Certificaiton audit summary - Ministry of Health€¦ · Web viewThe service provider and staff...

Hilary Isabel Bird

Current Status: 13 February 2014

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified.

General overview

This report follows a certification audit for the Tui Glen Rest Home in a suburb of Nelson city. A provisional audit was completed approximately a year ago, following the sale of the facility.

Tui Glen is a six bed rest home where individualised care is provided in a family-oriented environment. The manager and a caregiver live on site and provide supervision during the night.

The areas requiring improvement relate to informed consent processes; the review of organisational documents; corrective action planning; implementation of the staff orientation programme; care plan updates between evaluations; goals for activities plans; the need for a menu review; the privacy of residents when using the bathrooms; hazardous equipment; a review of the emergency equipment and training of the infection control officer.

Audit Summary as at 13 February 2014

Standards have been assessed and summarised below:

Key

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

Indicator Description DefinitionSome 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

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

Consumer Rights as at 13 February 2014

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.

Organisational Management as at 13 February 2014

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.

Continuum of Service Delivery as at 13 February 2014

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.


Safe and Appropriate Environment as at 13 February 2014

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.


Restraint Minimisation and Safe Practice as at 13 February 2014

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.

Infection Prevention and Control as at 13 February 2014

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.

Audit Results as at 13 February 2014

Consumer Rights

The Health and Disability Commissioner Code of Health and Disability Services Consumers’ Rights and information on advocacy services are on display and residents are informed about them on admission. Although there are not currently any residents who identify as Maori there is a comprehensive Maori Plan, a policy on meeting the needs of Maori and an adviser is available as required. Residents’ cultural needs, values and beliefs are acknowledged and considered during service delivery and there is no evidence of any form of abuse or neglect.

Good practise is demonstrated through the commitment to person-centred care and a family oriented approach, which are described in the philosophy of the service.

Visitors are welcome and as far as practicable, and according to preferences, links are maintained with family members and with the local community. A complaints management process is in place, however there has not been any complaint lodged since 2005. The development and implementation of an informed written consent process is an area requiring improvement.

Organisational Management

The service has a mission statement, philosophy and set of values. A current strategic business plan with objectives is available. Key documents include organisational policies and procedures, a quality plan, a risk management plan and a Maori plan. Review of these organisational documents is an area requiring improvement. Quality and risk management systems are in place with internal audits, satisfaction surveys, incidents and accident records, infection control, health

and safety and issues around service delivery being discussed at staff/quality meetings every two to three months. Incident and accident reports and internal audit results are being analysed and reviewed. The management of corrective actions requires improvement as although shortcomings are being addressed, this is not currently a formal process, and nor is there evidence of evaluation of the effectiveness of the interventions.

Accountable human resource processes are supporting the employment of suitable employees. Practising certificates of professionals involved with the residents are current. Training is made available to staff with all caregivers having completed or currently undergoing a national certificate in aged care. Additional topics are provided at in-house training sessions. The need for all new staff to participate in an orientation programme, and that records of participation are retained, are areas requiring improvement. Care plans are developed, daily progress notes about residents are being entered in the clinical record and six monthly reviews are occurring. Personal files are stored in a locked cupboard.

Continuum of Service Delivery

Entry into this service is confirmed following assessment by a Needs Assessment and Services Coordination (NASC) agency. Transfers from Tui Glen Rest Home may occur if a person requires a hospital stay, or a higher level of care. A welcome package guides the admission process, which is undertaken by a registered nurse. There is medical and clinical input into the development of the care plan, which is preceded by a full nursing assessment and the use of supplementary assessment tools for pain, falls, pressure area risk and continence, for example. All residents have a service delivery plan that includes goals and interventions for their care and support. Interventions being provided are consistent with the care plans.

An activities coordinator ensures a range of activities, including one-on-one time with residents are provided. Records of participation and monthly reviews are documented. The storage, administration, documentation, and overall management of medicines is occurring in a safe manner that is consistent with legislative requirements and guidelines. Staff managing medicines have current competencies.

Food items are being stored, cooked and disposed of in a safe manner and residents have their nutritional and hydration needs met according to a four weekly rotating menu, personal food preferences and any special dietary requirements. The need for individualised goals and interventions for activities, for care plans to be amended when changes occur between six monthly reviews, and for the menu to be reviewed by a dietitian, are areas requiring improvement.

Safe and Appropriate Environment

Methods of managing waste and of identifying and managing hazards are well documented and meet requirements. Personal protective equipment is readily available and being used by staff. The facility has a current building warrant of fitness. Electrical checks, equipment maintenance checks and calibration of medical equipment have been undertaken within the past twelve months. Some interior rooms are being renovated and/or redecorated and external areas landscaped.

Although access to the facility is steep the current residents are able to manage. Supervision with this is provided as required. Bathroom facilities are adequate despite being limited. The dining, lounge and kitchen spaces are open plan and comfortable. Fire evacuation trials are up to date, security arrangements are in place and call bells are operational. A review of the contents of the emergency kit and their storage is an area requiring improvement. Improvements are also required to ensure privacy for residents when they use the bathroom and to address the presence of rusty and broken items that have the potential to pose a safety risk.

Cleaning and laundry procedures and schedules are available and these systems are monitored as part of the internal audit system. All residents’ bedrooms and living areas have windows that are able to be opened for ventilation. Heat pumps and panel heaters are used in cooler weather. There is a sheltered designated area outside for residents who choose to smoke.

Restraint Minimisation and Safe Practice

There are currently no enablers or restraints, in use at the Tui Glen Rest Home. Policies and procedures on restraint minimisation are in place and meet the requirements of the standard, should they ever be required. All staff meet current training requirements for managing challenging behaviours and have completed questionnaires on enabler and restraint use within the past twelve months.

Infection Prevention and Control

An infection prevention and control programme and its associated policies and procedures have been signed off by the owner/manager for 2014. Training related to infection prevention focuses on hand washing. Staff undergo annual hand washing audits and complete a questionnaire on wider infection control information at orientation and annually thereafter. The need for the infection control officer/registered nurse to undertake a training update on infection control is an area requiring improvement. Surveillance procedures are detailed in the documents, however there was only one incidence of a probable infection recorded for 2013. The analysis of surveillance results is not possible.

HealthCERT Aged Residential Care Audit Report (version 3.91)

Introduction

This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under 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).

It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.

Audit Report

Legal entity name: Hilary Isabel Bird

Certificate name: Tui Glen Rest Home

Designated Auditing Agency: The DAA Group Ltd

Types of audit: Certification

Premises audited: Tui Glen Rest Home, 23 Tui Glen Road, Atawhai, Nelson

Services audited: Residential Aged Care

Dates of audit: Start date: 13 February 2014 End date: 14 February 2014

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: 6

Audit Team

Lead Auditor XXXXX Hours on site

14 Hours off site

12

Other Auditors Total hours on site

Total hours off site

Technical Experts Total hours on site


Consumer Auditors Total hours on site


Peer Reviewer XXXXX Hours 4

Sample Totals

Total audit hours on site 14 Total audit hours off site 16 Total audit hours 30

Number of residents interviewed 4 Number of staff interviewed 5 Number of managers interviewed 1

Number of residents’ records reviewed

6 Number of staff records reviewed 5 Total number of managers (headcount)

1

Number of medication records reviewed

6 Total number of staff (headcount) 7 Number of relatives interviewed 2

Number of residents’ records reviewed using tracer methodology

1 Number of GPs interviewed 1

Declaration

I, XXXXXXXX, Director of Wellington hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of the Designated Auditing Agency named on page one of this report (the DAA), an auditing agency designated under section 32 of the Act.

I confirm that:

a) I am a delegated authority of the DAA Yes

b) the DAA has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes

c) the DAA has developed the audit summary in this audit report in consultation with the provider Yes

d) this audit report has been approved by the lead auditor named above Yes

e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes

f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable

g) the DAA has provided all the information that is relevant to the audit Yes

h) the DAA has finished editing the document. Yes

Dated Thursday, 20 March 2014

Executive Summary of Audit

General OverviewThis report follows a certification audit for the Tui Glen Rest Home in a suburb of Nelson city. A provisional audit was completed approximately a year ago, following the sale of the facility.

Tui Glen is a six bed rest home where individualised care is provided in a family-oriented environment. The manager and a caregiver live on site and provide supervision during the night.

The areas requiring improvement relate to informed consent processes; the review of organisational documents; corrective action planning; implementation of the staff orientation programme; care plan updates between evaluations; goals for activities plans; the need for a menu review; the privacy of residents when using the bathrooms; hazardous equipment; a review of the emergency equipment and training of the infection control officer.

Outcome 1.1: Consumer RightsThe Health and Disability Commissioner Code of Health and Disability Services Consumers’ Rights and information on advocacy services are on display and residents are informed about them on admission.

Although there are not currently any residents who identify as Maori there is a comprehensive Maori Plan, a policy on meeting the needs of Maori and an adviser is available as required.

Residents’ cultural needs, values and beliefs are acknowledged and considered during service delivery and there is no evidence of any form of abuse or neglect.

Good practise is demonstrated through the commitment to person-centred care and a family oriented approach, which are described in the philosophy of the service.

Visitors are welcome and as far as practicable, and according to preferences, links are maintained with family members and with the local community.

A complaints management process is in place, however there has not been any complaint lodged since 2005.

The development and implementation of an informed written consent process is an area requiring improvement.

Outcome 1.2: Organisational ManagementThe service has a mission statement, philosophy and set of values. A current strategic business plan with objectives is available. Key documents include organisational policies and procedures, a quality plan, a risk management plan and a Maori plan. Review of these organisational documents is an area requiring improvement.

Quality and risk management systems are in place with internal audits, satisfaction surveys, incidents and accident records, infection control, health and safety and issues around service delivery being discussed at staff/quality meetings every two to three months. Incident and accident reports and internal audit results are being analysed and reviewed. The management of corrective actions requires improvement as although shortcomings are being addressed, this is not currently a formal process, and nor is there evidence of evaluation of the effectiveness of the interventions.

