Brookhaven Retirement Village Limited - Brookhaven ...

?Brookhaven Retirement Village Limited - Brookhaven Retirement VillageIntroductionThis report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).The audit has been conducted by Health and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).You can view a full copy of the standards on the Ministry of Health’s website by clicking HYPERLINK "" here.The specifics of this audit included:Legal entity:Brookhaven Retirement Village LimitedPremises audited:Brookhaven Retirement VillageServices audited:Rest home care (excluding dementia care); Dementia careDates of audit:Start date: 4 April 2019End date: 5 April 2019Proposed changes to current services (if any): NoneTotal beds occupied across all premises included in the audit on the first day of the audit: 79Executive summary of the auditIntroductionThis section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:consumer rightsorganisational managementcontinuum of service delivery (the provision of services)safe and appropriate environmentrestraint minimisation and safe practiceinfection prevention and control.As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.Key to the indicatorsIndicatorDescriptionDefinitionIncludes commendable elements above the required levels of performanceAll standards applicable to this service fully attained with some standards exceededNo short fallsStandards applicable to this service fully attained Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activitySome standards applicable to this service partially attained and of low riskA number of shortfalls that require specific action to addressSome standards applicable to this service partially attained and of medium or high risk and/or unattained and of low riskMajor shortfalls, significant action is needed to achieve the required levels of performanceSome standards applicable to this service unattained and of moderate or high riskGeneral overview of the auditBrookhaven Retirement Village is part of the Golden Healthcare Group (GHG). Brookhaven Retirement Village is certified to provide rest home and dementia level care for up to 92 residents with 79 residents on the days of audit. This certification audit was conducted against the 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, management, staff and the general practitioner. The manager has experience in aged care management and has been in the role for four years. He is supported by a corporate services manager, quality assurance manager, operations manager and clinical coordinator who oversee the eight local GHG facilities and support the clinical manager and nursing team at Brookhaven. Family interviewed all spoke positively about the care and support provided.The audit identified areas for improvement around accident/incident forms, enduring power of attorney and interventions. The service has been awarded a continuous improvement rating for quality initiatives around activities. Consumer rightsIncludes 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.Policies and procedures adhere with the requirements of the Code of Health and Disability Services Consumers’ Rights (the Code). Residents and families are informed regarding the Code and staff receive ongoing training about the Code. Personal privacy and values of residents are respected. There is an established Māori health plan in place. Individual care plans reference the cultural needs of residents. Discussions with residents and relatives confirmed that residents, and where appropriate their families, are involved in care decisions. Regular contact is maintained with families including if a resident is involved in an incident or has a change in their current health. Families and friends are able to visit residents at times that meet their needs. Examples of good practice were provided.There is an established system for the management of complaints, which meets guidelines established by the Health and Disability Commissioner. Organisational managementIncludes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner.Some standards applicable to this service partially attained and of low risk.Brookhaven Retirement Village is implementing the Golden Healthcare Group (GHG) quality and risk management system that supports the provision of clinical care.Services are planned, coordinated, and are appropriate to the needs of the residents. A facility manager and clinical coordinator are responsible for the day-to-day operations. Goals are documented for the service with evidence of regular reviews. A quality and risk management programme is embedded. Corrective actions are implemented and evaluated where opportunities for improvements are identified. Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice. An orientation programme is in place for new staff. Ongoing education and training is in place, which includes in-service education and competency assessments. The staffing policy aligns with contractual requirements and includes appropriate skill mixes to provide safe delivery of care. Residents and families reported that staffing levels are adequate to meet the needs of the residents. The integrated residents’ files are appropriate to the service type.Continuum of service deliveryIncludes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.Some standards applicable to this service partially attained and of low risk.Residents are assessed prior to entry to the service and an initial nursing assessment and care plan is completed upon admission by registered nurses. Registered nurses are responsible for interRAI assessments, care plan development and evaluation with input from residents and family. There is evidence of general practitioner and allied health involvement in the care of residents. Diversional therapists plan activities that are appropriate to the resident’s assessed needs and abilities including entertainment and regular outings. The dementia unit is a pet friendly area. Residents and family interviewed advised satisfaction with the activities programme. Medications are stored securely in each unit. Staff receive training in medication management and have current competencies. The general practitioner reviews medication charts three monthly. All meals are cooked on site. Food, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines and additional requirements/modified needs were being met. There are nutritious snacks available 24 hours. Safe and appropriate environmentIncludes 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.Standards applicable to this service fully attained.There is a current building warrant of fitness. There are two dementia units and a three-wing rest home area. Each bedroom has a full ensuite. Residents’ rooms are of sufficient space to allow services to be provided and for the safe use and manoeuvring of mobility aids. Each area has a lounge, dining area and safe access to the outdoor