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SHealthCERT Aged Residential Care Audit Report (version 4.3)IntroductionThis 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 ReportLegal entity name:G J & J M Bellaney LimitedCertificate name:G J & J M Bellaney LimitedDesignated Auditing Agency:Health and Disability Auditing New Zealand LimitedTypes of audit:Surveillance AuditPremises audited:Wimbledon VillaServices audited:Dementia careDates of audit:Start date:20 October 2015End date:20 October 2015Proposed changes to current services (if any): Total beds occupied across all premises included in the audit on the first day of the audit:22Audit TeamLead AuditorRobyn HooperHours on site9Hours off site6Other AuditorsSteve Baker-ShearmanTotal hours on site9Total hours off site5Technical ExpertsTotal hours on siteTotal hours off siteConsumer AuditorsTotal hours on siteTotal hours off sitePeer ReviewerRosie DwyerHours2Sample TotalsTotal audit hours on site18Total audit hours off site13Total audit hours31Number of residents interviewedNumber of staff interviewed4Number of managers interviewed3Number of residents’ records reviewed5Number of staff records reviewed6Total number of managers (headcount)3Number of medication records reviewed10Total number of staff (headcount)29Number of relatives interviewed4Number of residents’ records reviewed using tracer methodology1Number of GPs interviewed1DeclarationI, Melissa Broome, Programme Assistant of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of Health and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Act.I confirm that:a)I am a delegated authority of Health and Disability Auditing New Zealand LimitedYesb)Health and Disability Auditing New Zealand Limited has in place effective arrangements to avoid or manage any conflicts of interest that may ariseYesc)Health and Disability Auditing New Zealand Limited has developed the audit summary in this audit report in consultation with the providerYesd)this audit report has been approved by the lead auditor named aboveYese)the peer reviewer named above has completed the peer review process in accordance with the DAA HandbookYesf)if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the providerYesg)Health and Disability Auditing New Zealand Limited has provided all the information that is relevant to the auditYesh)Health and Disability Auditing New Zealand Limited has finished editing the document.YesDated Tuesday, 17 November 2015Executive Summary of AuditGeneral OverviewWimbledon Villa provides dementia level of care for up to 38 residents in two 18 roomed units. Two bedrooms in one unit can be used as double rooms. On the day of the audit there were 22 residents. The facility is privately owned. A clinical nurse manager and business facility manager are responsible for the daily operation of the facility. They are supported by a quality coordinator and full-time registered nurse. This unannounced surveillance audit was conducted against a sub-set of the relevant Health and Disability Standards and the contract with the district health board. The audit process included the review of policies and procedures, the review of residents’ and staff files, observations, and interviews with family, general practitioner, management and staff. The relatives and general practitioner spoke positively about the care and support provided at Wimbledon Villa.The service has addressed ten of ten shortfalls from the previous certification audit around corrective action plans, essential notifications, timely incident reporting, training requirements, dietitian referrals, assessments, weight loss interventions, evaluations, medication charts and medical equipment calibrations. This surveillance audit identified improvements are required around staff orientation, documented intervention for medical conditions and standing orders. Outcome 1.1: Consumer RightsThere is an open disclosure policy, which describes ways that information is provided to residents and families/next of kin at entry to the service continually, and as required. A system for managing complaints is in place and there is evidence of follow up. The rights of the resident and/or their family to make a complaint is understood, respected and upheld by the service. Outcome 1.2: Organisational ManagementWimbledon Villa has a current business plan and a quality assurance and risk management programme that outlines objectives for 2015 to 2016.There is an established quality system in place. Quality information is reported to monthly staff/quality meetings, weekly team management meetings and to the owner. There is a reporting process being used to record and manage resident incidents. There is an annual in-service training programme that has been implemented for the year and staff are supported to undertake external training. The service has a documented rationale for determining staffing and caregivers, residents and family members report staffing levels are sufficient to meet resident needs.Outcome 1.3: Continuum of Service DeliveryThe registered nurse is responsible for each stage of service provision. The registered nurse assesses, plans and reviews residents' needs, outcomes and goals with the resident (as appropriate) and/or family input. InterRAI assessments are in place for all residents. Resident files included medical notes and visiting allied health professionals.The activities coordinator provides an activities programme for the residents that is varied, interesting and involves the families and community. Residents have an individualised activity plan developed on admission that is reviewed six monthly. The service uses an electronic medication system. The care staff responsible for administration of medicines complete education and medication competencies. All meals are prepared on site. Individual and special dietary needs are catered for. Nutritional snacks are available 24 hours a day for the residents. Food, fridge, freezer and food temperatures are recorded.Outcome 1.4: Safe and Appropriate EnvironmentThe service has a current building warrant of fitness. Outcome 2: Restraint Minimisation and Safe PracticeRestraint policy and procedures are in place. The definitions of restraints and enablers are congruent with the definition in the restraint minimisation