Accountable human resource processes are supporting the employment of suitable employees. Practising certificates of professionals involved with the residents are current. Training is made available to staff with all caregivers having completed or currently undergoing a national certificate in aged care. Additional topics are provided at in-house training sessions. The need for all new staff to participate in an orientation programme, and that records of participation are retained, are areas requiring improvement.

Care plans are developed, daily progress notes about residents are being entered in the clinical record and six monthly reviews are occurring. Personal files are stored in a locked cupboard.

Outcome 1.3: Continuum of Service DeliveryEntry into this service is confirmed following assessment by a Needs Assessment and Services Coordination (NASC) agency. Transfers from Tui Glen Rest Home may occur if a person requires a hospital stay, or a higher level of care.

A welcome package guides the admission process, which is undertaken by a registered nurse. There is medical and clinical input into the development of the care plan, which is preceded by a full nursing assessment and the use of supplementary assessment tools for pain, falls, pressure area risk and continence, for example. All residents have a service delivery plan that includes goals and interventions for their care and support. Interventions being provided are consistent with the care plans.

An activities coordinator ensures a range of activities, including one-on-one time with residents are provided. Records of participation and monthly reviews are documented.

The storage, administration, documentation, and overall management of medicines is occurring in a safe manner that is consistent with legislative requirements and guidelines. Staff managing medicines have current competencies.

Food items are being stored, cooked and disposed of in a safe manner and residents have their nutritional and hydration needs met according to a four weekly rotating menu, personal food preferences and any special dietary requirements.

The need for individualised goals and interventions for activities, for care plans to be amended when changes occur between six monthly reviews, and for the menu to be reviewed by a dietitian, are areas requiring improvement.

Outcome 1.4: Safe and Appropriate EnvironmentMethods of managing waste and of identifying and managing hazards are well documented and meet requirements. Personal protective equipment is readily available and being used by staff.

The facility has a current building warrant of fitness. Electrical checks, equipment maintenance checks and calibration of medical equipment have been undertaken within the past twelve months. Some interior rooms are being renovated and/or redecorated and external areas landscaped.

Although access to the facility is steep the current residents are able to manage. Supervision with this is provided as required. Bathroom facilities are adequate despite being limited. The dining, lounge and kitchen spaces are open plan and comfortable. Fire evacuation trials are up to date, security arrangements are in place and call bells are operational. A review of the contents of the emergency kit and their storage is an area requiring improvement. Improvements are also required to ensure privacy for residents when they use the bathroom and to address the presence of rusty and broken items that have the potential to pose a safety risk.

Cleaning and laundry procedures and schedules are available and these systems are monitored as part of the internal audit system.

All residents’ bedrooms and living areas have windows that are able to be opened for ventilation. Heat pumps and panel heaters are used in cooler weather. There is a sheltered designated area outside for residents who choose to smoke.

Outcome 2: Restraint Minimisation and Safe PracticeThere are currently no enablers or restraints, in use at the Tui Glen Rest Home. Policies and procedures on restraint minimisation are in place and meet the requirements of the standard, should they ever be required.

All staff meet current training requirements for managing challenging behaviours and have completed questionnaires on enabler and restraint use within the past twelve months.

Outcome 3: Infection Prevention and ControlAn infection prevention and control programme and its associated policies and procedures have been signed off by the owner/manager for 2014.

Training related to infection prevention focuses on hand washing. Staff undergo annual hand washing audits and complete a questionnaire on wider infection control information at orientation and annually thereafter. The need for the infection control officer/registered nurse to undertake a training update on infection control is an area requiring improvement.

Surveillance procedures are detailed in the documents, however there was only one incidence of a probable infection recorded for 2013. The analysis of surveillance results is not possible.

Summary of Attainment

CI FA PA Negligible PA Low PA Moderate PA High PA Critical

Standards 0 35 0 9 1 0 0

Criteria 0 81 0 9 2 0 0

UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited

Standards 0 0 0 0 0 0 0 5

Criteria 0 0 0 0 0 1 0 8

Corrective Action Requests (CAR) Report

Code Name Description Attainment Finding Corrective Action Timeframe (Days)

HDS(C)S.2008 Standard 1.1.10: Informed Consent

Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

PA Low

HDS(C)S.2008 Criterion 1.1.10.4 The service is able to demonstrate that written consent is obtained where required.

PA Low There is not currently a documented informed consent process and nor is there any record of consents having been obtained for organisational procedures that have the potential impact on residents’ rights.

Informed consent is obtained where required and that there is a documented organisational policy and procedure for the obtaining of informed consent.

180

HDS(C)S.2008 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.

PA Low

HDS(C)S.2008 Criterion 1.2.3.4 There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service

PA Low There is not currently any documented evidence available that shows policies and procedures have been reviewed.

A document control system to manage policies and procedures is implemented. A procedure to guide implementation of the

180


providers and managed to preclude the use of obsolete documents.

Policies, procedures and key documents such as the quality plan, are not currently under a document control system. There is no system/policy and procedure that ensures documents are kept up to date and precludes the use of obsolete documents.

document control system is developed. All policies, procedures and key organisational documents are reviewed and up to date.

HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.

PA Low A formal process to ensure areas requiring improvement are adequately followed up is not currently developed and implemented.

A corrective action planning process is developed and implemented to ensure areas requiring improvement are addressed and evaluated.

180

HDS(C)S.2008 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

HDS(C)S.2008 Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided.

PA Moderate The orientation programme is not currently being implemented as documented and not all staff have a

All new staff receive an orientation/induction programme that covers the essential components of their role.

90


completed orientation checklist in their personnel file.

HDS(C)S.2008 Standard 1.3.4: Assessment

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

PA Low

HDS(C)S.2008 Criterion 1.3.4.2 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 Individualised goals for residents’ care and support are in place. There are not currently individualised activities goals, against which progress can be evaluated, for any of the residents.

Individualised activities goals and plans are developed for each resident.

180

HDS(C)S.2008 Standard 1.3.8: Evaluation

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

PA Low

HDS(C)S.2008 Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan.

PA Low Finding: There are four examples found in residents’ care plans where progress for the resident has been different from that expected. This has occurred between the six

Where progress for residents is different from that expected, relevant changes are made to care plans at the time the change is observed and interventions are modified accordingly.

180


monthly evaluations and updates have not been included in the evaluation section, or in the intervention section of the care plans.

HDS(C)S.2008 Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

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

PA Low

HDS(C)S.2008 Criterion 1.3.13.1 Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.

PA Low The food provided is not always consistent with that noted on the menu. The menu has not been reviewed by a dietitian within the last three years.

Food provided to the residents is to be more consistent with the menu.

The menu requires review by a dietitian to affirm that the food, fluid and nutritional needs of consumers are provided in line with recognised nutritional guidelines.

180

HDS(C)S.2008 Standard 1.4.2: Facility Specifications

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

PA Low

HDS(C)S.2008 Criterion 1.4.2.4 The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of

PA Low The presence of unused items that are broken, rusting and/or in a deteriorating

An environmental scan is undertaken and all items that have the potential to cause any harm are removed, or added to the

180


the consumer/group. condition have the potential to increase the likelihood of the spread of infection, or cause physical injury risk to residents and/or staff.

hazard register and efforts are made to mitigate the risks.

HDS(C)S.2008 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.

PA Low

HDS(C)S.2008 Criterion 1.4.3.1 There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.

PA Low Residents cannot be assured privacy when attending to personal hygiene needs, or when receiving assistance with personal hygiene needs. Signs that indicate occupancy are installed on the toilet/shower door and on the separate toilet door, however most residents are not using these and people enter them

Residents can be assured privacy when attending to personal hygiene cares, or being assisted with these cares.

180


while occupied (observed three times). Neither of these rooms have a lock on the door to enable people to have privacy.

HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems

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

PA Low

HDS(C)S.2008 Criterion 1.4.7.4 Alternative energy and utility sources are available in the event of the main supplies failing.

PA Moderate There is no list of the requirements this service needs for its emergency supplies. Some essential items are not in the emergency supply kit; there is no system in place for regular and ongoing audits of the emergency kit; items are in two different places without formal organisation and checks of the emergency equipment are not being documented.

Emergency supplies are reviewed, a system is implemented for ongoing and effective management of the emergency supplies and that all future checks of the emergency supplies are recorded.

60

HDS(IPC)S.2008 Standard 3.2: Implementing the infection control programme

There are adequate human, physical, and information resources to implement the infection control programme

PA Low


and meet the needs of the organisation.

HDS(IPC)S.2008 Criterion 3.2.1 The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.

PA Low There is no evidence available that the registered nurse has updated infection control education suitable for the role of infection control officer.

The infection control officer has suitable knowledge and experience for the role.

180

Continuous Improvement (CI) Report

Code Name Description Attainment Finding

NZS 8134.1:2008: Health and Disability Services (Core) Standards

Outcome 1.1: Consumer Rights

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, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs.

Standard 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1)Consumers receive services in accordance with consumer rights legislation.

ARC D1.1c; D3.1a ARHSS D1.1c; D3.1a

Attainment and Risk: FA

Evidence:The manager and staff are familiar with the Code of Health and Disability Services Consumers’ Rights (the Code) as evidenced during conversation and in policy documents. It is observed during the audit that residents are given choices about what they want to do, when they get up, and what they want to eat, for example. Residents and family members confirm this during interview and state that they believe the Code is being consistently upheld within this service.

Criterion 1.1.1.1 (HDS(C)S.2008:1.1.1.1)Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.


Evidence:

Finding:

Corrective Action:

Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2)Consumers are informed of their rights.

ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii


Evidence:A copy of the Code is sighted in the ‘Welcome Pack’ and the registered nurse who is responsible for admitting new residents informs she discusses the Code with new residents and any family members present. Three of three residents confirm during interview that the staff have taken time to talk about their rights and a copy of the Code is on display in the hallway (same sighted). Information about the Nationwide Health and Disability Advocacy Service is on the copy of the Code on display and a copy of the brochure on the Advocacy Service is also included in the’ Welcome Pack’ and provided to new residents on admission. Staff undertook training on the Code in October 2013.

