Hilary Isabel Bird. Introduction

Transcription

1 Hilary Isabel Bird 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: Premises audited: Services audited: Hilary Isabel Bird Tui Glen Resthome Rest home care (excluding dementia care) Dates of audit: Start date: 16 June 2014 End date: 16 June 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: 7 Hilary Isabel Bird Date of Audit: 16 June 2014 Page 1 of 22

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 Hilary Isabel Bird Date of Audit: 16 June 2014 Page 2 of 22

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 Tui Glen Resthome is certified to provide rest home level care for six residents. On the day of this spot surveillance audit there were seven residents, including one in a resident bedroom added since the previous audit. Consequently, a partial provisional audit was also undertaken to confirm the additional bedroom meets the requirements for rest home occupancy. The facility is in Atawhai Nelson and owned and operated by the manager who lives upstairs in the same facility. The manager oversees the day to day management of the facility, and is supported by another live in staff member and a part time registered nurse (RN). Eight areas identified as requiring improvement at the previous audit have been closed. Three other areas remain open, and three further areas for improvement have been identified as a result of this audit. These relate to induction documentation, activity plans and goals, short term care plans, medication reviews, a Code Compliance Certificate and updated evacuation plan. Consumer rights Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Standards applicable to this service fully attained. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 3 of 22

4 Residents and family interviewed verified that staff are very respectful of their needs, that communication is appropriate and they are given time for discussions to take place. They have a clear understanding of their rights and the facility s processes if these are not met. Written consent is now in place for all residents, addressing a prior required improvement. The complaints process is well managed within required timeframes and includes the principles of open disclosure. 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. The organisation s quality plan is current and documents the facility s purpose, values, scope, direction and goals. There is evidence that the owner manager and the registered nurse (RN) have the relevant experience and skill to manage the facility. There is now a defined document control system in place addressing a previous shortfall. Accidents and incidents are being reported and analysed and an internal audit programme is maintained to ensure that required standards are being upheld. Corrective action plans are now in place where audit results did not reach the required standard and evaluations are completed. induction and orientation programme is in place, however the related documentation is not always completed and this previous area identified for improvement has yet to be fully addressed. Employment practices meet best practice guidelines. A planned training programme is in place and professional development is supported by the organisation. The roster indicates that staffing levels are safe and that there is RN cover when the part time RN is on leave. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 4 of 22

5 Continuum of service delivery Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of low risk. The admitting RN develops a detailed care plan based on assessments to guide staff in service provision and reviews these within recommended timeframes. However activity plans or short term care plans are not always developed and these areas still need addressing. Observation of care staff, review of residents notes and resident and family interviews, confirmed that all staff provide individualised care that is reflective of the residents needs. A general practitioner (GP) is interviewed by telephone during the audit and confirmed the facility provides a good standard of care and his recommendations and treatments are carried out. There was evidence in files reviewed that the GP visits three monthly if the resident is assessed as clinically stable. An activities programme is planned and implemented by the activities person and it was confirmed by residents and family members that this is age appropriate and of interest to them. Policies and procedures are in place for all stages of medication management. A blister pack medication system is in use for the facility. The medication administration process is observed during the audit confirming safe practice occurred. Documented medication records are completed and reviewed by the resident s GP, although this is not always within the required timeframes, and this requires improvement. A dietary profile is completed for each resident on admission and any special dietary needs are met. Personal likes and dislikes are catered for. The kitchen service is managed from within the facility by the manager who is supported by kitchen staff. A nutritional review of the menu has occurred in the past 12 months and, as observed, the meals reflected the menu, addressing a previous required improvement. Appropriate monitoring of food procurement, transportation and storage of food occurs. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 5 of 22

6 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. The facility has a current building warrant of fitness. There have been additional internal modifications within the building footprint since the last audit allowing for an extra resident s bedroom; however there is no Code Compliance Certificate or evacuation plan for the additions and this need addressing. There is adequate space and natural light in the additional room, and sufficient toilet and communal areas to cater for the extra resident. Emergency lighting, a call bell and sprinklers have been added to the room. Previous areas identified as requiring improvement relating to locks on shower and toilets, essential and emergency equipment and the removal of unused or broken equipment have all been addressed. Cleaning and laundry services are appropriate to the increased number of residents in the facility. 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. A documented restraint and enabler use policy is in place and meets the standard requirements. At the time of audit there are no residents with either enablers or restraints in use at the facility. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 6 of 22