gardens with seating and shade. There is a designated laundry for personal clothing. Other laundry is laundered off-site. Chemicals and cleaning trolleys are stored securely when not in use. The service has implemented policies and procedures for civil defence and other emergencies. Gas cooking, food, water and equipment is available in the event of an emergency. There is a first aider on duty at all times. Communal living areas and resident rooms are appropriately heated and ventilated. Residents have access to natural light in their rooms and there is adequate external light in communal areas. Restraint minimisation and safe practiceIncludes 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.Staff receive training around restraint minimisation and the management of challenging behaviour. The service has appropriate procedures and documents for the safe assessment, planning, monitoring and review of restraint and enablers. There were no residents using enablers or restraints.Infection prevention and controlIncludes 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.Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and as part of the ongoing in-service education programme. The GHG clinical coordinator is the infection control coordinator with support from the registered nurse. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner. There have been no outbreaks since the previous audit. Summary of attainmentThe following table summarises the number of standards and criteria audited and the ratings they were awarded.Attainment RatingContinuous Improvement(CI)Fully Attained(FA)Partially Attained Negligible Risk(PA Negligible)Partially Attained Low Risk(PA Low)Partially Attained Moderate Risk(PA Moderate)Partially Attained High Risk(PA High)Partially Attained Critical Risk(PA Critical)Standards14103000Criteria18903000Attainment RatingUnattained Negligible Risk(UA Negligible)Unattained Low Risk(UA Low)Unattained Moderate Risk(UA Moderate)Unattained High Risk(UA High)Unattained Critical Risk(UA Critical)Standards00000Criteria00000Attainment against the Health and Disability Services StandardsThe following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.For more information on the standards, please click HYPERLINK "" here.For more information on the different types of audits and what they cover please click HYPERLINK "" here.Standard with desired outcomeAttainment RatingAudit EvidenceStandard 1.1.1: Consumer Rights During Service DeliveryConsumers receive services in accordance with consumer rights legislation.FABrookhaven are implementing the requirements that align with of the Code of Health and Disability Services Consumers’ Rights (the Code). Families and residents are provided with information on admission, which includes information about the Code. Staff receive training about resident rights at orientation and as part of the annual in-service programme. Interviews with care staff (eight caregivers, the clinical coordinator, two registered nurses, a diversional therapist and activities assistant) confirmed their understanding of the Code. Six rest home level residents and five dementia relatives interviewed confirmed that staff respect privacy, and actively encourages and support residents in making choices. Standard 1.1.10: Informed ConsentConsumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.PA LowThere are established informed consent policies/procedures and advanced directives. General written consents are obtained on admission and include outings and indemnity, photographs and treatment and care. Specific consents are obtained for specific procedures such as influenza vaccine. All nine resident files reviewed (five hospital including one resident under ACC and one respite care and four dementia care including one under the Mental Health Act) contained signed consents. Resuscitation status for competent rest home residents had been signed appropriately. Where residents were deemed to be incompetent a medically indicated resuscitation status was made by the GP in consultation with the enduring power attorney (EPOA). Copies of EPOA were in the rest home resident files where available. There were copies of EPOA in three of four dementia resident files. One resident was under the Mental Health Act. Two of three long-term dementia care residents did not have the EPOA activated. A medical care guidance plan is documented by the GP for dementia care residents in consultation with the next of kin. Advance directives where known and available, were sighted in the resident’s files. Resident admission agreements including a respite short-term agreement had been signed. Standard 1.1.11: Advocacy And SupportService providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.FAResidents are provided with a copy of the Code of Health and Disability Services Consumer Rights and advocacy pamphlet on admission. Interviews with residents and family confirmed they were aware of their right to access advocacy. Advocacy pamphlets are displayed in the main corridor. Advocacy is regularly discussed at resident/relatives’ meetings (minutes sighted).Residents interviewed confirmed they are aware of their right to access independent advocacy services. Discussions with relatives confirmed the service provided opportunities for the family/EPOA to be involved in decisions. The resident files include information on residents’ family/whānau and chosen social networks. Standard 1.1.12: Links With Family/Whānau And Other Community ResourcesConsumers are able to maintain links with their family/whānau and their community. FAResidents and relatives interviewed confirmed open visiting. Visitors were observed coming and going during the audit. The activities programme includes opportunities to attend events outside of the facility. Residents are supported and encouraged to remain involved in the community. Relatives and friends are encouraged to be involved with the service and care. Standard 1.1.13: Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. FAThe service has a complaints policy that aligns with Right 10 of the Code and describes the management of the complaints process. Complaints forms are available. Information about complaints is provided on admission. Interviews with all residents and relatives confirmed their understanding of the complaints process. Staff interviewed were able to describe the process around reporting complaints.A complaint register includes written and verbal complaints, dates and actions taken. The manager documents verbal complaints and these are managed as with written complaints. The clinical manager for GHG conducts investigations into complaints that involve resident cares. Complaints are being managed in a timely manner, meeting requirements determined by the Health and Disability Commissioner (HDC). There is evidence of lodged complaints being discussed in manager and staff meetings. Two complaints