Criterion 1.1.2.3 (HDS(C)S.2008:1.1.2.3)Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.2.4 (HDS(C)S.2008:1.1.2.4)Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3)Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4


Evidence:A policy and procedure on the prevention, detection and removal of abuse or neglect defines both abuse and neglect and lists signs and symptoms which may be indicative of abuse. The document references the Age Concern handbook on ‘Elder Abuse and Neglect’ and the awareness prevention kit. Procedures to be followed in the event of suspected abuse are detailed in the organisation’s policy and procedure, which also refers to residents’ rights, advocacy services and cultural sensitivity. Cultural safety for residents is detailed within a cultural safety policy and procedure and the objectives include race, age, spiritual beliefs, sexual orientation, gender, religion and chosen practices. A list of indications of a person’s culture and ways staff can avoid imposing their own perspective on resident are listed in the document.Separate policies on sexuality and intimacy, spirituality and counselling and on resident privacy and dignity are also sighted, each with their own set of objectives and all noting the rights of residents.

Staff inform during interview that respect of the residents is paramount in this service and that this ensures cultural and spiritual needs are met. They specify

the cultural needs of some of the residents. There is reportedly none of the six current residents who have any specific religious needs and there are not currently any residents who identify with an ethnicity other than European New Zealand.

Residents and staff spoken with state they have not experienced, or seen, anything that might constitute abuse or neglect. A senior staff person provided an explanation of actions that would be taken should this occur, or should it be suggested it might have occurred, The manager provides training records that show abuse and neglect is a topic staff are provided with training about.

Criterion 1.1.3.1 (HDS(C)S.2008:1.1.3.1)The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.2 (HDS(C)S.2008:1.1.3.2)Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.6 (HDS(C)S.2008:1.1.3.6)Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.3.7 (HDS(C)S.2008:1.1.3.7)Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.


Evidence:

Finding:

Corrective Action:


Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4)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.

ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i


Evidence:A comprehensive Maori Plan (2012 – 2013) is sighted and sits alongside a policy on how Maori needs will be addressed. In addition to a set of policy statements it has a set of objectives and a consultation plan. There is a set of goals in the Maori Plan 2012 – 2013. The manager informs that although it has remained dated 2013, this plan has been signed off for 2014 and this is evident in the front of the manual where the manager has signed it off and staff have signed off that they have read the plan. The policy includes related definitions, describes Maori cultural needs and outlines the contents of the organisation’s Maori Health Plan. The policy relates to Tui Glen and its wider community with a section on the local vision and a description of holistic care. It clearly describes how the needs of Maori will be met. Whanau is included throughout all documentation including the Maori Plan, the policy on addressing the needs of Maori and in the supporting documents.

Te Whare Tapa Wha model is described and documents attached to the policy and the Maori Plan include a copy of the Treaty of Waitangi, information on colonisation and on Maori health models.

The service has made contact with a new person who has agreed to be an adviser to the service on any issues relating to Maori and has agreed to support any person who identifies with their Maori culture and comes to live at Tui Glen. Contact details and the credentials for this person are noted in the Maori Plan.

There are not currently any residents who identify as Maori. Staff inform that between them they have many contacts within the wider community to support them with any advice on Maori cultural issues that may be needed.

Criterion 1.1.4.2 (HDS(C)S.2008:1.1.4.2)Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.3 (HDS(C)S.2008:1.1.4.3)The organisation plans to ensure Māori receive services commensurate with their needs.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.4.5 (HDS(C)S.2008:1.1.4.5)The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6)Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d


Evidence:Cultural safety for residents is detailed within a cultural safety policy and procedure. Objectives in the policy are inclusive of people regardless of race, age, spiritual beliefs, sexual orientation, gender, religion and chosen practices. A list of indications of a person’s culture and ways staff can avoid imposing their own perspective on resident are listed in the document.

During an interview with five staff explanations of what culture means to each are provided. Examples offered were the passion for music and for art of one person and of getting out and spending time alone for another. There are no residents from other ethnicities in this facility.

Residents and family members inform during interview that the residents have all their needs met including any specific cultural values or beliefs. This is also a question on the personal profile form completed on admission.

Criterion 1.1.6.2 (HDS(C)S.2008:1.1.6.2)The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs.


Evidence:

Finding:

Corrective Action:


Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7)Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

ARHSS D16.5e


Evidence:A policy of ways in which Tui Glen Rest Home will ensure residents are free from any discrimination, coercion, harassment, sexual, financial or other exploitation is sighted. The policy also notes the actions that will be taken by management in the event any such activities/behaviours are reported or discovered. There is no evidence of such activities at Tui Glen and residents spoken with are adamant that they have not seen or heard of any such behaviours. The manager states that such behaviour would not be tolerated.

Criterion 1.1.7.3 (HDS(C)S.2008:1.1.7.3)Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8)Consumers receive services of an appropriate standard.

ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c


Evidence:The service provider and staff demonstrate the delivery of services that are of a high standard and support good practice. There have been environmental improvements made and a commitment to spending time with the residents is evident with statements such as, laundry being dried in a dryer to enable staff to spend more time with the residents. The term resident-centred care and support and person-centred care are used in conversations and examples of this are sighted and heard throughout the audit. Two family members separately note the individualised devotion that is provided to all the residents and the homelike atmosphere and environment that this is provided in.

Criterion 1.1.8.1 (HDS(C)S.2008:1.1.8.1)The service provides an environment that encourages good practice, which should include evidence-based practice.


Evidence:

Finding:

Corrective Action:


Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9)Service providers communicate effectively with consumers and provide an environment conducive to effective communication.

ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 ARHSS A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3


Evidence:According to the completed forms sighted, open disclosure is evident, where this is appropriate, in the follow-up of incidents/accidents. The manager informs that only some of the residents have family members who want to hear about incidents, or are wanting to be involved in any sort of updates or reviews.

A communication record sheet has been placed in the front of each of the resident’s files. This is completed in most instances when family members are contacted, and also shows evidence of open communication processes. Relatives inform during interview that they believe they are well informed and this was especially evident during the sale of the facility in 2013. A weekly visitor informs that staff take time each week to provide updates and will telephone between visits when relevant.

During the audit, staff are observed sitting at the meal table and at morning and afternoon teas discussing what is happening.

The manager notes that any need for the interpreter service would be discussed with the Needs Assessment and Service Coordination (NASC) agency and contact details for the interpreter service are noted in the Interpreter Services/translator policy.

Criterion 1.1.9.1 (HDS(C)S.2008:1.1.9.1)Consumers have a right to full and frank information and open disclosure from service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.9.4 (HDS(C)S.2008:1.1.9.4)Wherever necessary and reasonably practicable, interpreter services are provided.


Evidence:

Finding:

Corrective Action:


Standard 1.1.10: Informed Consent (HDS(C)S.2008:1.1.10)Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

ARC D3.1d; D11.3; D12.2; D13.1 ARHSS D3.1d; D11.3; D12.2; D13.1

Attainment and Risk: PA Low

Evidence:It is observed throughout the audit that residents are being given verbal information and offered choices about a range of issues relating to their care and support with examples being about what they want to wear, what they want to eat and whether they are interested in a van ride. Relatives and residents inform during the interview that the residents are offered choices on a range of issues that they may make decisions about with one person noting he was given a choice about keeping his GP and is aware of the additional costs associated with that.

Completed informed consent forms are in clients’ files for influenza immunisations, however there is not currently an informed consent process for issues such as being transported in a vehicle, the taking of photographs or about what happens with their personal information, for example. This is an area for improvement.

A procedural document on advance directives is sighted and signed advance directives are sighted in client residents where this is relevant. The service provider manages advanced directives as per the organisational policy and procedure and the issues identified for improvement at the provisional audit have been addressed.

Criterion 1.1.10.2 (HDS(C)S.2008:1.1.10.2)Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.10.4 (HDS(C)S.2008:1.1.10.4)The service is able to demonstrate that written consent is obtained where required.


Evidence:There is no policy and procedure for obtaining written informed consent for organisational procedures that have the potential to impact on residents’ rights; such as being transported in a vehicle, the taking of photographs or about what happens with their personal information, for example. There is also no evidence of written consent being obtained for any issues or procedures other than those obtained by the GP for the administration of influenza immunisation of three residents.

Finding:There is not currently a documented informed consent process and nor is there any record of consents having been obtained for organisational procedures

that have the potential impact on residents’ rights.

Corrective Action:Informed consent is obtained where required and that there is a documented organisational policy and procedure for the obtaining of informed consent.

Timeframe (days): 180 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.1.10.7 (HDS(C)S.2008:1.1.10.7)Advance directives that are made available to service providers are acted on where valid.


Evidence:

Finding:

Corrective Action:


Standard 1.1.11: Advocacy And Support (HDS(C)S.2008:1.1.11)Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f


Evidence:The manager and five of five staff interviewed inform that although they have not had to approach advocacy services, they are aware of how to contact them. They accurately describe what the services offer and note that the local branch of Aged Concern have also offered to support residents with advocacy services should the need arise. Residents state during interview that they would approach their family for support if required and the third is aware of the advocacy service.

Criterion 1.1.11.1 (HDS(C)S.2008:1.1.11.1)Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.


Evidence:

Finding:

Corrective Action:


Standard 1.1.12: Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12)Consumers are able to maintain links with their family/whānau and their community.

ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f


Evidence:A visitors’ policy notes that all visitors to residents are welcome. Family members inform during interview that they (and other family members) are always welcome and are free to come and go as they please. The manager informs that some residents do not really have regular family links. Other community links are people who visit for entertainment purposes and for professional services.

The residents are taken into the community for drives and local events with a photo log of such events partially developed (sighted). Residents may go into the community for outings and to visit friends if they are able.