7 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. Standards applicable to this service fully attained. The facility has not had any infections recorded for 2014 or 2015 as verified in records reviewed. There are systems in place to monitor these should infections occur. The RN now has infection control knowledge and experience for the role addressing a previous required improvement. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 7 of 22

8 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 Hilary Isabel Bird Date of Audit: 16 June 2014 Page 8 of 22

9 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 : Informed Consent Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. Standard : Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. Standard 1.1.9: Communication Service providers communicate effectively with Attainment Rating Audit Evidence The facility has developed a policy regarding written consent that reflects documentation in files reviewed. For example, written consent is gained on admission and includes advance directives, influenza vaccinations, photographs, service delivery procedures and outings. This previous required improvement has now been addressed. The facility s complaints policy, which meets the requirements of Right 10 of the Code of Health and Disability Services Consumers Rights (the Code), is in place. Staff interviewed were aware of how to assist residents and family if they wished to make a complaint. Complaints are on the quarterly staff meeting agenda, with complaints identified and the resolution or on-going process included. This was confirmed in the complaints log. One recent Health and Disability Commissioner (HDC) complaint has been investigated and has now been resolved. Residents and family interviewed confirmed that the complaints process is easily accessible. Effective communication with residents and family was observed during the audit. For example, staff are heard addressing people as Mr or Mrs and their surname Hilary Isabel Bird Date of Audit: 16 June 2014 Page 9 of 22

10 consumers and provide an environment conducive to effective communication. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. Standard 1.2.2: Service Management The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers. unless they have indicated to use a first name. Communication was observed to be appropriate and residents were given time to answer. Residents and a family member interviewed verified that staff ensure that they are understood and communication is respectful. Open disclosure occurs according to the facility s policy. Incident reports reviewed provide evidence that a family member had been notified, and this is verified in family communication forms that the discussion that took place. The manager interviewed verified that interpreter services have not been used for any residents in recent months but confirmed how these needs would be met, if required. The organisation s quality plan 2015, which covers strategic and service goals was reviewed. There are clearly documented purpose, values, scope, direction and goals to support these included. Tui Glen Resthome documents inform the organisation will encourage resident group and family feedback when reviewing these goals. The recent owner/manager is in the process of implementing the interrai programme which is the major service delivery focus for the next twelve months. As well, structural plans are in place to increase the number of bed capacity to eight, and while these are only in the planning phase, an additional room has already been included with an upgrade to a room downstairs (refer to criterion ). Tui Glen Resthome (Tui Glen) has an overall goal to ensure the facility is able to maintain the service as a home-like environment where freedom of choice and independence can be maximised. The current owner/manager has been in place for approximately two years and is suitably qualified and experienced. She is supported in her role by a registered nurse at least four hours per week, who assumes a management role in her absence. Prior to ownership the manager was employed at the facility for two years. The service is managed by the facility owner who resides on the premises. During her absence a suitably experienced deputy assumes the role. The position descriptions of the facility manager/owner and her deputy include the requirements that they both undertake management responsibilities. A registered nurse, including a relief RN shares the clinical role. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 10 of 22

11 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. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to Tui Glen has incorporated the well-established and implemented quality management system from the previous owners. A meeting structure and reporting process which covers all key components of service delivery is documented and implemented. A risk management plan has been developed with eight top organisational risks identified. Any changes in risks are reported to the manager, and these are reviewed at the quarterly staff meetings and documented in the staff meeting minutes. The quality and risk management format is a new learning process for the manager/owner, however indications are that there is already a clear understanding of the requirements. Quarterly staff meetings include all aspects of quality and risk. The meeting includes a summary of incidents, accidents, infection control, health and safety and amended policies for implementation. Examples of discussions are documented in the minutes, including the recent HDC complaint. There have been regular efforts to learn from untoward events, including seeking external expert advice from Older Persons Health services, and other residential care facilities in Nelson. Corrective action processes have now been put in place where audit results did not reach the required standard and the manager is beginning to understand and complete evaluations following audit processes. This addresses a previous required improvement. A document control system has now been implemented to manage approval, review, version numbering and archiving of clinical and management documents addressing the previous issues. Documents or policies that have altered are included in the quarterly staff meetings. Staff who do not attend the quarterly meetings are provided with a copy of the minutes. An internal audit programme has been implemented. Examples sighted of internal audits undertaken to monitor systems include food and water temperatures, security, cleaning, and infection control. Where appropriate, recommendations for improvement have been made and implemented. The manager demonstrated examples of a thorough adverse event reporting system during the audit. Each incident is investigated and tracked, with detailed summaries and outcomes, including any on-going communication. A recent HDC complaint example was tracked and verifies the process. A further two examples Hilary Isabel Bird Date of Audit: 16 June 2014 Page 11 of 22

