Oceania Care Company Limited - Maureen Plowman Rest Home

Transcription

1 Oceania Care Company Limited - Maureen Plowman Rest Home Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008). The audit has been conducted by Health Audit (NZ) 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: Oceania Care Company Limited Maureen Plowman Home Rest home care (excluding dementia care) Dates of audit: Start date: 19 November 2014 End date: 19 November 2014 Proposed changes to current services (if any): None Total beds occupied across all premises included in the audit on the first day of the audit: 50 Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 1 of 24

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 Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 2 of 24

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 Maureen Plowman is part of the Oceania Group. This surveillance audit has been undertaken to establish compliance with the Health and Disability Services Standards and the District Health Board Contract. Maureen Plowman provides residential dementia and rest home level care for up to 55 residents with 50 residents occupying the service during the audit. A business and care manager had been in the role for three weeks with a clinical manager who provides clinical oversight. Staffing was appropriate to support the needs of residents requiring dementia and rest home care. There was a quality and risk management programme in place. Seven of eight improvements required at the last certification audit around open disclosure, document control processes, policy review, the quality and risk programme and most of the requirements related to care planning and medication processes have been addressed. One improvement continues to be required around documentation of interventions in care plans. Improvements are required to staff training and separation of dirty and clean laundry. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 3 of 24

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. Standards applicable to this service fully attained. Staff were able to demonstrate an understanding of residents' rights and obligations. This knowledge was incorporated into their daily work duties and caring for the residents. Information regarding resident rights, access to advocacy services and how to lodge a complaint was available to residents and their family and complaints were investigated. Staff communicated with residents and family members following any incident. The improvement required at the certification audit around open disclosure has been addressed. 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. Maureen Plowman has implemented the Oceania quality and risk management system that supports the provision of clinical care and support. Policies were reviewed and business status reports allowed monitoring of service delivery. Benchmarking reports were produced that included clinical indicators, incidents/accidents, infections and complaints. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 4 of 24

5 Staffing levels were adequate in the rest home and the dementia unit and rest home and interviews with residents and relatives demonstrated that they had adequate access to staff to support residents when needed. A new management team was on site that included the business and care manager and clinical manager. Both have extensive experience in leadership in aged care services. The improvement required at the certification audit around document control and review of policies and quality data has been addressed. Improvements are required to training for staff as per the training schedule. 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. Residents have an initial nursing assessment and care plan developed by the registered nurse on admission to the service. The person centred care plan was developed within the required timeframe. When there are changes in the resident`s needs, a short term care plan is implemented to reflect these changes. An improvement from the previous audit in relation to assessment has been effectively closed out. There is an improvement required in relation to the interventions documented requiring more input from the multidisciplinary review evaluations. Residents are reviewed by a general practitioner on admission to the service and at least three monthly. The provision of services is provided to meet the individual needs of the residents. Continuity of care is promoted. The families interviewed report consistency in delivery of care. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 5 of 24

6 The service has a planned activities programme to meet the recreational needs of the residents with a focus on residents with impaired cognitive function. Residents are encouraged to maintain links with family and the community. A safe medicine management administration system was observed at the time of audit. The service has documented evidence that staff responsible for medicine management are assessed as competent. Improvements from the previous audit have been closed out in relation to medicine management. Residents` nutritional requirements are met by the service. Special diets are catered for and food is available twenty four hours a day. The four week summer/winter menu plans have been approved by the organisation`s registered dietitian. 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 low risk. There is a current building warrant of fitness in place. There was a planned and reactive maintenance programme in place with issues addressed as these arise. Residents and family described the environment as meeting their needs. Improvements are required to separation of the clean and dirty areas in the laundry. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 6 of 24

7 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. The service has clearly described restraint minimisation and safe practice policies and procedures which comply with the standard. There are currently four residents using enablers. Staff have received training in de-escalation techniques for managing challenging behaviour and education about the service policy, regulations and safe and effective alternatives to restraint. Staff interviewed understand that the use of enablers is a voluntary process along with approval and informed consent processes. Safety was promoted at all times. 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. There is a monthly surveillance programme, where infections are recorded, analysed and where trends are identified these are actioned. The infection surveillance results are benchmarked and results are fed back to staff at the staff meetings and displayed in the nurse station. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 7 of 24