Criterion 1.1.12.1 (HDS(C)S.2008:1.1.12.1)Consumers have access to visitors of their choice.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.12.2 (HDS(C)S.2008:1.1.12.2)Consumers are supported to access services within the community when appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.1.13: Complaints Management (HDS(C)S.2008:1.1.13)The right of the consumer to make a complaint is understood, respected, and upheld.

ARC D6.2; D13.3h; E4.1biii.3 ARHSS D6.2; D13.3g


Evidence:The documented complaints procedure describes the process undertaken should a person wish to lodge a complaint. This includes contact details for the Advocacy Service, for the office of the Health and Disability Commissioner, the Ministry of Health and the Ombudsman. Response and investigation timeframes are noted and comply with Right 10 of ‘the Code’.

The manager and staff inform there has not been a complaint since 2005. A record of this complaint remains on file. There is no register because there has not been any complaints, although there is a section of the complaints file for this purpose if required. During interview staff are able to report the complaint process and know where complaint forms are publicly available. None of the residents or family members interviewed have an issue of concern and express confidence that they would be heard if they did have a concern.

Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1)The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.


Evidence:

Finding:

Corrective Action:


Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3)An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.


Evidence:

Finding:

Corrective Action:


Outcome 1.2: Organisational Management

Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.

Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1)The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5


Evidence:The values/philosophy and mission statement are documented and have a focus on ‘Making a Positive Difference in People’s Lives’. This document includes a set of goals and objectives that include providing a positive, caring, friendly environment with a family atmosphere; providing quality care designed to maintain dignity, privacy and individuality; promoting good health in comfort and safety and the retention of a purpose for living and maximising the enjoyment of residents’ final years.

A business plan for 2013 – 2018 provides background for the change of ownership, which occurred in 2013. This notes the need to evaluate the physical environment and workflow patterns, in order to establish an ongoing renovation and refurbishment programme. A set of priorities have been established (sighted) and there is evidence of progress with these. An overall revision of care and support is also underway with a change of registered nurse that has

taken place since the change of ownership. This review process will continue to occur alongside the upcoming introduction of the InterRAI resident assessment and care planning system.

Tui Glen Rest Home is managed by a manager/owner who is suitably qualified and experienced. She has social work qualifications, undertaken enrolled nursing training, has a certificate in mental health support and has spent a number of years working in aged care. Since commencing her role, she is attending all internal training supplied for all staff, District Health Board training sessions and receives mentoring with the previous manager. The manager describes herself as having a ‘passion’ for the industry and for caring for people generally. She has had previous caregiving roles that focused on restorative rehabilitation and on managing challenging behaviours. In addition the manager previously owned her own business, which she has since revived and is currently expanding this alongside managing Tui Glen.

Criterion 1.2.1.1 (HDS(C)S.2008:1.2.1.1)The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3)The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.


Evidence:

Finding:

Corrective Action:


Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2)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.

ARC D3.1; D19.1a; E3.3a ARHSS D3.1; D4.1a; D19.1a


Evidence:The manager has not been absent from the facility since she took this role on. She informs that the registered nurse will oversee management of the residents in this facility in her absence. This will be done with a caregiver, who as well as being a family member, also lives on site and is preparing to undertake business/management training. The manager advises that a condition of the sale of this facility was that the previous manager will be available to oversee its management when required, in particular during the absence of the owner/manager.

Criterion 1.2.2.1 (HDS(C)S.2008:1.2.2.1)During a temporary absence a suitably qualified and/or experienced person performs the manager's role.


Evidence:

Finding:

Corrective Action:


Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3)The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

ARC A4.1; D1.1; D1.2; D5.4; D10.1; D17.7a; D17.7b; D17.7e; D19.1b; D19.2; D19.3a.i-v; D19.4; D19.5 ARHSS A4.1; D1.1; D1.2; D5.4; D10.1; D16.6; D17.10a; D17.10b; D17.10e; D19.1b; D19.2; D19.3a-iv; D19.4; D19.5


Evidence:The quality plan for 2013 states that policy reviews occur annually and bi-annually with the infection control manual, policies and procedures, risk manual, nursing care plans and medical assessment form review, the human resources manual and orientation, the governance manual and the Maori plan were all due for review prior to January 2014 and the quality plan by December 2013. With these reviews not having formally occurred, the review of organisational policies and procedures and of other key documents is an area for improvement.

Staff responsibilities for quality improvement are described in the quality plan, which also includes a quality calendar, satisfaction survey details, the role of staff, family/whanau, resident and management meetings within the service and notes staff training will be at least eight hours a year. External reviewers for accounting, fire safety and equipment are noted, as are supplier reviews and indirect quality activities.

Terms of reference for an occupational health and safety committee, which is scheduled to meet four times a year are documented, as are its objectives and basic functions. The manager informs this occurs as part of the staff/quality meeting process, as does review of infection control information as required.

Every two to three months a staff meeting is held and quality issues are addressed at this time. This is evident in the last meeting minutes (January 2014). Topics discussed and reports provided include resident and family satisfaction survey results, an analysis of the 2013 accidents and incidents, infection control summary, results of a range of internal audits, staffing issues and service delivery updates. Corrective actions for identified shortcomings are occurring, however there is no system or documented planned process in place to ensure this occurs in a consistent manner and to ensure the actions are evaluated. During the audit a corrective action planning form is developed and is intended to guide the actions of issues that require improvement. Three corrective action planning forms are filled in during the audit.

A documented risk philosophy is sighted. Risk is defined in a documented policy that guides the identification and prioritisation of actual and potential risks within Tui Glen Rest Home. An additional policy details hazard control and types of management/control of hazards. Identified external, internal and operational risks at the home are listed and a risk scoring formula provided. This list is comprehensive and reviews of each of these are occurring as

specified, such as through monitoring processes, staff appraisals or internal audits for example. However, as noted under 1.2.3.4, a review of the risk management policy and the system itself is an area requiring improvement.

Criterion 1.2.3.1 (HDS(C)S.2008:1.2.3.1)The organisation has a quality and risk management system which is understood and implemented by service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.3 (HDS(C)S.2008:1.2.3.3)The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.4 (HDS(C)S.2008:1.2.3.4)There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.


Evidence:A range of policies and procedures guide practices within this service. The manager informs that policies and procedures have been reviewed and checked for relevance, however there is no documented evidence to confirm this and there is no system in place for this to occur within. The risk register is undated and has not been reviewed since the ownership changed and the quality plan is overdue for review. There is no policy and procedure on how to manage the organisation’s policies and procedures and there is not currently a system in place to control the documents, which would ensure documents are updated and that there are no obsolete or duplicate ones available. For example, the content of a medicines policy is duplicated in another that appears to have superseded it.

Finding:There is not currently any documented evidence available that shows policies and procedures have been reviewed. Policies, procedures and key documents such as the quality plan, are not currently under a document control system. There is no system/policy and procedure that ensures documents are kept up to date and precludes the use of obsolete documents.

Corrective Action:A document control system to manage policies and procedures is implemented. A procedure to guide implementation of the document control system is developed. All policies, procedures and key organisational documents are reviewed and up to date.


Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5)Key components of service delivery shall be explicitly linked to the quality management system.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.6 (HDS(C)S.2008:1.2.3.6)Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7)A process to measure achievement against the quality and risk management plan is implemented.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.3.8 (HDS(C)S.2008:1.2.3.8)A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.


Evidence:Examples of corrective actions being undertaken to address areas requiring improvement are evident in maintenance records, the hazard register and in the incident reporting data. There is not currently any process to formally plan such corrective actions, to report on progress with them or to evaluate the effectiveness of the actions. During the audit, a corrective action form is developed and two different corrective actions are written up.

Finding:A formal process to ensure areas requiring improvement are adequately followed up is not currently developed and implemented.

Corrective Action:A corrective action planning process is developed and implemented to ensure areas requiring improvement are addressed and evaluated.


Criterion 1.2.3.9 (HDS(C)S.2008:1.2.3.9)Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include:(a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk;(b) A process that addresses/treats the risks associated with service provision is developed and implemented.


Evidence:

Finding:

Corrective Action:


Standard 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4)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.

ARC D19.3a.vi.; D19.3b; D19.3c ARHSS D19.3a.vi.; D19.3b; D19.3c


Evidence:The manager is aware of statutory and/or regulatory reporting requirements with examples being the need to report significant events or incidents involving residents or staff, any incidence of abuse or neglect, any infectious outbreak(s), hazards such as chemical spills or broken power lines and any intention to sell. A report on a resident with dementia wandering from the rest home is sighted. The procedure for managing residents who wander was implemented when the absence was observed. The police were contacted and the person was tracked down as they wear a necklace tracker when they leave the rest home. Family were contacted and a report was written and reviewed with staff at the quality meeting.

A policy on open disclosure includes a definition for open disclosure, lists elements of open disclosure, notes who is responsible, and details the principles. The procedure to disclose includes its use following adverse events that may or may not have caused harm, the level of involvement of the resident and/or family member and what information they are to be provided with. There is evidence of relatives being contacted in some of the incident forms. The manager informs that for two to three residents there is no family member who is interested in being advised of any such information and this is noted in the care plans.

An accident/incident reporting and investigation policy and procedure has a list of objectives that include the intention to eliminate or minimise the recurrence of any accident or incident, the need to investigate them and to analyse trends for corrective and preventive purposes. A December report is sighted of the analysis of incidents/accidents for 2013. Trends are identified form the collated data and recommendations made. It is noted that the data was skewed with the frequency of falls of one person who has since shifted to a facility providing a higher level of care. Incident reports are provided at the three monthly staff/quality meetings and staff confirm during interview that they are kept updated on information emerging form the data.

Criterion 1.2.4.2 (HDS(C)S.2008:1.2.4.2)The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.4.3 (HDS(C)S.2008:1.2.4.3)The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.