standard. The service had no residents using an enabler or restraint. Staff receive education and training in restraint minimisation, dementia care and managing challenging behaviours. Outcome 3: Infection Prevention and ControlThe clinical nurse manager is the infection control coordinator. A surveillance policy describes the surveillance methods and infection events. Data is collated monthly and is used to identify trends, education needs and quality activities within the facility. External benchmarking occurs. Summary of AttainmentCIFAPA NegligiblePA LowPA ModeratePA HighPA CriticalStandards01403000Criteria03703000UA NegligibleUA LowUA ModerateUA HighUA CriticalNot ApplicablePendingNot AuditedStandards000000033Criteria000000061Corrective Action Requests (CAR) ReportCodeNameDescriptionAttainmentFindingCorrective ActionTimeframe (Days)HDS(C)S.2008Standard 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 LowHDS(C)S.2008Criterion 1.2.7.4New service providers receive an orientation/induction programme that covers the essential components of the service provided.PA LowTwo of six staff files reviewed did not evidence that the orientation programme documents were retained in the staff file. The service provided a copy of one staff members completed orientation documentation on the day following the audit.Ensure that all staff complete an orientation programme and that a copy of the documents are kept in the staff file.90HDS(C)S.2008Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.PA LowHDS(C)S.2008Criterion 1.3.6.1The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.PA LowThere were no documented interventions for one resident diagnosed as a diet controlled diabetic on admission as per GP admission notes. Ensure interventions are documented to reflect the residents’ medical needs. 60HDS(C)S.2008Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.PA LowHDS(C)S.2008Criterion 1.3.12.1A 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.PA Lowi) The standing orders have not been reviewed annually. ii) The standing orders do not include contraindications.iii) One bottle of standing order medication had expired June 2014. i) and ii) Ensure the standing orders meet legislative requirements. iii) Ensure standing order medications are within the expiry dates. 60Continuous Improvement (CI) ReportCodeNameDescriptionAttainmentFindingNZS 8134.1:2008: Health and Disability Services (Core) StandardsOutcome 1.1: Consumer RightsConsumers 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 1.1.9: 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; D20.3Attainment and Risk: FAEvidence:Open disclosure related policies and procedures alerts staff to their responsibility to notify family/next of kin of any accident/incident and ensures full and frank open disclosure occurs. Wimbledon Villa provides families with an information pack that gives a comprehensive range of information regarding the scope of service provided to the resident and their family/whānau. The information pack includes a copy of the code of rights and information about dementia services. The information pack is available in large print and advised that this can be read to residents. Interpreter services are available as required. Interviews with four family members’ evidences that family are informed. Discussions with staff and management identified their knowledge around open disclosure. Resident meetings are held. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Criterion 1.1.9.4 (HDS(C)S.2008:1.1.9.4)Wherever necessary and reasonably practicable, interpreter services are provided.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.1.13: 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; D13.3gAttainment and Risk: FAEvidence:The service has a complaints policy that describes the management of the complaints process. Complaints forms are freely available throughout the facility. Information about complaints is provided on admission. There is a complaints register that includes all complaints. There have been two complaints made in 2015 (year to date), the complaints were resolved within the required timeframes. A review of complaints documentation evidence followed up with the complainant and discussion with staff occurs.Discussions with family members confirmed that any issues are addressed and they feel comfortable to bring up any concerns. Discussions with the care assistants stated that concerns/complaints were discussed at monthly staff/quality meetings.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Outcome 1.2: Organisational ManagementConsumers 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; D17.5Attainment and Risk: FAEvidence:Wimbledon Villa provides dementia care for up to 38 residents in two separate 18 room units. Two rooms in one unit can be used as double rooms. At the time of the audit, there were 22 residents, with 10 in one unit and 12 in the other unit. The service is managed by a clinical nurse manager who works from Tuesday to Saturday and has 30 years of aged care, management and psychiatric nursing experience. She has been a registered nurse at Wimbledon Villa since April 2012 and clinical nurse manager since July 2013. A business facility manager, who has a management and business background and has been a manager at the facility since September 2010, supports the clinical nurse manager. The manager has maintained at least eight hours annually of professional development activities related to managing a rest home. The facility is privately owned and the managers frequently report to the owner. The organisation has documented values, mission statement and philosophy and these are displayed in the reception area. The information is recorded in the organisation's business plan. The current business plan includes goals, specific KPIs for 2015 – 2016, and strategic direction. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.2.3: 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; D19.5Attainment and Risk: FAEvidence:Wimbledon Villa has a documented quality assurance and risk management programme in place. The service employs a quality coordinator who coordinates and records quality data, develops corrective actions plans and collates results. Quality activity information is communicated to the owners, management and staff. Corrective action plans were evidenced to have been completed and signed off. The service has addressed this previous finding. A documented and implemented internal audit schedule includes an annual review of audit results for the year. Each month, the quality coordinator collates incidents and accidents data, and infection control. Incidents are collated monthly on to a reporting sheet to monitor issues and trends and these are displayed on the staff room notice board. Monthly data analysis includes the comparison against set KPIs for the service, which are also benchmarked against similar services. Annual analysis is also documented and presented to the staff, quality and management meetings. A report is presented to monthly staff and quality meetings, monthly team management meetings and a monthly report to the owner, as evidenced in meeting minutes. Annual resident and relative surveys have been completed. The survey (September 2015) documents an 86% satisfaction overall compared to 80% overall satisfaction result for the previous year. The facility implements organisational policies and procedures to support service delivery. All policies are scheduled for review every two years. Policies are available to staff and have been updated to reflect the implemented InterRAI procedures. Health and safety policies and procedures, and a health and safety plan are in place for the organisation. The hazard register is regularly reviewed. All identified hazards include a risk rating, controls that are in place and monitoring procedures.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.2.4: 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; D19.3cAttainment and Risk: FAEvidence:The service collects a comprehensive set of data relating to adverse, unplanned and untoward events. The service advised that they notified the DHB of a previous coroner’s case. The previous finding around provider awareness of their statutory obligations in regards to essential notifications has been addressed. The reporting system is integrated into the quality risk management system. Once incidents and accidents are reported, the immediate actions taken are documented on incident forms. Twenty-one incident forms reviewed identify the RN has been notified within a timely manner. All incidents have been investigated by the clinical nurse manager, who monitors preventative and corrective actions as documented. The previous finding around RN notification of incidents has been addressed. Actions were reflected in the individual residents long-term care plans. If risks are identified these are also processed as hazards. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.2.7: 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, D17.11Attainment and Risk: PA LowEvidence:A human resources policy establishes the requirements for vetting of qualifications and the maintenance of practising certificates for registered nursing staff. Relevant checks are completed to validate individual qualifications and experience. A record of practising certificates is maintained for two registered nurses and other health professionals including the pharmacist, GPs and the dietitian. Six of six staff files reviewed indicates that all staff have a signed contract, job description and evidence of recruitment. A comprehensive in-service education programme is in place. The annual training plan covers a wide range of subjects and exceeds the required eight hours annually. The previous finding around staff competencies and first aid training has been addressed. Discussions with staff and a review of documentation demonstrate a commitment to the education of staff that is implemented into practice. Wimbledon Villa has an orientation programme in place that provides new staff with relevant information for safe work practice. The orientation programme is relevant to the dementia unit and includes management of challenging behaviours with alternative strategies and activities. Completed orientation documentation was not evident in all staff files reviewed. There are 17 care assistants of whom 10 have completed the required dementia standards; five are in progress and two are to be enrolled.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: PA LowEvidence:Wimbledon Villa has an orientation programme in place that provides new staff with relevant information for safe work practice. Completed documentation for four of six staff files reviewed was evidenced. The orientation programme is relevant to the dementia unit and includes a session on how to implement activities and therapies Finding:Two of six staff files reviewed did not evidence that the orientation programme documents were retained in the staff file. The service provided a copy of one staff members completed orientation documentation on the day following the audit.Corrective Action:Ensure that all staff complete an orientation programme and that a copy of the documents are kept in the staff file.Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.2.8: 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; D17.8Attainment and Risk: FAEvidence:The service has a documented rationale for determining staffing levels and skill mixes for safe service delivery. Care assistants interviewed reported that staffing levels and the skill mix was appropriate and safe. Family members interviewed stated that they felt there was sufficient staffing. The roster and staffing in place for the current residents includes a trained first aider on each shift. There is a full time clinical nurse manager Monday to Friday and a registered nurse on the remaining two days. The staffing roster evidences a minimum of one care assistant allocated in each dementia care unit per shift. Staff carry walkie-talkies on them at all times. During the day, organised activities are provided until 3pm and during these hours, residents from both units (that want to be involved) are brought together. There were adequate staff noted on each unit during the audit.