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 Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 8 of 24

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 : Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. Attainment Rating Audit Evidence The organisation s complaints policy and procedures is in line with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) and includes time-frames for responding to a complaint. Complaint s forms are available in the dementia unit and rest home. There is also a mail box and anyone can put a note in the box with follow up according to the complaints policy. A complaints register is in place and the register includes the date the complaint was received; the source of the complaint; a description of the complaint; and the date the complaint was resolved. Evidence relating to each lodged complaint is held in the complaint s folder. All complaints are included in the indicator /quality monitoring processes with results reviewed by head office staff. Two complaints lodged in 2014 were selected for review. There is documented evidence of time-frames being met for responding to these complaints with documentation indicating that the complainants are happy with the outcome. The complaints are also part of the reporting process through review of indicators with benchmarking occurring. Residents and family state that they would feel comfortable complaining. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 9 of 24

10 The Oceania clinical and quality manager confirmed that there have not been any complaints with the Health and Disability Commission (HDC), Ministry of Health or District Health Board since the last audit. The District Health Board contract requirements are met. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. Accident/incidents, the complaints procedure and the open disclosure procedure alert staff to their responsibility to notify family/enduring power of attorney of any accident/incident that occurs. These procedures guide staff on the process to ensure full and frank open disclosure is available. Family are informed if the resident has an incident, accident, has a change in health or a change in needs, evidenced in 10 of 10 completed accident/incident forms and in the resident files. Interviews with eight family members (three from the dementia unit and five rest home) confirm they are kept informed. Family also confirm that they are invited at least six monthly to the care planning meetings for their family member with this confirmed on the multi-disciplinary form. Family interviewed confirm that they are invited to attend the resident meetings which are held at least two monthly. There have been two resident/family meetings since the new business and care manager has been in the service and these have been well attended. Interpreter services are available when required from the District Health Board. There are no residents currently requiring interpreting services and all residents interviewed confirm that staff are approachable and communicate well. The information pack is available in large print and advised that this can be read to residents. Staff have had training around communication in 2014 with a number of sessions offered during the year to accommodate staff. Family contact is recorded in residents files sighted in five of five resident files reviewed (three rest home and two dementia). The improvement required at the certification audit has been addressed. The District Health Board contract requirements are met. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 10 of 24

11 Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. Maureen Plowman is part of the Oceania group with the executive management team including the chief executive officer, general manager, operations manager, regional operational managers and clinical and quality managers providing support to the service. Communication between the clinical and quality manager and the business and care manager takes place on a monthly basis with more support provided as required (confirmed by the clinical and quality manager and business and care manager interviewed). Oceania has a clear mission, values and goals. The vision is to be the provider of choice for senior New Zealanders of care and lifestyle options in a way that meets and exceeds the expectations of our residents, staff and stakeholders. The mission is we provide excellent contemporary care that reflects our residents individuality and their right to choice, respect and dignity. We provide a positive and welcoming environment in which our residents are encouraged and supported to improve their quality of life. The facility can provide care for up to 55 residents with 15 residents in the dementia unit (a 17 bed unit) and 34 residents in the rest home (38 total beds available). The business and care manager is responsible for the overall management of the facility. The business and care manager is an enrolled nurse, has 16 years experience in aged care including management roles and has been in the role for six weeks. The business and care manager is supported by a clinical manager who has two years prior experience as a clinical manager in another facility. The District Health Board contract requirements are met. 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. Maureen Plowman uses the Oceania quality and risk management framework that is documented to guide practice. The business plan is documented and reported on through the business status reports. This includes financial monitoring, review of staff costs, progress against the healthy workplace action plan, review of complaints, incidents, relationships and market presence action plan and review of physical products. The service implements organisational policies and procedures to support service delivery. All policies are subject to reviews as required with all policies current. Head office reviews all policies with input from business and care managers. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 11 of 24