Evidence:

Finding:

Corrective Action:


Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7)Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

ARC D17.6; D17.7; D17.8; E4.5d; E4.5e; E4.5f; E4.5g; E4.5h ARHSS D17.7, D17.9, D17.10, D17.11

Attainment and Risk: PA Moderate

Evidence:Every effort is made to ensure that appropriate service providers are employed. In six of six staff files that were reviewed there are records of staff interviews and referee checks and all but one have evidence of police checks and copies of curriculum vitae in their file. Five of five staff confirm during interview that they have had previous experience working in the aged care field. Six of six staff files have completed three month post-employment performance appraisals and/or an annual performance appraisal, depending on their length of employment.

Annual practising certificates of professional staff who attend Tui Glen Rest Home are all current. Verification of license to practice is sighted for the registered nurse, two GPs, a visiting podiatrist and two local pharmacists.

An orientation programme has been developed and three of six staff files viewed include evidence of having completed the programme. Four of five staff inform during interview that they were supervised by the manager for a minimum of two shifts. The fifth did not have this experience. Ensuring the completion of the orientation programme by new staff is an area for improvement, as not only is the manager unfamiliar with the programme but the three staff files who do not have records of these on file (including the registered nurse) have been employed within the past six to nine months.

Employer responsibilities, employee responsibilities and training protocol are described in a staff training policy. This policy notes a thorough and comprehensive orientation/induction process is provided by the manager, that staff will be familiar with organisational policies and procedures, all staff are to attend emergency procedure training and undertake a six monthly trial evacuation, all staff are to have a first aid certificate and an occupational health and safety officer is an internal resource person. Staff training records are held by the manager in individual staff files (same sighted). The quality plan notes that eight hours of staff training are offered each year. Topics in a 2013-2014 training plan include medication, consumer rights, restraint minimisation, first aid, infection control, manual handling, continence, abuse and neglect, and occupational safety and health kitchen hygiene. The manager informs that all staff are supported to undertake formal certificated training programmes with the caregivers at different stages. Five of five staff confirmed during interview that training is encouraged. Two people whose first aid certificate require renewal are already enrolled for an update. A person who has completed the core component of aged care education is now planning to undertake the divisional therapy training.

Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2)Professional qualifications are validated, including evidence of registration and scope of practice for service providers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3)The appointment of appropriate service providers to safely meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4)New service providers receive an orientation/induction programme that covers the essential components of the service provided.


Evidence:An orientation programme is included in the human resource documentation, although the manager informs she is not familiar with it. Completed orientation programmes are not in two files of more recently engaged employees. One staff person employed within the past twelve months informs she did not have any form of orientation or induction.

Finding:The orientation programme is not currently being implemented as documented and not all staff have a completed orientation checklist in their personnel file.

Corrective Action:All new staff receive an orientation/induction programme that covers the essential components of their role.


Criterion 1.2.7.5 (HDS(C)S.2008:1.2.7.5)A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8)Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

ARC D17.1; D17.3a; D17.3 b; D17.3c; D17.3e; D17.3f; D17.3g; D17.4a; D17.4c; D17.4d; E4.5 a; E4.5 b; E4.5c ARHSS D17.1; D17.3; D17.4; D17.6; D17.8


Evidence:A staffing levels and skill mix policy describes how residents have access to a GP, which chemist will provide their services, how specialist medical attention is provided and what access they have to a podiatrist. This policy also notes a registered nurse is available on a weekly basis and on call, that one senior caregiver is available to respond to residents’ needs at all times and that additional staff will be called on if the manager or registered nurse consider the skill mix is not adequate to cater for residents’ needs. A description of safety measures, residents’ rights, acknowledgement of the Treaty of Waitangi and access to resources and equipment are also noted in the policy.

The current roster is sighted. This is developed on a six weekly cycle and shows that a caregiver is employed between 7.30am and 1.30pm and another from 1.30pm to 7.30pm. The manager and a caregiver, both of whom live on-site, undertake the 7pm to 7.30am timeslots on alternate nights. From 11pm until 7.30 am this is a sleepover shift with two hourly surveillance checks undertaken at alarmed timeframes of 1am, 3am and 5am. The sleepover person commences work at 7am. The use of a sleepover, rather than the contractual requirements for a caregiver to be on duty at all times, has been approved by the Nelson Marlborough District Health Board and a letter dated February 2005 confirming this is sighted. The registered nurse provides four to six hours of input with weekly visits and is available on request.

The roster folder also describes the daily routines, residents shower routines and details of the cleaning routines.

Criterion 1.2.8.1 (HDS(C)S.2008:1.2.8.1)There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.


Evidence:

Finding:

Corrective Action:


Standard 1.2.9: Consumer Information Management Systems (HDS(C)S.2008:1.2.9)Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

ARC A15.1; D7.1; D8.1; D22; E5.1 ARHSS A15.1; D7.1; D8.1; D22


Evidence:A record of basic information about each resident is entered electronically. All other information and records about the residents are held in their personal files. These are individualised and integrated with all records in the one file. They are stored in a locked cupboard in the hallway, where the medications are stored (sighted). Residents’ records are up to date with evidence of six monthly reviews and of daily progress reporting occurring. An entry is made into each person’s record every day and these provide a good reflection of how each person is every day. All records are legible and are signed by the author. It is observed that the designation of the author was not being entered on earlier records. The registered nurse informs she provided an education/information session to the staff at the last staff meeting (January) asking them to do this.

Criterion 1.2.9.1 (HDS(C)S.2008:1.2.9.1)Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.7 (HDS(C)S.2008:1.2.9.7)Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.9 (HDS(C)S.2008:1.2.9.9)All records are legible and the name and designation of the service provider is identifiable.


Evidence:

Finding:

Corrective Action:


Criterion 1.2.9.10 (HDS(C)S.2008:1.2.9.10)All records pertaining to individual consumer service delivery are integrated.


Evidence:

Finding:

Corrective Action:


Outcome 1.3: Continuum of Service Delivery

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.

Standard 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1)Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.

ARC A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2; E3.1; E4.1b ARHSS A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2


Evidence:Enquiries about entry to the service may be made from the general public at any time, however a completed NASC service needs assessment is still required prior to entry and acts as the entry screening process. The manager informs that the service is known about through the aged care networks and through the needs assessors in the district.

A new logo is currently under development and has delayed a reprint of brochures about the services. A ‘Welcome Package’ (sighted) is in use and the manager and registered nurse currently use it to guide the admission process into Tui Glen. There are plans to review this once the new brochure is printed.

When a bed is available Tui Glen Rest Home can provide respite services and the most recent permanent resident was a person who entered the service for respite care and is now wanting to remain. This is consistent with his needs assessment.

The residents interviewed are all very happy here. Family members and residents inform they are respected and welcomed at the start and this does not change.

Criterion 1.3.1.4 (HDS(C)S.2008:1.3.1.4)Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.


Evidence:

Finding:

Corrective Action:


Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2)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.

ARHSS D4.2


Evidence:The manager informs that because they are only a small service, and some of the clients are in younger age brackets, it is not appropriate to have a waiting list. Where referral/entry to the service needs to be declined, the manager informs that this usually occurs at the time of the initial request. It is also reported

that because the NASC service has running records of occupancy rates, referrals are not usually made unless there is a spare bed. Although options of alternative services are usually provided by the NASC service, rather than by the rest home, the manager informs that when a person needs to transfer to another service from Tui Glen they may need to discuss options with the resident and/or the family. This is evident in the records of a person who recently transferred to another service that provides services for people who require a higher level of care and support.

Criterion 1.3.2.2 (HDS(C)S.2008:1.3.2.2)When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services.


Evidence:

Finding:

Corrective Action:


Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3)Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals.

ARC D3.1c; D9.1; D9.2; D16.3a; D16.3e; D16.3l; D16.5b; D16.5ci; D16.5c.ii; D16.5e ARHSS D3.1c; D9.1; D9.2; D16.3a; D16.3d; D16.5b; D16.5d; D16.5e; D16.5i


Evidence:Residents and family members interviewed are very satisfied with the services provided by the manager and staff at Tui Glen. During interview staff talk about the positive aspects of the services provided at Tui Glen and compare it favourably with services at other facilities they are, or have been familiar with. The opportunities to spend uninterrupted time with all residents on a one on one basis and the family/homely atmosphere of this small facility are repeatedly talked about. The GP believes that appropriate assessments are being made by the registered nurse and the manager before he is called in and notes that his

instructions are followed through. He expresses confidence in the level of personal and clinical care being provided to residents in the Tui Glen Rest Home.

A registered nurse provides four to six hours of support every week and is available to be called in should the need arise. Although the registered nurse accepts responsibility for the care plans, the caregivers provide feedback and are the key people providing the care and support. All are selected and trained in an ongoing manner as detailed in section 1.2.7 of the standard.

Although caregivers mostly work alone while on a duty, others, such as the manager and/or activities coordinator, may come and go. All say they feel part of a team that gets together to catch up at shift changes and at three monthly staff meetings. The care is provided in a team-like manner as all inform they follow the care plans, which is evident in progress notes.

Tracer: XXXXXX This information has been deleted as it is specific to the health care of a resident.

Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1)Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.3 (HDS(C)S.2008:1.3.3.3)Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.3.4 (HDS(C)S.2008:1.3.3.4)The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.


Evidence:

Finding:

Corrective Action:


Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4)Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

ARC D16.2; E4.2 ARHSS D16.2; D16.3d; D16.5g.ii


Evidence:All residents have a copy of their NASC assessment on file. Each person also has a completed nursing assessment which include some diagrams for clarification purposes, on file. Other assessment tools that are being used when results of the medical and/or nursing assessment indicate, include the Braden Scale for predicting pressure area risk, the Coombe falls assessment, a pain assessment and management tool and a continence assessment. The resident has completed copies of each of these assessments in her file and updates are evident at the six monthly reviews. The assessments are being used to guide the goals in the service delivery/care plan.

Residents have completed personal profiles in their files. These are reportedly completed by the activities co-ordinator several weeks following admission. The personal profiles are not being used to develop personalised activities related goals and plans. Although there is a range of activities provided and multiple examples of one-on-one activities, the lack of individualised activities plans that specify needs and include activity related goals, is an area for improvement.

