two residents with a wound were reviewed. Both had a comprehensive assessment and progress notes documented. A wound management plan is required to be completed. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 20 of 36

21 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. PA Moderate The activities programmes confirm that independence is encouraged and choices are offered to residents. There are two activities coordinators who develop and implement the activity programmes. They work five days a week for a total of 26 hours a week across the rest home, hospital and in the dementia unit. An activities plan is documented for each day/week/month and displayed in pictorial form for residents. A separate one is displayed for residents in the dementia unit and one for residents in the hospital and rest home areas. Activities include: physical; mental; spiritual and social aspects of life, to improve and maintain residents wellbeing. During the onsite audit, activities included: residents going for an outing; music; and one-on-one activities. Residents and family confirm they are satisfied with the activity programmes. On admission, the activities coordinator completes a recreation assessment for each resident. Residents files reviewed during the onsite audit had a monthly activity review completed and a daily log of attendance is expected to be completed. Residents in the dementia unit are expected to have a 24-hour activity care plan documented that links to the long term care plan for managing challenging behaviours. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Moderate Four of the six residents files that required six monthly review have this completed in a timely manner. There are frequent reviews completed by the general practitioner for each resident. All reviewed had the need for a three monthly review to be completed however each of the eight resident files reviewed indicated that the resident had been reviewed by a general practitioner at least one or two monthly with some who had deteriorated reviewed weekly or as required. A review of resident records indicates that the general practitioners respond in a timely manner when notified of any changes in a resident s condition (generally the next day). The general practitioners stated that staff are responsive to any changes in the resident condition and inform them in a timely manner. Progress records in each resident file document any change in condition. Progress notes are completed at every shift by the clinical team for residents in the hospital, within 48 hours for residents in the rest home and dementia unit and any changes recorded as these occur. Progress notes reflect response to interventions and treatments. Residents are assisted in working towards goals. Short term care plans are developed for acute problems, for example: infections; wounds; and other short term conditions. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 21 of 36

22 Records reviewed indicate that staff respond quickly to any change in a resident s condition with appropriate authorities or referrals made. 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. The clinical manager stated that residents are supported in access or referral to other health and disability providers. The registered nurses manage referrals for residents to the GP; dietitian; physiotherapist and mental health services. The general practitioners confirmed involvement in the referral processes. The review of residents files included evidence of recent external referrals to the physiotherapist, podiatrist, wound and other specialists. Members of the allied health team document in the resident record with each resident having a physiotherapy on entry to the service and at least six monthly. At handover on the day of audit, two residents were referred to the physiotherapist for review because of a change in mobility and both were documented as able to be seen the following day. 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. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Moderate There are policies and procedures for the management of waste and hazardous substances that have a focus on risk management. Waste is mostly of a domestic-type and is managed via a recycling programme or by local council contracted services. Medical hazardous waste is collected by an external contractor. Personal protective equipment for staff is readily available and adequate supplies are maintained for daily use and for use in an emergency situation. The building has a current warrant of fitness which is due to expire 8 February Since the previous surveillance audit the facility has extended the current sitting area in the hospital unit to create a full lounge area/dining area. This renovation was planned in 2013 and Waitemata DHB was informed at the time and came and inspected the area involved. At the suggestion of Waitemata DHB during that site visit the service incorporated a divider to separate the new area from the hallway and laundry doorways on the opposite side of the corridor. The extension has obtained a certificate of completion to the existing fire alarm system (issued 10 December 2015) from Fire Protection Inspection Services Limited and the extension forms part of the current building warrant of fitness. The rest home is at 100 years old and has been upgraded and is undergoing ongoing planned and reactive maintenance. The rest home and hospital are connected and the dementia unit has a separate roof line and the building is connected to the hospital unit by a Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 22 of 36

23 covered walkway. The hospital and dementia units are purpose built units. Planned and reactive maintenance is implemented by the maintenance person and contractors. The physical environment internally and externally is maintained to minimise risk of harm, promote safe mobility, aid independence and is appropriate to the needs of the current residents. Some fencing should be reviewed as this has been scaled by a resident. The electrical equipment is checked and records maintained. Testing and calibration checks of medical measuring equipment occur annually. The service has two vans used for transporting residents. There is a system for managing the vehicle warrant of finesses and current registrations. 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. Standard 1.4.4: Personal Space/Bed Areas Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. There are sufficient toilets, hand basins and showering facilities available for residents. All bar two rooms have hand basins in their room. The rest home has communal toilets with some containing showers. The dementia unit has large communal toilets with combined showers. The hospital includes some bedrooms with an ensuite. There are appropriate privacy protections in place when showers and toilets are in use. All residents have their own room except for three rooms in the rest home room which are double rooms that are able to accommodate couples. On the day of audit one of the three double rooms was occupied by a couple. The hospital rooms have double doorways for beds and easy hoist access if required. There is ample room for mobility aides to be used safely in each resident s room. Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs. There are large lounges in all units including the dementia unit. There are smaller rooms available throughout the building with comfortable seating for family/visitors and group meetings. The lounges are also used for activities. Each area has a dedicated dining room area. There is a sunny enclosed sunroom in the rest home adjoining the rest home lounge that is very popular and well utilised by residents. Craigweil House Care Limited - Craigwell House Date of Audit: 29 September 2016 Page 23 of 36