12 Policies are linked to the Health and Disability Sector Standard, current and applicable legislation, and evidenced-based best practice guidelines. Policies are readily available to staff in hard copy at the nurses stations and in the business and care managers office. The improvement required at the certification audit around updating of policies and document control has been addressed. All staff interviewed including four health care assistants, the activities coordinator, the clinical manager, the registered nurse report they are kept informed of quality improvements. There are monthly meetings that include the following: health and safety, quality improvement, restraint, staff meetings and the registered nurse meetings. The organisation has a comprehensive risk management programme in place. Health and safety policies and procedures, and a health and safety plan are in place for the service. There is a hazard management programme documented with a hazard register for each part of the service. There is evidence that any hazards identified are signed off as addressed or risks minimised or isolated. The business and care manager confirmed their role in managing and addressing hazards. The organisation holds a current ACC Work Safety and Management Practice tertiary level accreditation. There is a Community Connect newsletter from the organisation that is given/sent to residents and family. The last resident/family satisfaction survey is collated (completed last in September 2014) and the service has informed all family and residents of the report. A collated report from the survey indicates that residents and family are satisfied overall. Service delivery is monitored through complaints, review of incidents and accidents, surveillance of infections, pressure injuries, soft tissue/wounds, implementation of an internal audit programme noting that improvements identified as being required have a corrective action plan documented and evidence of resolution of issues documented in meeting minutes particularly in the quality and risk meeting minutes and other meeting minutes when these are documented. The complaint clinical indicators results sighted includes all complaints and the register in individual resident files that includes all incidents is up to date. The improvement required at the certification audit has been addressed. There are meetings held across the service including monthly quality and risk Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 12 of 24

13 meetings, health and safety, registered nurse, health care assistant, housekeeping, weights committee, staff, food service, maintenance. There are three monthly restraint meetings. There are a number of opportunities for residents and family to have input into the service through three monthly meetings and a new resident/family welcome group held two monthly. There is an interdisciplinary service continuum meeting which includes health professionals including doctors, pharmacists, occupational therapist, clinical team, podiatrist. The improvement required at the previous audit around rating, dating, signing off and identification of audit location in the audit records has been addressed. The District Health Board contract requirements are met. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. The business and care manager is aware of situations in which the service would need to report and notify statutory authorities including police attending the facility, unexpected deaths, critical incidents, infectious disease outbreaks. There are no times since the last audit when authorities have had to be notified. There have been no outbreaks since the last audit. The service is committed to providing an environment in which all staff are able and encouraged to recognise and report errors or mistakes and are supported through the open disclosure process, evidenced in interviews with staff, the business and care manager and clinical and quality manager. Staff receive education at orientation on the incident and accident reporting process. Staff understand the adverse event reporting process and their obligation to documenting all untoward events. Ten incident reports selected for review have a corresponding note in the progress notes to inform staff of the incident. There is evidence of open disclosure for each recorded event. Information gathered is regularly shared through the monthly meetings with documentation of incidents which are then graphed, trends analysed and benchmarking of data occurring with other Oceania facilities. The results are displayed in the staff room and registered nurses and health care assistants describe sighting these and reviewing trends. The District Health Board contract requirements are met. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 13 of 24

14 Standard 1.2.7: Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low All registered nurses and the clinical manager hold a current annual practising certificate. Visiting practitioner s practising certificates include the general practitioner, dietitian, podiatrist and physiotherapist and these are current. Eight staff files include appointment documentation. There is an annual appraisal process in place with all staff having a current performance appraisal. First aid certificates are held in staff file along with other training records. Police checks are completed sighted in all employee files reviewed apart from those staff who have been employed more than five years ago. All staff undergo a comprehensive orientation programme that meets the educational requirements of the Aged Residential Care (ARC) contract. Health care assistants are paired with a senior health care assistant for shifts or until they demonstrate competency on a number of tasks including personal cares. Annual medication competencies are completed for all registered nursing staff and health care assistants who administer medicines to residents. Other competencies are completed including hoist, oxygen use, hand washing, wound management, moving and handling, restraint, nebuliser, blood sugar and insulin, assisting residents to shower. Completion of the annual competencies now occurs at the time of the performance appraisal for each staff member and this ensures that all are up to date. Mandatory training is identified on an Oceania wide training schedule with some training occurring over the year for staff. Education and training hours exceeds eight hours a year for all staff reviewed. There are six health care assistants who work in the dementia unit. Two have completed the dementia unit training and four are enrolled. An improvement is required to training. The District Health Board contract requirements are met. Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. The staffing policy is the foundation for work force planning. Staffing levels are reviewed for anticipated workloads, identified numbers and appropriate skill mix, or as required due to changes in the services provided and the number of residents. Rosters sighted reflect staffing levels that meet resident acuity and bed occupancy. The rest home and dementia units are staffed as per the staffing policy with a review of rosters indicating that staffing meets resident acuity and numbers. A registered nurse is rostered on for 40 hours a week. The arrangement of staffing is appropriate to the needs of the resident as confirmed Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 14 of 24