12 affected consumers and where appropriate their family/whānau of choice in an open manner. 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. Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative PA Low PA Low reviewed showed analysis and trending of information. These examples have been communicated through the staff meetings to identify improvements. The manager during interview showed knowledge of her responsibility for the facility s compliance with legislation, including statutory obligations for essential notifications, with the exception of the notification to the Ministry of Health about the addition of an extra room. The facility manager is responsible for human resources management. Professional registration is sighted and recorded in the two RN files. On the day of the audit the RN was on leave and the relieving RN was due to provide relief cover on Wednesday. While progress has been made on an induction and orientation programme for new staff, in files reviewed not all documentation has been completed and this requires ongoing improvement. The system for on-going education is evolving, with all staff required to complete Careerforce training; however not all have managed to do so, as the facility does not currently have access to an assessor. The manager during interview explains she is planning to engage a person externally for this. The 2015 training programme has been reviewed. Content has been added to reflect service needs, for example the diabetes educator has been invited to provide an inservice education session. There is a staff member on each shift who has completed first aid training. The roster is reviewed and reflects the facility s skill mix policy. A care staff of five is rostered to cover shifts from 7am to 9pm with two persons, including the manager, providing one sleepover night cover from 9pm to 7am. These staff excludes the registered nurse (RN) cover of one day (four hours minimum) per week. The manager reports that the RN is usually in on a Wednesday but this time can be flexible depending on the resident s requirements. An example is provided when a new resident was admitted on a Thursday and the RN was able to change days to ensure the resident s admission assessments were completed on the day of admission. Within the facility s clinical policies there are detailed medication management policies and procedures that include each health professional s responsibility in relation to medicine prescribing, administration, reconciliation, dispensing, storage and disposal. The additional room will have no effect on medication Hilary Isabel Bird Date of Audit: 16 June 2014 Page 12 of 22

13 requirements and safe practice guidelines. 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. management systems. The facility has a blister pack system in place for all residents requiring medication assistance. The blister packs are reconciled into the facility by the registered nurse weekly. Discontinued medications are returned to the pharmacy weekly, including controlled medications, as sighted in records signed by the RN and the pharmacist. There are no residents with controlled medications at the time of the audit. The resident's prescription medication record is completed and updated by the resident's GP and administered by the facility s care staff who are competent to perform the function. The records reviewed were legible and each record signed individually by the GPs. However the medication record was not always reviewed at three monthly intervals as is required. Prescription records consistently included the reason for pro re nata (prn) medications. When an alteration occurs the GP updates the record in the facility as sighted in the records reviewed. One care staff with a current medication competency was observed administering medications, demonstrating safe practice on the day of the audit. The medication trolley holds all current medication, blister packs and medication records and was observed to be locked and securely stored when not in use. There is a separate area in the kitchen fridge for medications and temperatures were recorded and within recommended guidelines. There was one resident assessed as being suitable to self-administer medications, complying with the facility s policies and procedures. 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 in May 2015, and the menu content on the day of the audit did reflect the menu version in the documentation provided. The additional resident will have no effect on food management systems. Care staff and the manager share the role of cook and all have the appropriate food safety qualifications. Other kitchen duties are shared among the cooks and afternoon and night care staff. Dietary profiles are written on admission. These were sighted and included likes Hilary Isabel Bird Date of Audit: 16 June 2014 Page 13 of 22