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Outcome 1.3: Continuum of Service DeliveryConsumers 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 1.3.3: 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; D16.5iAttainment and Risk: FAEvidence:In the five files reviewed, the registered nurse (RN) had completed the initial assessment/care plan within 24 hours of admission and the long-term care plans within three weeks of admission. The full-time RN is InterRAI trained. All residents admitted after 1 July 2015 have had an InterRAI assessment completed. Residents have an InterRAI assessment completed six monthly as their care plan review falls due. The long-term care plans reviewed had been evaluated six monthly or earlier with changes in health condition. The general practitioners (GP) have seen their residents within two working days of admission and complete three monthly medical reviews. Residents retain their own GP. There is evidence of visits at other times for resident concerns. There is a local on-call GP roster until 10pm and then the emergency department after 10pm. The GP interviewed commented very positively on the service and care at Wimbledon Villa. There is close liaison and consultation between allied health professionals and the RN/management team. Elder Health, needs assessment service and dementia care nurse specialist services are readily available. All files identified integration of allied health and a team approach was evident. A physiotherapist is available by referral. There was evidence of a dietitian referral in one file for a resident with unintentional weight loss, and includes dietitian notes and dietary recommendations, which have been implemented. The previous finding around dietitian referrals has been addressed. Care staff interviewed could describe a verbal and written handover that maintains a continuity of service delivery. Progress notes are maintained on every shift.Tracer Methodology - Dementia care resident: The resident has dementia and a chronic medical condition. The resident file, long-term care plan, behaviour assessment, progress notes, medical notes, medication chart and incident form were reviewed. The relative, clinical nurse manager, care staff and activity coordinator were interviewed. The staff interviewed were able to describe the resident’s behaviours, triggers, interventions and activities to de-escalate/manage the behaviours over the 24 hour period. The use of ‘as required’ medication had been monitored by the clinical nurse manager and GP. The long-term care plan had been updated to reflect recent behaviours as documented on the incident form and in progress notes. There were documented interventions for the management of the chronic condition. The relative commented positively on the staff management and care provided and has been informed promptly of challenging behaviour incidents.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.3.4: 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.iiAttainment and Risk: FAEvidence:The resident files reviewed, evidenced relevant risk assessments and behaviour assessments had been completed on admission and reviewed six monthly as part of the InterRAI assessment and care plan review. The previous finding around the review of risk assessments has been addressed. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.3.6: 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; D18.4Attainment and Risk: PA LowEvidence:When a resident's condition alters, the registered nurse initiates a review and if required, GP or nurse specialist consultation. The family members confirmed they are notified of any changes to their relative’s health as evidenced on the next of kin contact sheet. Not all resident care plans reviewed documented the required interventions to meet the resident’s needs. The clinical nurse manager/RN was able to describe the referral process should they require assistance from a wound specialist, continence nurse or other nurse specialist service. Adequate dressing supplies were sighted. Wound assessments treatment and evaluations were in place for the one chronic wound and three skin tears. The chronic wound has been linked to the long-term care plan. There was evidence of GP, wound nurse specialist and investigations in the management of the chronic wound. Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified. 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.Attainment and Risk: PA LowEvidence:Short-term care plans included interventions for short-term needs such as infections, wounds, and rash and weight loss. Ongoing needs were transferred to the long-term care plans. Monitoring forms were in use for behaviour, weight, food and fluid intake and pain monitoring. Four of five care plans evidence documented interventions for identified needs.Finding:There were no documented interventions for one resident diagnosed as a diet controlled diabetic on admission as per GP admission notes. Corrective Action:Ensure interventions are documented to reflect the residents’ medical needs. Timeframe (days): 60 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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; D16.5hAttainment and Risk: FAEvidence:The activities coordinator is a qualified caregiver who is progressing through the diversional therapy course. He is employed for 32 hours per week Monday to Friday. An activity assistant assists with activities as required (outings) and hours are increased with resident occupancy. The activity coordinator provides individual and group activities. The monthly programme is varied and appropriate for people with dementia and includes outings. The residents (as appropriate) attend community events such as concerts, seniors club, and Lion’s club functions with positive feedback from the community. Two staff accompany residents on outings in the van. The activity coordinator has a current first aid certificate. Activities were observed to be occurring in small groups and individual basis. There are resources available for care staff to use for one on one time with the resident and at any time of day and weekends. Relatives stated they were satisfied with the activities provided and have the opportunity to feedback on the programme. A resident profile is completed on admission in consultation with the resident/family (as appropriate). Activity plans sighted in all five files were reviewed six monthly at the same time as the care plans. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.3.8: 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; D16.4aAttainment and Risk: FAEvidence:All initial care plans sampled, were evaluated by the RN within three weeks of admission. Long-term care plans have been reviewed at least six monthly in five of five files sampled or earlier for any health changes. The previous finding around six monthly evaluations has been addressed. Written evaluations demonstrate progress towards resident/family goals. There is evidence of family involvement in the care plan reviews. The GP reviews the residents at least three monthly or earlier if required. Ongoing nursing evaluations occur daily/as indicated and are documented within the progress notes.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.3.12: 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; D19.2dAttainment and Risk: PA LowEvidence:The service introduced an electronic medication system in August 2014. Registered nurses and senior care assistants who administer medication have completed training and an annual medication competency assessment. Registered nurses who administer insulin have completed insulin administration competencies. The care staff interviewed were able to describe their role in safe medication management. The standing orders currently in use do not meet requirements. There were no residents self-medicating. Not all standing order medications were within the expiry dates. Ten of ten medication charts reviewed on the electronic medication system met legislative prescribing requirements, including three monthly GP reviews. Respite care residents have medication charts entered onto the electronic medication system on admission. The previous finding around GP reviews and respite medication charts has been addressed. 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.Attainment and Risk: PA LowEvidence:There are standing orders in use, which were last reviewed in August 2014. The standing orders include the indication for use and maximum dose, however, the format does not meet the requirements for standing orders. Standing order stock expiry dates are checked regularly however one bottle of medication had expired.Finding:i) The standing orders have not been reviewed annually. ii) The standing orders do not include contraindications.iii) One bottle of standing order medication had expired June 2014. Corrective Action:i) and ii) Ensure the standing orders meet legislative requirements. iii) Ensure standing order medications are within the expiry dates. Timeframe (days): 60 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Standard 1.3.13: 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; D19.2cAttainment and Risk: FAEvidence:All meals at Wimbledon Villa are prepared and cooked on site. There is a Monday to Friday and weekend cook. A catering assistant is employed daily in the afternoons for the evening meals. There is a four weekly seasonal menu, which has been reviewed by a dietitian. Dietary needs are known, with individual likes and dislikes accommodated. Pureed, soft, diabetic desserts and gluten free diabetic desserts are provided. Staff were observed assisting residents with their meals and drinks. Additional nutritious snacks are available over 24 hours for the residents. Family members interviewed were satisfied with the food and confirmed alternative food choices were offered for dislikes.Fridge and freezer temperatures are taken and recorded. End cooked food temperatures and re-heating temperatures are recorded. All foods in the pantry, fridge and freezer were dated. Food services staff have completed training in food safety unit standards and chemical safety.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Outcome 1.4: Safe and Appropriate EnvironmentServices 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 1.4.2: 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; D20.4Attainment and Risk: FAEvidence:There is a current BWOF that expires on 6 July 2016. All clinical equipment has been calibrated by an external service. The previous finding has been addressed. Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1)All buildings, plant, and equipment comply with legislation.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)NZS 8134.2:2008: Health and Disability Services (Restraint Minimisation and Safe Practice) StandardsOutcome 2.1: Restraint MinimisationServices 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 D16.6Attainment and Risk: FAEvidence:The restraint policy includes the definitions of restraint and enablers and comprehensive restraint procedures. Interviews with the care assistants and the clinical nurse manager/RN confirm their understanding of restraints and enablers. The clinical nurse manager is the restraint coordinator. Staff attend challenging behaviour education and complete restraint minimisation and safe practice competencies. There were no residents using an enabler or restraint. 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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) StandardsStandard 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.Attainment and Risk: FAEvidence:There is a policy describing surveillance methodology for monitoring of infections. The infection control coordinator (clinical nurse manager) collates information monthly. Surveillance data is used to determine infection control activities and education needs in the facility. Definitions of infections in place are appropriate to the complexity of service provided. Infection control data, identified trends and analysis is reported at the team (all staff) meetings. Monthly comparison and trends for infection rates are analysed on an individual basis. The GP reviews antibiotic (including prophylactic) use at least three monthly with the medication review. There have been no outbreaks. Systems in place are appropriate to the size and complexity of the facility. The service participates in external benchmarking.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.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)Criterion 3.5.7 (HDS(IPC)S.2008:3.5.7)Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.Attainment and Risk: FAEvidence:Finding:Corrective Action:Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) ................
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