Criterion 1.3.4.2 (HDS(C)S.2008:1.3.4.2)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.


Evidence:A range of activities are being provided, records of participation are made and monthly reviews are written up.

Finding:Individualised goals for residents’ care and support are in place. There are not currently individualised activities goals, against which progress can be evaluated, for any of the residents.

Corrective Action:Individualised activities goals and plans are developed for each resident.


Standard 1.3.5: Planning (HDS(C)S.2008:1.3.5)Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

ARC D16.3b; D16.3f; D16.3g; D16.3h; D16.3i; D16.3j; D16.3k; E4.3 ARHSS D16.3b; D16.3d; D16.3e; D16.3f; D16.3g


Evidence:All residents have service delivery plans that are individualised and include goals, objectives and interventions under pre-listed headings. The service delivery plans provide clear instructions about the services to be delivered for each person under these headings with examples being hygiene, continence, mobility, nutrition and hydration and communication.

The registered nurse and the manager inform that the registered nurse is the one who is primarily responsible for making changes to the care plans.

A short term care plan is sighted in the personal file of the newest resident. The manager and registered nurse provide an adequate explanation about why this person does not yet have a completed long term care plan and the reason is confirmed by the resident. A long term care plan is expected to be completed within the next three to four weeks.

There is no other evidence of the use of short term care plans, however the registered nurse informs there has not been an events for any resident that has created a need for one.

There are two areas of the carer plan that do not accurately reflect the level of care required. This is raised as an area for improvement under Standard 1.3.8 as it is a change that required amendment between evaluations/reviews.

All personal files of the residents are integrated and include NASC reports and assessment, planning, intervention, clinical (medical and nursing) records and reviews/updates, caregiver progress notes, activities, specialist letters and reports, and family/whanau-related documentation. In addition the personal files hold forms, such as those for nutritional needs and incident/accident reporting.

Criterion 1.3.5.2 (HDS(C)S.2008:1.3.5.2)Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.5.3 (HDS(C)S.2008:1.3.5.3)Service delivery plans demonstrate service integration.


Evidence:

Finding:

Corrective Action:


Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6)Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

ARC D16.1a; D16.1b.i; D16.5a; D18.3; D18.4; E4.4 ARHSS D16.1a; D16.1b.i; D16.5a; D16.5c; D16.5f; D16.5g.i; D16.6; D18.3; D18.4


Evidence:Policies and procedures on continence management, managing challenging behaviours, pain management, personal grooming and hygiene, skin management, wound management, procedure following death, and the assessment and management of falls risk, are sighted and meet requirements of the ARC agreement.

All six care plans sighted show that the Tui Glen philosophy of providing person-centred and family oriented care is being upheld. Similarly interviews residents, family members and a GP confirm this. A family member volunteers the information that she believes the care is centred on her relative, rather than the staff, or what other people might need. Residents are satisfied with the interventions they receive from staff.

During an interview with staff, all inform that the service delivery plan is the main information source about what to do for the residents. They note that the communication diary informs when they need to check a change in a person’s care plan and that the progress notes, which are written at least daily, are also informative. All service delivery plans are being reviewed at six monthly intervals and records of the due dates for each of these are in a diary. These are scheduled to follow the GP visit. A GP residents writes the date of the next follow-up visit (whether this be one month or three, as required in the ARC agreement) in the resident’s medical notes and this is entered into the diary.

Criterion 1.3.6.1 (HDS(C)S.2008:1.3.6.1)The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.


Evidence:

Finding:

Corrective Action:


Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7)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.

ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h


Evidence:An activities coordinator is employed for 12.5 hours a week. This person has completed the pre-requisite training for diversional therapy and the manager and the activities coordinator both inform that plans are underway for the activities coordinator to commence the diversional therapy certificate training.

Completed personal profiles are in each of the six personal files of the residents. These provide information about the resident, which the activities coordinator informs she uses to help plan the activities programme.

A person who is less active than previously, confirms that she is not wanting to go out for rides as she previously did. This is confirmed by the activities coordinator and a family member and options are being considered to ensure opportunities to socialise and see the outside world are maintained. This person states she is much more comfortable now that she has a walking frame, which she says gives her more freedom than she had previously.

Activities offered in this facility are meaningful to the resident(s). Residents say that they enjoy the different things they do. A range of types of activities are being provided. A checklist of different types of activities are filed in each person’s file. Participation in a specific activity/activities is checked off every day over monthly timeframes and a summary of this participation is written up by the activities coordinator every month. Examples of the activities offered include twice weekly van trips, three times weekly exercises and ball skills, weekly pampering sessions with hand massages and foot spas, external entertainers coming in such as a story-teller and a keyboard operator, weekly men’s morning teas and outings and one on one time with individuals. It is observed during the audit that the caregiver staff also help occupy the resident on a one on one basis by sitting playing games with one of them, folding washing with another and accompanying another outside to distract them. Residents who are capable of making their own hot drinks independently are permitted to do this. The activities coordinator and individual staff (as time permits) also take residents one-on-one on short walks.

Criterion 1.3.7.1 (HDS(C)S.2008:1.3.7.1)Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.


Evidence:

Finding:

Corrective Action:


Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8)Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

ARC D16.3c; D16.3d; D16.4a ARHSS D16.3c; D16.4a


Evidence:Staff interviewed inform that they know the residents very well and that because of their familiarity with all their goals they are often able to respond to these in the progress notes Comprehensive progress notes are being documented for each resident on a daily basis (or more frequently if needed).

Six monthly evaluations are occurring for five of the six residents. The sixth has not been at the service long enough. The registered nurse informs that family members and the resident are invited to participate in this review at the level they choose. Family and residents affirm during interview that they are invited to participate in this process. Records of the evaluation process are dated and entered into the service delivery plan and changes are made to the goal and/or interventions as needed.

An area for improvement is the need for interim changes between the six monthly evaluations of goals to be documented and for interventions to be amended accordingly.

Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2)Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3)Where progress is different from expected, the service responds by initiating changes to the service delivery plan.


Evidence:Daily progress notes are being written for all residents. Six monthly evaluations of care plans are being completed. During discussions with the registered nurse and reviews of the care plans of the six residents, there is evidence that service delivery plans are not all being amended when changes occur between the six monthly evaluations.

Finding:Finding: There are four examples found in residents’ care plans where progress for the resident has been different from that expected. This has occurred between the six monthly evaluations and updates have not been included in the evaluation section, or in the intervention section of the care plans.

Corrective Action:Where progress for residents is different from that expected, relevant changes are made to care plans at the time the change is observed and interventions are modified accordingly.


Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9)Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs.

ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4


Evidence:Referrals are being made with other health and disability services and/or links are being maintained with them. Examples of these are the NASC services, mental health services, the psychogeriatric services, the addictions service, podiatry, the diabetes clinic and other specialist consultants as recommended by the GP, such as eye and heart specialists. All referrals and visits to clinics are noted in progress notes and copies of all correspondence forwarded to the resident is filed in the medical section of the resident’s file. A number of examples are sighted.

On one of the audit days, a family member takes one of the residents to a private dentist of their choice. Details of treatment are not documented in the resident’s file, however a record of attendance is noted in the progress notes (same sighted). All other residents, except one with false teeth, reportedly attend a nearby dental surgery once a year.

Criterion 1.3.9.1 (HDS(C)S.2008:1.3.9.1)Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.


Evidence:

Finding:

Corrective Action:


Standard 1.3.10: Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10)Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

ARC D21 ARHSS D21


Evidence:The manager informs that if a resident’s level of care and support increases there may be a need to transfer them to another facility. An assessment service is asked to reassess the person and assist with the transfer process. A procedure to guide the process is available.

Records of a person who transferred to another facility are viewed. These show that family were involved and that forms to provide an overview of care to staff in the new facility were completed.

A transfer form is used when a person goes into the local public hospital. Staff discuss the completion of this form during interview, which they provide a copy of to the person accepting the transfer. The form notes who needs to be contacted and what items are to accompany the resident, such as their medicines.

Criterion 1.3.10.2 (HDS(C)S.2008:1.3.10.2)Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives.


Evidence:

Finding:

Corrective Action:


Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12)Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d


Evidence:A medication policy describes administration, storage, pharmacy involvement and expectations around prescribing by GPs or specialist. There is a section on managing errors, incidents and adverse reactions, one on controlled drugs and another on medication self-administration. A separate document called ‘Procedure for safe storage and administration of medicines’ supplements the policy document.

The medicines management system is consistent with the policy and procedure documents. Although it is not possible to view a medicine ‘round’ as such, because of the small number of residents who receive medicines at mid-day, the process of administration is described and meets requirements. Medicines are being stored in a locked cupboard in the hallway. A controlled medicine is stored in a metal locked container attached to the inside of the locked cupboard (sighted). The controlled medicine is supplied in single doses and are being signed in every week as stocks are replenished weekly. In addition the registered nurse rechecks supplies every week and reviews the controlled medicines register.

The GPs are prescribing and signing for all regular and pro re nata (prn) medicines on resident’s medicines records. This includes signing and dating all discontinued medicines. Medicines are dispensed by the pharmacy who blister packages the regular medicines and one of the staff uplifts these when required. An accountable reconciliation system undertaken by the registered nurse, is in place and records of this are sighted. Over the counter medicines are administered according to standing orders and are limited to only a few items such as creams and lotions.

The process around a person self-administering insulin when away from the facility is documented in the care plan. Another person self-administers an inhaler and another holds their own nitro-glycerol spray. There are records (sighted) of three monthly reviews of the ability of residents to self-administer these medicines.

All staff have a current medicine administration competency (records sighted). This is an annual process. Medicines are being signed off by staff when they are administered and records of their sample initials are on each of the signing sheets sighted. Medications are reviewed every three months (or as needed) at the same time as the GP reviews the residents’ medical conditions. This is signed and dated in the review section of the medicine record. During interview, the GP expresses satisfaction that the residents are receiving medicines as prescribed and informs he cannot recall when he last had to follow up on any medicine error.