14 Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in PA Low and dislikes, preferences for beverages, and any other special dietary instructions. The manager will oversee if there are any changes in dietary requirements. She is guided by the RN and the dietitian as sighted in one file reviewed. Residents' preferences are adhered to and this is verified by residents interviewed who confirmed there is variety in the food provided and that food met their needs and preferences. The facility kitchen is organised and well maintained. There is one large dining table for residents and the facility also caters for residents who prefer to eat in their own room. There is evidence that stock rotation occurs. Food waste is disposed of in the local rubbish and in the kitchen disposal unit. No residents are experiencing weight loss issues. Observation of the meal service confirmed that residents enjoy the meals provided. A review of residents meetings minutes and survey results verified that overall residents were complimentary about the food. The manager interviewed confirmed that prior to admission the Needs Assessment and Service Coordination (NASC) agency completes an interrai assessment to ensure the placement is appropriate, and the manager in conjunction with the RN makes the final decision based on the assessment. The facility RN completes an appropriate assessments on admission to the facility, including a pressure area risk assessment, falls risk assessment, continence assessment, nutritional assessment, and if required, a wound assessment. The RN and the manager are completing interrai training and will undertake assessments using the tool from 1 July Updated assessments are completed at least every six months, as verified in records reviewed, and an updated care plan is completed based on the completed assessment. There is evidence in files reviewed that resident/family input is sought. Those reviewed are completed in a timely manner by the RN. While there has been some progress made identifying activity goals for residents these are not included on an individual activity plan or with interventions and evaluations as to how these will or have been met. The facility s RN documents appropriate interventions on the resident's long term care plan, based on prior completed assessments and the interrai assessment Hilary Isabel Bird Date of Audit: 16 June 2014 Page 14 of 22

15 order to meet their assessed needs and desired outcomes. 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. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. 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 PA Low tool. Progress notes are written each shift by care staff and those sighted confirmed residents' needs were met and service delivery was provided in a timely manner. This was verified during interviews with residents, a family member and care staff. GP assessments sighted were detailed on the medical clinical forms in the integrated residents files and the subsequent interventions included on the residents long term care plans. The GP confirmed interventions were always implemented by the facility. A social activity profile was developed by the activity person following admission to the facility in files reviewed. An activity attendance record is maintained. Progress notes were observed to be completed monthly and report on progress relevant to the resident s individual activity programme and social interactions. The activities person does not complete an individual activity plan and this is addressed in criterion The general activity programme includes local shopping run, church services, arts and crafts, outings, singing group visits, reading, quizzes, puzzles, bowls, bingo, entertainers. Residents and family interviewed were very happy with the content and the variety of activities provided. Care plan reviews are the responsibility of the RN. The RN was not available for interview during the audit. The manager reported that when progress is less than expected a short term care plan was to be developed, however the evidence in files confirmed this does not always occur, and this previous required improvement has yet to be addressed. In files reviewed documented evidence verifies the RN completes care plan evaluations six monthly. The evaluations are resident centred and detail the progress toward outcomes identified. Staff, residents and family interviewed verify that they discuss progress with the RN and have input into care plan reviews. A waste management policy is available to staff and describes current practices. The disposal of waste and hazardous substances is being managed according to identified legislative and local council requirements. Recycling and general waste wheelie bins are put out for weekly collection and a contractor may be called to Hilary Isabel Bird Date of Audit: 16 June 2014 Page 15 of 22

16 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. 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. 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 PA High dispose of additional waste. Personal protective equipment including plastic aprons, disposable gloves, masks and protective eye goggles is available throughout the facility. Staff were observed to be using these and during interview could explain reasons why it was important to protect themselves. There is a current warrant of fitness for the building that expires 4 July The facility manager reports that a room within the footprint of the building has been altered with two doors and a wall added to allow for an extra resident s bedroom; however this has not been notified to the Ministry or a Code Compliance Certificate issued. The facility s evacuation plan has not been updated to include this room (Refer criterion ). The room reviewed is of a reasonable size with a large external window and an external door that leads to a courtyard. Other communal areas in the facility are accessed from the bedroom up the small stairway with a handrail on the right wall. The resident is observed managing this comfortably. There are no longer any unused and broken items sighted addressing a previous required improvement. There are an adequate number of toilets and showers for residents staff and visitors in the facility, including the additional room. All toilet and bathrooms now have locks for privacy addressing a previous required improved. The additional bedroom is spacious and with sufficient room for any aids and equipment required. The communal lounge and dining room are sufficiently spacious to accommodate the extra resident, including space for private conversation. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 16 of 22