for 2018 and four complaints from 2019 year to date have been responded to and managed appropriately with letters of acknowledgement, investigations, staff meetings and memos and letters of response and outcomes to complainants. Management operate an ‘open door’ policy. Standard 1.1.2: Consumer Rights During Service DeliveryConsumers are informed of their rights.FAThere is an information pack given to prospective residents and families that includes information about the Code and the nationwide advocacy service. There is the opportunity to discuss aspects of the Code during the admission process. Residents and relatives interviewed confirmed that information had been provided to them around the Code. Large print posters of the Code and advocacy information are displayed throughout the facility. The facility manager (FM) or clinical coordinator or registered nurses discuss the information pack with residents/relatives on admission. Families and residents are informed of the scope of services and any liability for payment for items not included in the scope. This is included in the service agreement. Standard 1.1.3: Independence, Personal Privacy, Dignity, And RespectConsumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.FAA tour of the premises confirmed there were areas that support personal privacy for residents. During the audit, staff were observed to be respectful of residents’ privacy by knocking on doors prior to entering resident rooms. Staff could describe definitions around abuse and neglect that aligned with policy. An annual resident satisfaction survey was completed in March 2018 and the results showed that the vast majority of respondents reported overall resident experience as being good or very good. Residents and relatives interviewed confirmed that staff treat residents with respect. A further survey was completed in March 2019 and results are pending. The service has a philosophy that promotes quality of life and involves residents in decisions about their care. Resident preferences are identified during the admission and care planning process and this includes family involvement. Interviews with residents confirmed their values and beliefs were considered. Staff attend education and training on abuse and neglect. Interviews with caregivers described how choice is incorporated into resident cares. Standard 1.1.4: Recognition Of Māori Values And BeliefsConsumers 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.FAThe Māori health plan for the organisation references local Māori health care providers regionally within New Zealand and provides recognition of Māori values and beliefs. Family/whānau involvement is encouraged in assessment and care planning, and visiting is encouraged. Links are established with disability and other community representative groups as requested by the resident/family. Cultural needs are addressed in the care plan. There are currently two residents who identify as Māori. Their Iwi and support groups are recorded on file with an individual health care plan tailored to meet Māori cultural requirements. Care plans included access to the Māori language with supporting music and cultural groups. One resident has Māori songs downloaded to a portable player which is used to de-escalate behaviours.Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And BeliefsConsumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. FAAn initial care-planning meeting is carried out where the resident and/or whānau as appropriate are invited to be involved. Individual beliefs or values are discussed and incorporated into the care plan. Six monthly multi-disciplinary team meetings occur to assess if needs are being met. Family are invited to attend. Discussions with relatives confirmed that residents’ values and beliefs are considered. Residents interviewed confirmed that staff consider their values and beliefs.Standard 1.1.7: DiscriminationConsumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.FAJob descriptions include responsibilities of the position and signed copies of all employment documents were included in the nine staff files sampled. Staff comply with confidentiality and the code of conduct. The registered nurses and allied health professionals’ practice within their scope of practice. Management and staff meetings include discussions on professional boundaries and concerns/complaints as they arise (minutes sighted). Interviews with the manager, the registered nurses and care staff confirmed an awareness of professional boundaries. Standard 1.1.8: Good PracticeConsumers receive services of an appropriate standard.FABrookhaven policies and procedures align with current accepted best practice. The content of policy and procedures are sufficiently detailed to allow effective implementation by staff. Staff are made aware of new/reviewed policies and sign to indicate they have read them. An environment of open discussion is promoted. Staff reported the manager and registered nurses are approachable and supportive.An annual in-service training programme is implemented as per the training plan with training for registered nurses from the DHB and involvement in the Careerforce programme for all care and housekeeping staff. Staff complete relevant workplace competencies as appropriate to their role including but not limited to: hand hygiene, manual handling, wound management, neurological observations, fire warden and medication.Golden Healthcare Group identifies annual key performance indicators, which are based on evidence and best practice. Clinical indicators are benchmarked between all homes and service levels. Quality and clinical governance is provided at combined managers meetings and training days. Residents’ falls are analysed and discussed in detail at clinical staff and quality meetings. Feedback is provided to staff via the various meetings. Brookhaven staff are continually identifying areas for improvement and incorporating improved practises into everyday activities. Strategies for individual residents have been successfully developed and implemented to address behaviour management associated with activities of daily living. Buffet breakfasts have been implemented for both dementia and rest home units. Residents in the dementia unit can choose to have their bedroom doors painted in their preferred colour. Allied health professionals are available to provide input into resident care. The registered nurses have access to external training. Discussions with residents and family were very positive about the care they receive. Standard 1.1.9: CommunicationService providers communicate effectively with consumers and provide an environment conducive to effective communication.FAThere is an accident/incident reporting policy to guide staff in their responsibility around open disclosure. Staff are required to record family notification when entering an incident into the system. All 