Overall medicines are being managed safely and the procedures are consistent with current legislative requirements and safe practice guidelines.

Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1)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 legislation, protocols, and guidelines.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3)Service providers responsible for medicine management are competent to perform the function for each stage they manage.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5)The facilitation of safe self-administration of medicines by consumers where appropriate.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6)Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.


Evidence:

Finding:

Corrective Action:


Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13)A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c


Evidence:The kitchen and food handling policy/principles lists a set of objectives and notes the policy and procedures for Tui Glen Rest Home. Principles of kitchen and food handling monitoring and monitoring and surveillance activities are also described.

A four week rotating menu is in place and guides the meals prepared and provided by staff. Staff report that changes may be made depending on the availability of menu items, however there is no record made when these changes occur. For example, on the day of audit the protein for the main meal had been swapped over to a sausage casserole instead of a lamb casserole. The manager informs that although she knows that the menu was originally reviewed by a dietitian, there is no longer a record of this review available and that if found it would be three or more years old.

Residents inform during interview that they are given another option if they do not like the food on the menu and on day one of the audit this occurs for a person who does not like sausages. Food preferences and any allergies are noted on admission and written on the menu. One resident discusses his health and works alongside staff to ensure his special dietary needs are met. There are no other specific dietary requirements, no resident requires feeding and there is no special feeding equipment required by any of the residents.

Groceries are ordered on-line and delivered to the facility once a week and the person on duties puts them away. Milk is delivered to the facility twice a week and fresh fruit and vegetables and meat products are picked up from the town once a week. These are refrigerated immediately. All pantry items, leftovers and frozen foods are labelled and dated with decanted items having the label from the packaging attached to the container. Food is disposed of either down the insinkerator, or are put into the general rubbish, which is collected weekly by the local council.

All staff have completed the requirements for a food handling certificate within the past six months. The manager informs that the Tui Glen kitchen has recently been accepted for a contract that requires a Food safety Authority certificate and changes to meet these requirements have commenced.

Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1)Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.


Evidence:Staff report that changes may be made to the menu depending on the availability of listed items, however there is no record made when these changes occur.

For example, on the day of audit the protein for the main meal had been changed to a sausage casserole instead of a lamb casserole. The manager informs that although she knows that the menu was originally reviewed by a dietitian, there is no longer a record of this review available and that if found it would be three or more years old. .

Finding:The food provided is not always consistent with that noted on the menu. The menu has not been reviewed by a dietitian within the last three years.

Corrective Action:Food provided to the residents is to be more consistent with the menu. The menu requires review by a dietitian to affirm that the food, fluid and nutritional needs of consumers are provided in line with recognised nutritional guidelines.


Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2)Consumers who have additional or modified nutritional requirements or special diets have these needs met.


Evidence:

Finding:

Corrective Action:


Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5)All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.


Evidence:

Finding:

Corrective Action:


Outcome 1.4: Safe and Appropriate Environment

Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures 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.

Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1)Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

ARC D19.3c.v; ARHSS D19.3c.v


Evidence:Waste management policy and procedures are described in a quality manual document. These include procedures for the management of general rubbish, hazardous waste, waste contaminated with body fluids, sharp and food scraps. Glass and cans are recycled through the local rubbish collection.

Hazardous body substances are disposed of according to infection prevention and control procedures. All household chemicals are stored in cupboards in the laundry, which is kept locked via a key lock on the door handle or a slide bolt that is used when the staff person is out the back.

The manager informs that food waste is disposed of via the insinkerator, or the general rubbish collection process. The local council collects general rubbish and recycling items (which are separated at the point of disposal) once a week. Sharps are disposed of in a sharps container and a contractor is advised and collects it when it is full.

Personal protective equipment is sighted. For example, plastic aprons, plastic gloves, gum boots, goggles and hand sanitiser are available (all sighted). The infection control training package advocates the use of these items and four of four staff report that they use these items when the need arises. Masks and other goggles are available in an infection control kit for use in an outbreak or a suspected outbreak (sighted).

Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1)Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.1.6 (HDS(C)S.2008:1.4.1.6)Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2)Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a; D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4


Evidence:The building has a current warrant of fitness (expiry date 5 July 2014). All building warrant of fitness checks that includes fire system checks and tests are being completed as required. A folder holding records of these checks is sighted. The safety inspections of electrical equipment are current and the calibration of clinical equipment, including the tympanic thermometer and the sphygmomanometer has been completed. These actions address areas for improvement raised at the provisional audit. The facility van that is used to transport residents has both a current warrant of fitness and a current registration.

One of the objectives of the current business plan is about the redecoration and renovation of some internal and some external areas. Progress with this has commenced and is evident during a tour of the facility. During the tour of the facility, the manager also shows the auditor aspects of the environment that will be modified and the plans for the modification of the laundry area are sighted. There are areas where the physical environment has the potential to increase the likelihood of the spread of infection, or cause physical injury risk to residents and/or staff. Disused and broken items, rusting edges and broken plastic are evident. The need to check the environment is clean and safe is an area requiring improvement.

There is a transportation policy document and a documented transportation procedure.

A health and safety policy informs staff and management of responsibilities for ensuring the environment is healthy and safe, how Tui Glen complies with the safety requirements of New Zealand legislation, such as building, equipment and fire service checks, and notes the need to record hazards in the hazard register.

A driveway from the road has a gradual slope and a steep pathway leads up to the house. All residents are mobile and although one person uses a walking frame all residents are currently able to walk up and down the path with two requiring supervision. There is a wooden deck where residents may sit and overlook the valley and there is a paved courtyard area where people may also sit.

Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1)All buildings, plant, and equipment comply with legislation.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.2.4 (HDS(C)S.2008:1.4.2.4)The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.


Evidence:The new manager informs she is making improvements to the physical environment as money becomes available. There is evidence of this in changes to the landscaping, in the placement of ramps at doors onto the deck and in the progressive redecoration of residents’ rooms, for example. A relative from out of town, who is not able to visit often, has noticed the difference and expresses gratitude that these changes are occurring. The manager informs of planned changes to the laundry and area immediately outside it (plans sighted) that are expected to improve this environment.

There are currently areas where the physical environment has the potential to increase the likelihood of the spread of infection, or cause physical injury risk to residents and/or staff. Examples of this include the placement of cleaning buckets in the shelf beneath the clean bed linen and the presence of unused items that are broken, rusting and/or in a deteriorating condition, such as an ironing board, clothes frames and broken edges on kitchen rubbish bins. This is an area for improvement that has been rated as a low risk as to date nobody has been harmed as a result of the environment and time-framed plans are in place to address previously self-identified environmental issues of concern.

Finding:The presence of unused items that are broken, rusting and/or in a deteriorating condition have the potential to increase the likelihood of the spread of infection, or cause physical injury risk to residents and/or staff.

Corrective Action:An environmental scan is undertaken and all items that have the potential to cause any harm are removed, or added to the hazard register and efforts are made to mitigate the risks.


Criterion 1.4.2.6 (HDS(C)S.2008:1.4.2.6)Consumers are provided with safe and accessible external areas that meet their needs.


Evidence:

Finding:

Corrective Action:


Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3)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.

ARC E3.3d ARHSS D15.3c


Evidence:There is one unisex shower that is shared between the six residents. One toilet is in this shower room and there is one other unisex toilet. Both are identifiable by labels on the doors and both have a sign for residents to slide across when occupied. This is not occurring and people are being interrupted while using the facilities. The intrusion on residents’ privacy is an area requiring improvement. Commodes are available for residents to use during the night if they choose. Each bedroom has a wash hand basin installed. One family member and one resident both comment that ‘it would be good if there was another shower and toilet area’.

Criterion 1.4.3.1 (HDS(C)S.2008:1.4.3.1)There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.


Evidence:There is one unisex shower that is shared between the six residents. One toilet is in this shower room and there is one other unisex toilet. Both rooms are downstairs. Three of the residents say they are comfortable with this arrangement. One family member and one resident made comment that ‘it would be good if there was another shower and toilet area’ and a relative notes that although not having an ensuite was initially a disappointment for her relative, the benefits of Tui Glen now outweigh this.

Finding:Residents cannot be assured privacy when attending to personal hygiene needs, or when receiving assistance with personal hygiene needs. Signs that indicate occupancy are installed on the toilet/shower door and on the separate toilet door, however most residents are not using these and people enter them while occupied (observed three times). Neither of these rooms have a lock on the door to enable people to have privacy.

Corrective Action:Residents can be assured privacy when attending to personal hygiene cares, or being assisted with these cares.


Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4)Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii


Evidence:Each resident has their own personal room. One resident’s room is upstairs, which is his choice. All sighted are of a good size and all are personalised according to individual preferences. The manager informs that the rooms are progressively being redecorated and this is evident for two of the rooms sighted.

Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1)Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.


Evidence:

Finding:

Corrective Action:


Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5)Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

ARC E3.4b ARHSS D15.3d


Evidence:A television lounge and dining area is open plan with the dining area beside the kitchen. The television lounge that extends around the corner has comfortable seating and the dining area has a large table and sufficient numbers of chairs for all six of the residents and for staff to join them. Residents and family members interviewed note the family and homely atmosphere that this facility offers. On the two days of audit some of the residents and a visitor sat on the deck extending from the dining area.

Criterion 1.4.5.1 (HDS(C)S.2008:1.4.5.1)Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.


Evidence:

Finding:

Corrective Action:


Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6)Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e


Evidence:Policy and procedure documents, which include laundry policies, laundry related processes, including use of protective equipment and a description of washing, drying and pressing/ironing procedures for different types of articles, are sighted.

Cleaning policies and procedures are detailed in the infection control manual and specific duties are listed in the roster manual.

Internal audits are undertaken twice a year on cleaning and laundry. Results of those undertaken January 2014 are sighted.