17 relaxation, activity, and dining needs. Standard 1.4.6: Cleaning And Laundry Services Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided. Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. Standard 1.4.8: Natural Light, Ventilation, And Heating Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature. Standard 3.1: Infection control management There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service. Standard 3.2: Implementing the infection control programme PA Moderate All cleaning and laundry services are managed within the facility by current care staff who are appropriately trained. The laundry and cleaning systems are supported by documented policies and procedures. There are clean and dirty linen areas with separate storage areas for dirty linen. Residents personal laundry is undertaken on site. Chemicals are supplied by an external contractor who monitors and documents the results. Chemicals are labelled and stored in an area accessible only by keypad code and not left unattended on cleaning trolleys. There are emergency call bells in communal areas, each bathroom and toilet, and beside each bed, including the additional room. The facility holds regular fire drills and emergency evacuation practice but requires an updated fire evacuation plan due to the additional room. There is appropriate signage, documentation and training in place. The facility carries sufficient stocks of fresh water, dried food and other emergency supplies; these are stored in secure, dry areas. There is an emergency generator available and a gas barbeque for cooking. This addresses a previous required improvement. There are two staff who sleep over at night. One of these staff has the responsibility of checking residents and answering call bells. The additional room has natural light, ventilation, and opening windows, plus an external door and a heat pump. The infection control systems in place are not affected by the additional resident and bedroom. There is documented evidence that the RN has updated and recent infection control education addressing a previous required improvement. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 17 of 22

18 There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation. 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. The facility has not had any infections recorded for 2014 or This is verified in residents records and meeting minutes reviewed. The facility has a current infection control programme and templates for recording infections, including for surveillance purpose and process. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. A documented restraint and enabler use policy is in place and meets the standard requirements. The facility uses enablers such as bedrails where required. At present there are no residents with either enablers or restraints in use at the facility. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 18 of 22

19 Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion : 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 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low The manager has developed an induction and orientation check list and quiz for all staff to complete that covers all aspects of required components of service delivery. One of one staff member interviewed confirms she has completed this programme. However in records reviewed not all staff have this checklist or quizzes completed. In records reviewed three of five staff does not have the checklist completed or documentation provided to indicate induction and orientation has been completed. Staff receive an orientation and induction programme that covers all aspects of service delivery. 180 days Criterion A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with PA Low The resident's prescription medication record is completed and updated by the resident's GP. Prescription records consistently included the reason for pro re nata (prn) medications. When an alteration occurs the GP updates the record in the facility as sighted in the records In the files reviewed there are three of seven records that show medication reviews have not always been completed three monthly. Medications are reviewed at least three monthly as required. 180 days Hilary Isabel Bird Date of Audit: 16 June 2014 Page 19 of 22

20 legislation, protocols, and guidelines. reviewed. However the medication record is not always reviewed by the GP three monthly. Criterion The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Low The activity person interviewed reports that an activity attendance record is completed for residents. On the side panel is a place for goals and these are altered each month. Progress notes relating to activity attendances are recorded each month. In residents files there are not individual activity plans with goals and interventions developed or an evaluation of activity plans completed every six months. Activity plans include goals and interventions and these are reviewed at least six monthly. 180 days Criterion Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Low The RN is responsible for care plan development and reviews. Care plans are regularly reviewed at least six monthly. Residents file progress notes reviewed have identified that in some cases issues have arisen within the six month timeframe that have not been transferred to a short term care plan, or the long term care plan updated. There are two examples in the residents care plans where progress has been different than expected, but a short term care plan has not been developed, or the long term care plan updated to reflect the residents updated needs. The progress notes indicated that interventions were appropriate at the time in one file reviewed. When progress is not as expected a short term care plan is developed or the long term care plan is updated to reflect the changed needs. 180 days Criterion All buildings, plant, and equipment comply with legislation. PA High The facility includes six single bedrooms upstairs and two bedrooms downstairs, one is the care staff member who is on sleepover duty at night. The second room has recently been altered. Within the footprint of the building a wall and two doors have been added to provide a seventh resident s room to the facility, however there is no current Code Compliance Certificate for this addition. There is a resident occupying this room. The Ministry of Health was notified on the day of the audit of this addition. The facility has added a resident bedroom to the facility, however there is no Code Compliance Certificate plan to include this occupied room. Provide a Code Compliance Certificate for the additional resident s room added within the facility. 7 days Hilary Isabel Bird Date of Audit: 16 June 2014 Page 20 of 22

21 Criterion Where required by legislation there is an approved evacuation plan. PA Moderate The facility manger reports during the audit that an extra bedroom has been added to the existing footprint of the building. While there has been no external changes, two doors and a wall have been constructed internally. Alternative energy, sprinklers and a call bell system have been added to the room. The current evacuation plan has not been updated to include the extra room. The current evacuation plan has not been updated to include the change in the number of residents rooms. An updated and approved evacuation plan is required to be in place. 90 days Hilary Isabel Bird Date of Audit: 16 June 2014 Page 21 of 22

22 Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 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. Hilary Isabel Bird Date of Audit: 16 June 2014 Page 22 of 22