15 by the clinical manager and the business and care manager interviewed. Residents and families interviewed confirm staffing is adequate to meet the residents needs. On call arrangements are in place with the clinical manager and the registered nurse. The District Health Board contract requirements are met. Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. The medication management policy provides guidance on medication reconciliation, prescribing, ordering, checking, storage, administration and documentation of the medicines management system. The process for disposing expired and unwanted medications and returns to pharmacy is noted. A folder is kept for this purpose. There is a medication incident reporting system. No residents are self-medicating medications. A process is in place should this occur. The GP interviewed reports all medications are reviewed and there are stamps the GP uses to verify in the medical records that this has occurred as well as signing off the medication record. Medication records were randomly selected to review. All medicine records have each medicine individually prescribed. Medications are received from the contracted pharmacy in a pre-packed delivery system. Medicines are stored in locked medicine trolleys in the medication room. Medication fridges are monitored daily and records maintained. Staff signing register and abbreviation lists are located in the front of each medication folder. Allergies and sensitivities are documented appropriately on the medication record and the medical notes. There are documented competencies sighted for the staff registered nurses and senior health care assistants. The lunchtime medication rounds in the rest home and the dementia unit were observed. Standing orders were signed and dated and meet legislative requirements. Controlled drugs are managed appropriately and checks are performed weekly. The register is available and is current and up to date with correct balances and checks evidenced. There were five improvements from the previous audit that have each been closed out. As documented all medication is stored appropriately and there is a policy for medications that are able to be crushed if and when required that has been developed and implemented. The DHB contract requirements are met. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 15 of 24

16 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. Oceania policies and procedures are available to guide staff. Infection prevention and control requirements are also detailed. Cleaning schedules were available for the kitchen. The staff are trained in food handling practices and meet the requirements of the Food Act There is a four week rotating cycle menu with summer and winter variations. The menu is reviewed by a dietitian employed by Oceania Group Ltd. The food service is managed by and experienced cook who is responsible for the ordering of all supplies, hygiene standards for staff, checking deliveries, storage, stock rotation, waste management and temperature monitoring. Regular monitoring and surveillance of the food preparation and hygiene maintained and records are available for review. A nutritional profile is completed on admission as part of the admission assessment process. The cook receives a copy. This information provided likes, dislikes, special foods and dietary needs. A whiteboard is used in the kitchen for this purpose to remind staff when preparing meals. Guidelines are available for special diets, soft diets, diabetic diets, light diet and a normal diet. Portion sizes are included as well as practices to ensure the residents remain appropriately hydrated. The main rest home dining room is adjacent to the kitchen for increased efficiency. There is food and nutritional snacks available 24 hours a day. The families and residents interviewed reported they are satisfied with the food services provided in both the rest home and the dementia unit. Meals are served at appropriate times of the day. The DHB contract requirements are met. Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. All assessment tools sighted are appropriate for the rest home and dementia care provided. Initial assessment includes falls, skin integrity, challenging behaviour, nutritional needs, continence, communication, end - of- life, self-medication and pain. Assessments are undertaken by the registered nurse. The five residents` records reviewed two dementia and three rest home level have initial assessments that include identifying behaviour particular to the resident. In specific residents who are assessed with challenging behaviours identified in the initial or ongoing care review, a specialised assessment is utilised. The behaviour Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 16 of 24