20 adverse events reviewed met this requirement. Family members interviewed confirmed they are always notified following a change of health status of their family member. A family meeting is held three monthly for the families of dementia residents, two monthly for rest home residents. A regular newsletter ensures residents and families are kept informed of communal activities and special events.There is an interpreter policy in place and contact details of interpreters were available. Standard 1.2.1: GovernanceThe governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.FABrookhaven Retirement Village provides care for up to 92 rest home and dementia specific residents. On the day of audit, there were 79 residents – 47 rest home including three respite residents and one under an ACC contract and 32 dementia (across two units) including one resident under the mental health act. All other residents are under an age related residential care contract. The manager is an experienced aged care manager who has been in the role for four years. Golden Healthcare Group (GHG) organisation has a corporate services manager who oversees all eight Christchurch based facilities. The organisation employs a quality assurance manager, an operations and human resource manager and an acting clinical manager who each work across all facilities and provide support to the manager and registered nurses at Brookhaven. One of three clinical coordinator positions reporting to the acting clinical manager actively supports the registered nurses at Brookhaven. There is also an assistant manager at Brookhaven.Golden Healthcare Group has comprehensive quality and risk management systems implemented across its facilities. There is an overall GHG group strategic plan for 2019 to 2024 that includes development of new facilities, external audits, provision of a comprehensive range of services and occupancy. The GHG quality and risk management programme for 2019 includes a quality programme for Brookhaven Retirement Village with clearly defined goals and objectives. Additional quality improvement projects have been developed and are being implemented. Annual reviews are conducted of the quality and risk programme - last conducted January 2019. Across GHG, benchmarking groups are established for facilities with similar service levels. Benchmarking of key clinical quality and incident data is conducted. The manager has completed at least eight hours of professional development relating to managing an aged care facility. Standard 1.2.2: Service Management The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers. FAThe assistant manager provides cover in the absence of the manager as required. The GHG management team also provide assistance and support to the manager, registered nurses and care staff.Standard 1.2.3: Quality And Risk Management SystemsThe organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.FAAn established quality and risk management system is embedded into practice. Quality and risk performance is reported across facility meetings and to the quality manager. Discussions with the managers reflected staff involvement in quality and risk management processes.Rest home resident meetings are two monthly and family meetings for the dementia unit are held three monthly. Minutes are maintained. Annual resident and relative surveys are completed with results communicated to residents and staff. Survey results reflect excellent results in all areas.The service has policies and procedures, and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards, including those standards relating to the Health and Disability Services (Safety) Act 2001. Policies are reviewed two yearly in consultation with relevant expertise. Clinical guidelines are in place to assist care staff. Updates to policies and procedures are introduced at staff meetings and circulated to all staff. The quality-monitoring programme is designed to monitor contractual and standards compliance, and the quality of service delivery at Brookhaven and across the organisation. Goals and objectives for 2018 have been completed and data collated against the other GHG homes. Goals for 2019 have been documented. The service collates accident/incident and infection control data. Monthly comparisons, trends and graphs are displayed for staff information (link 1 2.4.3). An internal audit programme covers all aspects of the service. Any areas for improvement are identified and implemented. A monthly summary of internal audit outcomes is provided to the staff meetings for discussion. Corrective actions are developed, implemented and signed off. Reviews and audits are conducted more frequently where issues are identified. The manager reviews corrective actions to ensure that changes have been imbedded in practice. The registered nurse and caregivers interviewed were aware of quality data results, trends and corrective actions. Health and safety policies are implemented and monitored by the health and safety committee. The health and safety representative interviewed confirmed his understanding of health and safety processes. He has completed the external health and safety training. Risk management, hazard control and emergency policies and procedures are in place. The hazard register is reviewed at health and safety meetings and annually in December. There are procedures to guide staff in managing clinical and non-clinical emergencies. The service documents and analyses incidents/accidents, unplanned or untoward events and provides feedback to the service and staff so that improvements are made. Staff confirmed they are kept informed on health and safety matters at meetings.Falls prevention strategies are in place including sensor mats and individual interventions.Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. PA LowThere is an incident/accident reporting policy that includes definitions, and outlines responsibilities including immediate action, reporting, monitoring, corrective action to minimise and debriefing. Staff have received training on completion of incident forms. Accidents/incidents were also recorded in the resident progress notes. The service reports aggregated figures to the staff/quality meeting and the quality and risk management meeting. Staff interviewed confirm incident and accident data are discussed at the staff meeting and information and graphs are made available. A review of twenty incident/accident forms for the month of March 2019 identified that forms were fully completed and include immediate follow-up by a registered nurse. However, investigation and opportunities to minimise future events were not always documented. Neurological observations have been carried out two-hourly for any suspected injury to the head. The clinical coordinator and acting clinical manager is involved in the adverse event process.The facility manager was able to identify situations that would be reported to statutory authorities including (but not limited to) infectious diseases, serious accidents and unexpected death. Section 31 forms have been completed for three pressure injuries and one absconding with police involvement and one accidental death which the MOH have referred to the DHB for further investigation. 