The health and safety policy notes cleaning materials are to be stored in a safe place and are to be used according to manufacturers’ instructions. Sighted cleaning materials stored in a cupboard in the laundry which has a locked entry door. A slide bolt (sighted) is used when staff are outside the laundry.

Criterion 1.4.6.2 (HDS(C)S.2008:1.4.6.2)The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.6.3 (HDS(C)S.2008:1.4.6.3)Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.


Evidence:

Finding:

Corrective Action:


Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7)Consumers receive an appropriate and timely response during emergency and security situations.

ARC D15.3e; D19.6 ARHSS D15.3i; D19.6


Evidence:Training records sighted confirm staff have been trained in responding to all emergency situations within the last twelve months. Records of attendance at the most recent six monthly fire evacuation trial on 5 February 2014 are also sighted. Smoke alarms and a sprinkler system are installed throughout the facility.

There is a fire service letter of approval for the fire evacuation plan dated 8 August 2000,

Alternative energy supplies that are available in the event of the main supplies failing include a gas barbecue for cooking purposes, several torches for lighting and spare blankets are stored in plastic containers for warmth. Stocks of additional food and water are available. The emergency items are in more than one place, which could be confusing in an emergency. There is a lack of essential items for an emergency kit, for example, there is no radio and the spare batteries are not the size for the torches. Also, there is no list of emergency supplies and there is no evidence that checks of the emergency supplies are occurring. A review of the emergency supplies is an area requiring improvement.

The call bell system is of an older style, however is functional when tested. The residents inform during interview that call bells are answered and the one person who uses it at night confirms they are answered in a reasonable timeframe.

Security arrangements include locking doors, shutting windows and drawing curtains at nightfall. The windows in residents’ rooms have security stays on them that prevent them from being opened beyond a safe width. External doors are alarmed when locked at night (system demonstrated). Additional family/whanau of the owner/manager live on site as does the owner/manager. One resident who is able to walk independently may become confused and wander. This person wears a necklace tracker, which is linked to the local police station.

Criterion 1.4.7.1 (HDS(C)S.2008:1.4.7.1)Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.3 (HDS(C)S.2008:1.4.7.3)Where required by legislation there is an approved evacuation plan.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.4 (HDS(C)S.2008:1.4.7.4)Alternative energy and utility sources are available in the event of the main supplies failing.


Evidence:A gas fuelled barbecue is available for cooking purposes in the event of mains power failing. There are stores of blankets in plastic containers in a separate shed, along with bottled water, personal hygiene products, toilet paper and additional canned, frozen and dry food for use in the event of an emergency. Near the fire evacuation board are torches and some batteries that do not fit the torch. One candle and some matches are in the box. There is no radio. There is no record of checks of these emergency supplies.

Finding:There is no list of the requirements this service needs for its emergency supplies. Some essential items are not in the emergency supply kit; there is no system in place for regular and ongoing audits of the emergency kit; items are in two different places without formal organisation and checks of the emergency equipment are not being documented.

Corrective Action:Emergency supplies are reviewed, a system is implemented for ongoing and effective management of the emergency supplies and that all future checks of the emergency supplies are recorded.


Criterion 1.4.7.5 (HDS(C)S.2008:1.4.7.5)An appropriate 'call system' is available to summon assistance when required.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.7.6 (HDS(C)S.2008:1.4.7.6)The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.


Evidence:

Finding:

Corrective Action:


Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8)Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.

ARC D15.2f ARHSS D15.2g


Evidence:The facility is heated by a heat pump, which is installed in the hallway upstairs and another is in the lounge and dining area downstairs. Each of the residents have a small panel style heater in their bedroom. Residents spoken with inform they are always warm and comfortable. Windows in every room, including each bedroom, are of normal proportions and are able to be opened. On the day of audit the doors are open to let in the warm sunshine and to ventilate the

building.

There is a small sheltered designated smoking area in a garden courtyard where residents may smoke if they choose.

Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1)Areas used by consumers and service providers are ventilated and heated appropriately.


Evidence:

Finding:

Corrective Action:


Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2)All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.


Evidence:

Finding:

Corrective Action:


NZS 8134.2:2008: Health and Disability Services (Restraint Minimisation and Safe Practice) Standards

Outcome 2.1: Restraint Minimisation

Services demonstrate that the use of restraint is actively minimised.

Standard 2.1.1: Restraint minimisation (HDS(RMSP)S.2008:2.1.1)Services demonstrate that the use of restraint is actively minimised.

ARC E4.4a ARHSS D16.6


Evidence:The restraint minimisation policy and procedures state Tui Glen Rest Home will only use restraint for emergency purposes and safety reasons and that all other options to manage behaviour would be consistently tried first. Definitions of physical restraint, personal restraint, environmental restraint, enablers, seclusion and de-escalation are listed and policy statements on what would and would not occur at Tui Glen are outlined. The restraint minimisation policy covers the key aspects of the requirements of the standard.

The manager informs that there are no enablers or restraints currently in use at Tui Glen Rest Home and that any such use would be a last resort. This is confirmed during the interview with five staff and the residents and family members also confirm that they have never experienced or observed any form of restraint being used.

All staff have completed enabler and restraint use questionnaires and undertook training on managing challenging behaviour in 2013.

Criterion 2.1.1.4 (HDS(RMSP)S.2008:2.1.1.4)The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.


Evidence:

Finding:

Corrective Action:


NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards

Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1)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.

ARC D5.4e ARHSS D5.4e


Evidence:Infection control policies and procedures clearly describe the role of the infection control officer, which is the registered nurse, and the infection control team, which is the registered nurse in consultation with the owner/manager. It is noted that infection prevention and control is to be discussed as an issue on the agenda of staff/quality meetings and this is evident in the January 2014 meeting minutes that are sighted.

The infection prevention and control programme is clearly documented and is signed off by the owner/manager in the front of the infection control manual, as

per the policy document on sign off of the programme.

A staff health policy covers staff being advised not to come to work if they have a suspected infection. The manager advises that in the ‘flu’ season a notice is placed on the door asking visitors not to enter if they have had, or have a suspected infection. The manager and registered nurse informs that they know the regular visitors/family members well and discuss any concerns with them should the need arises. A policy covers these actions.

Criterion 3.1.1 (HDS(IPC)S.2008:3.1.1)The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.3 (HDS(IPC)S.2008:3.1.3)The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.


Evidence:

Finding:

Corrective Action:


Criterion 3.1.9 (HDS(IPC)S.2008:3.1.9)Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.


Evidence:

Finding:

Corrective Action:


Standard 3.2: Implementing the infection control programme (HDS(IPC)S.2008:3.2)There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.



Evidence:The registered nurse has been delegated the role of infection control officer. The manager advises that they will work together on infection control if the need arises, although the registered nurse will be considered the expert. There is no record available confirming that the registered nurse has received an update on infection control training and this is an area for improvement. The manager and registered nurse advise that a regional infection control nurse from the local District Health Board is available to provide advice in the event of an outbreak.

Criterion 3.2.1 (HDS(IPC)S.2008:3.2.1)The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.


Evidence:The registered nurse has been delegated the role of infection control officer. There is no record available confirming that the registered nurse has received an update on infection control training.

Finding:There is no evidence available that the registered nurse has updated infection control education suitable for the role of infection control officer.

Corrective Action:The infection control officer has suitable knowledge and experience for the role.


Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3)Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a


Evidence:A suite of infection control policies and procedures are sighted. These include an introduction for the management of infection control at Tui Glen Rest Home. The objectives reflect a rest home environment and potential infection risks are identified. Policies and procedures are available for hand-washing; infection control reporting processes, single use items; exposure to blood and body fluids; and standard and transmission based precautions. The infection control programme describes the role and responsibilities of the infection control officer, related policies and procedures and staff education. Infection control surveillance, monitoring and infection outbreak management are defined in the policies and procedures with some action points outlined with a focus on managing a gastro-enteritis outbreak. An anti-microbial usage policy includes the management of obtaining and processing specimens for suspected infections. The manager, in consultation with the registered nurse, has signed off review of these policies and procedures for 2014.

Criterion 3.3.1 (HDS(IPC)S.2008:3.3.1)There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.


Evidence:

Finding:

Corrective Action:


Standard 3.4: Education (HDS(IPC)S.2008:3.4)The organisation provides relevant education on infection control to all service providers, support staff, and consumers.



Evidence:The focus of infection control education for this facility is on hand washing and basic hygiene practices. Hand washing internal audits are undertaken annually and the results for this audit that was undertaken in January 2014 are sighted.

Staff complete an infection control questionnaire that is marked by the infection control officer at orientation and annually thereafter. These are sighted in staff files. The manager and staff inform that they remind residents about the need to wash their hands, or use hand sanitiser; about cough etiquette and the management of continence products, as applicable. There are no records of this kept as it is incidental and opportunistic.

Criterion 3.4.1 (HDS(IPC)S.2008:3.4.1)Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.


Evidence:

Finding:

Corrective Action:


Criterion 3.4.5 (HDS(IPC)S.2008:3.4.5)Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept.


Evidence:

Finding:

Corrective Action:


Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5)Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.


Evidence:This service has only six beds. The incidence of infection is minimal with only one probable urinary tract infection (UTI) recorded for 2013. This infection is recorded as per the procedure for the service.

The registered nurse, who is also the infection control coordinator states there were no other suspected infections. Infection control policies and procedures describe the surveillance process. Definitions of the infections to be included in the surveillance reports specify UTIs both with and without a catheter; respiratory; gastro-intestinal; eye/ear; viral; gland; fungal and oral thrush. The accident/incident form is used for any incidence of infection.

With the low rate of infection, audit of criterion 3.5.7 is not applicable, although the incidence of the one probable infection is noted in the quality minutes in January 2014 as a summary for 2013.

Criterion 3.5.1 (HDS(IPC)S.2008:3.5.1)The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.


Evidence:

Finding:

Corrective Action:


Certificaiton audit summary - Ministry of Health€¦ · Web viewThe service provider and staff...

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