17 assessments sighted include the triggers, description of the behaviour, contributing factors and solutions/de-escalation techniques. The records reviewed evidence staff have taken into consideration the NASC assessment on admission and family/whanau information. The service has a continence assessment and management procedure, wound care management procedures, wound care protocols and behaviour management processes, which include seeking expert advice as required. Where a need is identified, interventions for this are recorded on the plan. All of the files reviewed have falls risk assessments and pressure are risk assessments. There is an improvement from the previous audit which has been closed out in relation to ensuring that the cultural and spiritual needs are identified and documented during the assessment process. This is able to be verified in all five resident records randomly selected for review. There is a chapel on site. Residents and families are able to access the chapel. The visiting pastor interviewed provided devotions today and grace at lunchtime in the dining room. Two interdenominational services are held every Sunday. Any ethnic or cultural needs are also documented on the resident`s record if required. The DHB contract requirements are met. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. PA Low There is an improvement that remains open from the previous audit in relation to detailed interventions being documented to ensure goals set by the resident can be met. The five records reviewed identified that all identified needs of the residents have been considered and documented with appropriate interventions to meet goals in the person centred care plans reviewed. Cultural and spiritual needs of individual residents are documented. Short term care plans are documented as required. No multidisciplinary reviews can be evidenced in the five resident records reviewed. The DHB contract requirements are not all met. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. Oceania policies and procedures for managing all aspects of service delivery and appropriate recognised assessment tools are readily available to guide staff. The resident records reviewed evidence consultation and involvement of family. There is detailed policy and procedures that outline the steps to be completed upon death of Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 17 of 24

18 a resident. It covers who should be notified and what documentation is required. A suite of clinical management policies and procedures include assessment on admission, weight and bowel management, clinical notes and referral information. Skin integrity, wound care management, continence, falls, grooming and personal hygiene is included in comprehensive detail. The service has adequate dressing and continence supplies to meet the needs of the residents. The personal centred care plans reviewed record interventions that re consistent with the residents` assessed needs and desired goals. Observations indicate residents are receiving care that is consistent with the residents` needs. The clinical manager and the registered nurse interviewed report that the care plans are reviewed to reflect the resident`s individual needs six monthly or more often if required. The DHB contract requirements are met. 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. The activities co-ordinator has been in this role for 10 years and previously had worked as a healthcare assistant for eight years. Activities training was commenced with career force but this lapsed as no follow-up was available or workplace assessor was on site. The activities co-ordinator has completed the ACE training. An assistant has just been appointed to assist with the programme on a part-time basis. The activities co-ordinator networks with a support group two monthly. Minutes of meetings were available. A qualified diversional therapist oversees and reviews the programme. The sighted activities programme covers cognitive, physical and social needs. The activities are modified to suit the individual needs and capabilities of each resident. There are both group and individual activities that focus on sensory activities and reminiscence. The activities co-ordinator reports of trying to engage resident`s interests and long term memories and providing belonging and meaningful activities to reflect normal life interests. The programme is flexible and activities can be changed depending on the residents` responses. There is easy access to outside areas. Raised gardens are visible and water features. There are activities specifically for the dementia unit that identify recreational, motivational and individual activities for individual residents over the twenty four hour period. Daily activities attendance records are maintained. The activities plans are reviewed Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 18 of 24

19 six monthly or more often if required. Participation is voluntary. Families are encouraged to participate. Family and residents interviewed report that they enjoy a range and variety of planned activities. The pastor interviewed provides devotions and church services and visits residents on a regular basis. There is a chapel on site and special church services and funerals can be held if and when required. The service has a close link with the community. Trips and outings are arranged and visitors and entertainers are welcome to participate in the programme by arrangement. The DHB contract requirements are met. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. Residents` records reviewed have a documented evaluation that has been conducted within the past six months. Evaluations are reviewed for all of the issues in the care plan. These evaluations are resident focused and indicate the degree of achievement or response to supports/interventions and progress towards meeting the desired goals. If a resident is not responding to the interventions being delivered, or their health status changes, then this is discussed with their GP. The GP interviewed verified this does occur. Short term care plans are available and used as required. The clinical staff interviewed demonstrate good knowledge of short term care plans and report these are identified at handover. This is an improvement from the previous audit which is effectively closed out. Resident s records reviewed have recently been reviewed by the clinical manager. Family interviewed report they can consult with the staff at any time if they have concerns or if there are changes the staff contact the family. The GP interviewed spoke highly of the registered nurses and contacts to the GP are always appropriately managed. The DHB contract requirements are met. Standard 1.4.2: Facility Specifications A current building warrant of fitness is posted in a visible location at the entrance to the facility (expiry date 2 July 2015). There have been no building modifications Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 19 of 24