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. FAHuman resources policies include recruitment, selection, orientation and staff training and development. Nine staff files reviewed (the clinical coordinator, two registered nurses, three caregivers, the cook, a diversional therapist and a housekeeper) included a comprehensive recruitment process which included reference checking, signed employment contracts and job descriptions, police checks, completed orientation programmes and annual performance appraisals.A register of registered nursing staff and other health practitioner practising certificates is maintained.The orientation programme provides new staff with relevant information for safe work practice. Staff interviewed advised that new staff were adequately orientated to the service on employment. There is an implemented annual education and training plan that exceeds eight hours annually. The manager holds overall responsibility for staff education. There is an attendance register for each training session. The assistant manager maintains comprehensive spreadsheets of attendance and competency attainment for all staff. Records sighted demonstrate a high attendance. There are 38 caregivers employed across Brookhaven, with 30 who regularly work in the dementia unit. All 30 have completed the required dementia unit standards. A staff education board in the foyer of the main entrance displays staff qualificationsRegistered nurses are supported to maintain their professional competency. Three registered nurses plus the clinical coordinator have completed their interRAI training. There are implemented competencies for registered nurses including (but not limited to) medication competencies, insulin and wound competencies. Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.FAGolden Healthcare Group policy includes staff rationale and skill mix. Sufficient staff are rostered on to manage the care requirements of the residents. Staff interviewed stated there were adequate staff numbers on each duty to meet the resident needs as per the care plans. The facility manager is on duty Monday to Friday and on-call at all times. An RN is on call for clinical support. Advised that extra staff can be called on for increased resident requirements. Bureau staff are used as a last resort. The acting CM for the organisation and the clinical coordinator for Brookhaven are available to offer support and guidance. The clinical coordinator visits Brookhaven 2 to 3 times a week.Activities staff cover week days and a number of volunteers provide weekend activities such as pet therapy and church services. There are dedicated staff responsible for the kitchen, housekeeping and laundry services. Maintenance staff attend the site weekly and as needed and are based at head office.Staffing for the rest home with 47 current residents across three wings is as follows: Morning shift – one RN (Monday to Friday) and four caregivers (three long and one seven-hour shift). On afternoon shift there is one RN (four afternoons per week) and four caregivers (two long and two short). There is two caregivers on at night.The two dementia wings are staffed separately. One RN is rostered over the two dementia units 8.00 am to 4.30 pm five days a week and a second RN covers 2.00 pm to 9.30 pm four days a week. Sumner with 12 residents, rosters two caregivers (both long) on morning shift and two caregivers on afternoon shift (one long and one short) and one caregiver on night shift. Hillview with 20 current resident rosters three full shift caregivers on morning shift and three caregivers (two long and one short) on afternoon shift. There are two caregivers on night shift.Golden Healthcare Group has a group of registered nurses who provide afterhours on-call cover to facilities. The caregivers and family interviewed informed there are sufficient staff on duty at all times.Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.FAThe resident files are appropriate to the service type. All relevant initial information is recorded within required timeframes into the resident’s individual record. All resident records containing personal information is kept confidential. Entries were legible, dated and signed by the relevant caregiver or registered nurse including designation. Files are integrated. Standard 1.3.1: Entry To Services Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified.FAResidents are assessed prior to entry to the service by the need’s assessment team or older persons mental health services for admission to the dementia unit. The service maintains and enquiry list. The service has specific information available for residents/families/EPOA at entry and it included associated information such as the Health and Disability Code of Rights, advocacy and complaints procedure. There is information around the secure environment and potential behaviours of dementia care residents. An admission checklist also identifies a resident and relative orientation to the facility and services provided. The resident’s admission agreement evidenced resident and/or family and facility representative sign off. The admission agreement reviewed aligned with the ARC contract and exclusions from the service were included in the admission agreement.Standard 1.3.10: Transition, Exit, Discharge, Or Transfer Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. FAThe emergency policy outlines the procedures around transferring and what has to occur, depending on the reason for transfer. The manager is consulted prior to any resident transfer. The transfer/discharge/exit procedures included a transfer/discharge form and the completed form placed on file. All copies of documentation were forwarded with the resident and a copy on the resident file.Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.FAMedication policies align with accepted guidelines. The RNs and senior caregivers are responsible for the administration of medications in the rest home and dementia care units. Registered nurses and senior HCAs complete competencies for the administration of medications. Medications are stored safely in the rest home and dementia units. Registered nurses check the blister packs on delivery. All medications are prescribed for the residents. No impress stock is held and there are no standing orders. There were no residents self-medicating on the day of audit. The medication fridge temperature is monitored weekly. Eyedrops were dated on opening. Seventeen medication charts on the electronic medication system and one paper-based medication chart (for the respite care resident) were reviewed. All medication charts had photo identification and allergy status. All medication charts had been reviewed three monthly by the GP. Administration signing sheets corresponded with the medication chart. ‘As required’ medications charted recorded indications for use. The effectiveness of medications was recorded in the electronic medication system and in the progress notes. Standard 1.3.13: Nutrition, Safe Food, And Fluid ManagementA consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery. FAAll meals at Brookhaven are prepared and cooked on site by two qualified cooks who are supported by an on-call cook, morning and afternoon kitchenhands. All staff have completed food safety training. A five-weekly seasonal menu has been reviewed by a dietitian. The main meal is at midday and the menu includes resident preferences. Meals are plated and served from the kitchen which is adjacent to the rest home dining room. Meals are delivered in hot boxes to the dementia care units and plated and served by care staff. The cook receives nutritional profiles for all residents and updated with any changes. The menu accommodates diabetic desserts, vegetarian and pureed meals. Resident dislikes are known and accommodated. There are nutritious snacks and finger foods delivered to the dementia units including fruit platters, sandwiches and ice-cream and home-baking. The food control plan has been verified and expires 2 July 2019. Food is stored appropriately in the kitchen and pantry and is labelled and dated. The fridge, freezer and hot food end temperatures are recorded daily. The dishwasher temperatures and function are checked at least monthly by the chemical provider. A daily cleaning schedule is maintained. Family/resident meetings and surveys allow the opportunity for feedback on the meals and food services generally. Family members and residents interviewed indicated satisfaction with the food service. Standard 1.3.2: Declining Referral/Entry To Services Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate. FAThe reason for declining service entry to potential residents would be recorded and when this has occurred, the service stated it had communicated to the potential resident/family/EPOA and the appropriate referrer. Advised by the registered nurses that potential residents would be declined if not within the scope of the service or if a bed was not available.Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.FAAll residents are admitted with an InterRAI assessment completed by the need’s assessment and service coordination team prior to admission. Personal needs information, medical history and allied health input and consultation with the resident/family or significant other gathered during admission, forms the basis of resident goals and objectives. Risk assessments are completed on admission and evaluated as part of the initial care plan review. Behaviour assessments had been completed on admission and six monthly for the four-dementia files reviewed. The registered nurses (RN) complete the first interRAI assessment and six monthly thereafter or with any significant change to health. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.FAResident files include all required documentation. The long-term care plan records the resident’s problem/need and objectives (link 1.3.6.1). The outcomes of the interRAI assessments were linked to the care plans and interventions documented to achieve the resident goals. The four dementia care resident files contained care plans for dementia unit residents that included the resident behaviours, triggers, interventions including de-escalation techniques and activities. Short-term care plans are used for short-term needs and evaluated regularly and either resolved or added to the long-term care plan if an ongoing problem. Resident files reviewed, identified that the resident (as appropriate) and family were involved in the care plan development and ongoing care needs of the resident. Families interviewed confirmed their involvement in the care planning process. Care plans included allied health involvement in the care of the resident. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.PA LowWhen a resident's condition alters, the registered nurses initiate a review and if required a GP consultation or referral to the appropriate health professional. Residents and relatives interviewed, stated the residents’ needs are being met. Significant events and communication with families are documented on the family consultation record and in progress notes for all incidents, infections, GP visits, medication changes, appointments and health changes. Short-term care plans are utilised for short-term needs and supports. These are evaluated regularly to monitor progress against the interventions to meet the resident needs/goals. Not all long-term care plans are updated to reflect changes in care and supports required to meet the resident needs/goals. Dressing supplies were available, and a treatment room stocked for use. Wound assessment, treatment plan (including dressing type and frequency of dressing changes) and evaluation notes were in place for rest home and dementia care residents with wounds. Wound change of dressings and evaluations had occurred at the required frequency, however not all wounds had documented sizes to monitor healing progress. There were no pressure injuries. A Nurse Maude wound nurse can be accessed for advice and wound training. Continence products were available and resident files included a urinary continence assessment, bowel management, and documented most continence products identified for day use, night use, and other management. Monitoring charts/forms are in use to monitor progress including vital observations, weight, food and fluid, behaviour reporting chart, re-positioning charts, catheter monitoring forms and the checking of whereabouts of residents as required. Standard 1.3.7: Planned ActivitiesWhere 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.CIThere are three qualified diversional therapists who coordinate and implement the activity programme in each of the units. The rest home DT is on duty from 9.00 am to 4.30 pm Monday to Friday. The programme is planned monthly and residents receive a personal copy of planned monthly activities. Activities planned for the day were displayed on noticeboards around the facility. Activities offered in the rest home included (but were not limited to); word games, board game, walking club, exercise to music, hand cares, arts and crafts, barbeque lunches, bowls and happy hours. There are van drives and outings to community clubs. Some activities such as men’s group, entertainment and events are integrated with dementia are residents attending (as appropriate) under supervision. There is an activity person who covers all the units in the weekends with some activities such as movies