20 Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. since the last audit. There is a planned maintenance schedule implemented. The lounge areas in both the dementia unit and rest home are designed so that space and seating arrangements provide for individual and group activities with the activity programme offered in the lounges on the day of the audit. The areas are suitable for residents with mobility aids. The following equipment is available: pressure relieving mattresses, shower chairs, hoists and sensor alarm mats. There is a test and tag programme and annual checks of medical equipment. The dementia unit is secure with an outdoor area suitable for residents who wander. There are outdoor areas for rest home residents. The District Health Board contract requirements are met. 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. PA Low There is a laundry area. There is one door with communal laundry taken offsite. The returns are put into the laundry room. Personal laundry is completed by staff. An improvement is required to separation of clean and dirty laundry in the laundry room. 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 infection control surveillance undertaken is appropriate to the size and complexity for the dementia and rest home services provided. All staff are required to take responsibility for surveillance activities as described in policy. Monitoring is described in the quality plan and management meeting minutes reviewed, to describe actions taken to ensure residents`, visitors and staff safety. There is monthly surveillance and the service monitors in particular urinary tract infections (UTIs), eye infections, respiratory tract infections, wound infections, multiresistant organisms, diarrhoea and vomiting and other infections. The monthly analysis of the infections includes comparison with the previous month, reason for the increase or decrease and actions taken to reduce infections. The analysis includes the feedback that is provided to staff. The facility is benchmarked against other Oceania Group sites. Evidence is sighted of a recent Norovirus outbreak October An Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 20 of 24

21 outbreak log was maintained and was sighted. Correspondence by evidenced the communication between the DHB, Public Health and other agencies. Policies and procedures dated are available to guide staff. Outbreak preparedness is documented. The clinical manager is the infection control co-ordinator for this service. The clinical manager is experienced and an additional job description for this role is available and a copy is retained in the clinical manager`s person file reviewed. Education is provided to all staff at orientation and is ongoing as per the Oceania education programme displayed. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. Oceania Group Ltd has documented policies and procedures for restraint minimisation and safe practice. The policy and procedures are comprehensive with clear definitions which are understood by all staff interviewed. The restraint process is clearly linked to the challenging behaviour management policy, which provides good practical information about the management of behaviour before restraint is considered. There are four enablers in use presently and the register is available and is up to date. Staff interviewed are aware that enabler use is voluntary. Staff received training on restraint minimisation and safe practice November Education is provided during the orientation process and is ongoing as sighted in the Oceania education programme displayed. The DHB contract requirement is met. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 21 of 24

22 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 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low Some training has been provided over the last two years as per the Oceania training schedule. Training is not completed as per the training plan and some training has not been provided since Ensure that staff are provided with opportunities to improve knowledge. 180 days Criterion Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low The interventions are documented in the resident person centred care plans reviewed. The interventions documented need to be further developed to meet the goals set for the individual residents. The person centred care plans have recently been reviewed by the clinical manager as part of a clinical project. A schedule is available and an update was provided by the clinical manager. The interventions documented require further development to meet the set goals of three of the five residents` person centred care plans. There is minimal evidence of multidisciplinary team evaluations occurring. To ensure adequate interventions are documented in the person centred care plans after further evaluations have been completed by the multidisciplinary team. 180 days Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 22 of 24

23 Criterion Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals. PA Low There is a laundry area. There is one door with communal laundry taken offsite. The returns are put into the laundry room by the external provider. Personal laundry is completed by staff. The laundry room is cluttered and when the offsite provider returns clean linen, this is placed next to dirty laundry ready to be washed. Ensure that there is separation of clean and dirty laundry in the laundry room. 180 days Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 23 of 24

24 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. Oceania Care Company Limited - Maureen Plowman Rest Home Date of Audit: 19 November 2014 Page 24 of 24