and entertainment planned in advance. One-on-one time is spent with residents who prefer to stay in their rooms. The environment has been enhanced by many wall hangings that prompt discussion and interest. There is a DT in each dementia unit from 10.00 am to 5.00 pm. Activities offered include music, dancing, walking, bowls, ball games, newspaper time, van outings and happy hour. The activity team have initiated a pet friendly environment with meaningful activities including animal care. A sensory room has been set up which has helped with reducing challenging behaviours. A 24-hour diversional therapy plan has been developed for each individual resident based on assessed needs. Community visitors to the service include school groups, kapa haka group, singing groups, churches and youth groups.A resident profile is completed on admission. Each resident has an individual activity plan which is reviewed at the same time as the care plan. Family meetings and the resident/relative survey provide a forum for feedback relating to activities as well as resident verbal feedback. Family members and residents interviewed discussed enjoyment in the programme. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner.FALong-term care plans (including the resident under ACC) have been evaluated. One rest home and one dementia care resident (under the Mental Health Act) had not been at the service six monthly. Short-term care plans are utilised for residents and any changes to the long-term care plan were dated and signed. Multidisciplinary review notes are recorded, and evidence input from the RN, GP, DT and resident/relative. Evaluations record the degree of achievement of goals and interventions. Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External)Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs. FAThe service facilitates access to other services (medical and non-medical) and where access occurred, referral documentation is maintained. Residents and/or their family/EPOA are involved as appropriate when referral to another service occurs. There was evidence of referrals to needs assessment for re-assessment of level of care. Family communication sheets confirmed family involvement. Standard 1.4.1: Management Of Waste And Hazardous Substances Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.FAThere are policies and procedures in place for waste management and hazardous substances to ensure incidents are reported in a timely manner. Safety data sheets and products charts are readily accessible for staff. There are designated areas for storage of chemicals and chemicals are stored securely. There is a spill kits available. There are two sluice rooms with personal protective clothing available. There is a chemical mixing system in place. Chemical bottles sighted have correct manufacturer labels. Personal protective clothing is available for staff and was observed being worn by staff they were carrying out their duties on the day of audit. Relevant staff have attended chemical safety training. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.FAThe facility is divided into two dementia units – one with 14 beds (Sumner) and one with 27 beds (Hillview). The rest home area has three wings with 51 rooms. The service has a current building warrant of fitness, which expires on 1 July 2019. The property maintenance manager has been in the role over five years and covers eight Golden Age Group (GHG) sites. He completes monthly audits of each site. At Brookhaven there is a property assistant who completes and signs off any requests for repairs. There is a planned maintenance schedule in place that covers internal and external building maintenance, resident related equipment, facility equipment and monthly hot water checks. All electrical equipment has been tested and tagged and clinical equipment calibrated. There are essential contractors available 24 hours. The gardens and grounds are maintained by a gardening group employed by GHG. There have been ongoing refurbishments including new curtains, lighting and new age appropriate armchairs in the rest home lounges. Residents were observed safely mobilising throughout the facility. There is safe and easy access to the outdoors and courtyards with seating and shade available. The dementia unit residents (in both units) can access secure outdoor pathways, gardens, raised garden beds, seating and shade. In the grounds of the Hillview there is a chicken house and rabbit hutches. Interviews with the registered nurses and the caregivers confirmed that there was adequate equipment to carry out the cares according to the residents’ care plans.Standard 1.4.3: Toilet, Shower, And Bathing FacilitiesConsumers 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.FAAll rooms have full ensuite facilities. The number of visitor and resident communal toilets (near communal areas) provided is adequate. Hand washing and drying facilities are available in all toilets. Fixtures, fittings and floor and wall surfaces are made of accepted materials to support good hygiene and infection prevention and control practices. Rest home residents interviewed confirmed staff respected their privacy when carrying out hygiene cares. Standard 1.4.4: Personal Space/Bed Areas Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. FAThe rooms are spacious enough to meet the assessed needs of residents. Residents are able to safely manoeuvre mobility aids around their bed and personal space areas. All beds are of an appropriate height for the residents. Caregivers interviewed reported that rooms have sufficient space to allow cares to take place. Bedrooms are personalised. Bedroom doors in both dementia units have been painted in bright individual colours chosen by the residents. This has brightened up the environment and has aided some residents to identify their own room. Standard 1.4.5: Communal Areas For Entertainment, Recreation, And DiningConsumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.FAThere is a rest home lounge with conservatory which opens out onto a courtyard with seating and shade. There is also a smaller lounge available for activities or visitors. Rest home residents have two dining areas with tea/coffee making facilities for families. The dining rooms are spacious, and located directly off the kitchen/servery areas. All areas are easily accessible for residents with ramps and rails in place to the outdoors. Residents were seen to be moving freely both with and without assistance throughout the audit. There are many seating alcoves throughout the facility providing areas for rest stops. Both dementia units have lounge and dining areas with kitchenettes where meals are plated and served. The sensory room is located in Sumner (14 bed) unit (link CI 1.3.7), and in the larger unit (Hillview) there is a large dining room and a large lounge with doors that open out onto the courtyard.Standard 1.4.6: Cleaning And Laundry ServicesConsumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.FAThere are documented systems for monitoring the effectiveness and compliance with the service policies and procedures. There is a separate laundry area where all personal clothing is laundered. The laundry is located within the Hillview dementia care unit. There is a defined clean/dirty area and an external entrance for dirty rest home laundry. A contracted company collects and launders linen off site. Clean linen is delivered three times a week. Housekeeping staff launder, iron and label personal clothing as required. Housekeeping trolleys sighted were well equipped and kept in locked cupboards when not in use. The chemical provider completes checks on the effectiveness of chemicals in the laundry and cleaning services. Staff attend infection prevention and control education and there is appropriate protective clothing available. Cleaners are employed seven days a week. Manufacturer’s data safety charts are available in the work area. Housekeeping staff have completed Careerforce level two and circle of safety laundering/cleaning courses. Residents and family interviewed reported satisfaction with the laundry service and cleanliness of the facility.Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations.FAThe service has a fire and emergency procedures manual. The New Zealand Fire Service approved the evacuation scheme on 12 January 2011. The last fire drill was conducted in March 2019. There is at least one person with a first aid certificate on each shift. Fire safety and emergency training has been provided. There is a call bell system in place. A civil defence kit is stocked and checked monthly. Water is stored, sufficient for at least three days. Alternative heating and cooking facilities are available. Emergency lighting is installed. Staff conduct checks of the building in the evenings to ensure the facility is safe and secure. The facility has gas cooking. There are emergency management plans in place to ensure health, civil defence and other emergencies are included. Standard 1.4.8: Natural Light, Ventilation, And Heating Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.FAAll communal and resident bedrooms have external windows with plenty of natural sunlight. The facility has central and underfloor heating. Electric panel heaters in bedrooms can be individually adjusted. There are air conditioning units. The general living areas and resident rooms were appropriately heated and ventilated on the day of audit. Family and residents interviewed stated the environment is comfortable.Standard 3.1: Infection control managementThere 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. FAGHG Brookhaven has an established infection control programme. The infection control programme, its content and detail, is appropriate for the size, complexity and degree of risk associated with the service. It is linked into the incident reporting system and the GHG group KPIs. The clinical coordinator for Brookhaven is the designated infection control nurse with support from the acting clinical manager and quality assurance manager and the combined health and safety and infection control committee. Minutes are available for staff. Audits have been conducted and include hand hygiene and infection control practices. Education is provided for all new staff on orientation. The infection control programme has been reviewed annually.Standard 3.2: Implementing the infection control programmeThere are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.FAThe clinical coordinator at Brookhaven is the designated infection control (IC) nurse. There are adequate resources to implement the infection control programme for the size and complexity of the organisation. The IC nurse and IC team (comprising the quality and health and safety team) has good external support from the local laboratory infection control team and IC nurse specialist at the DHB. The infection control team is representative of the facility. Infection prevention and control is part of staff orientation and induction. Hand washing facilities are available throughout the facility and alcohol hand gel is freely available. Standard 3.3: Policies and proceduresDocumented 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.FAThere are Golden Health Group infection control policies and procedures appropriate to for the size and complexity of the service. The infection control manual outlines a comprehensive range of policies, standards and guidelines and includes defining roles, responsibilities and oversight, the infection control team and training and education of staff. The policies were developed by the GHG management team and have been reviewed and updated by the DHB nurse specialist. The policies are reviewed and updated at least two yearly.Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers.FABrookhaven is committed to the ongoing education of staff and residents. The Brookhaven GHG infection control nurse with support from the registered nurse facilitates education. All infection control training has been documented and a record of attendance has been maintained. Information was provided to residents and visitors that are appropriate to their needs and this was documented in medical records. Education around infection prevention and control has been provided in 2018 and 2019. Standard 3.5: SurveillanceSurveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.FAInfection surveillance is an integral part of the infection control programme and is described in GHGs infection control manual. Monthly infection data is collected for all infections based on signs and symptoms of infection. An individual resident infection form is completed which includes signs and symptoms of infection, treatment, follow-up, review and resolution. Short-term care plans are used. Surveillance of all infections is entered onto a monthly infection summary. This data is monitored and evaluated monthly and annually and is provided to GHG head office. Infections are part of the key performance indicators. Outcomes and actions are discussed at quality meetings and staff meetings and plans and interventions resulting from surveillance create improvements. If there is an emergent issue, it is acted upon in a timely manner. Reports are easily accessible to the facility manager. There have been no outbreaks since the previous audit.Standard 2.1.1: Restraint minimisationServices demonstrate that the use of restraint is actively minimised. FAThe service is committed to restraint minimisation, and safe practice was evidenced in the restraint policy and interviews with clinical staff. A restraint coordinator (clinical coordinator) who is the registered nurse oversees restraint minimisation. Staff training is in place around restraint minimisation and enablers, falls prevention and analysis and management of challenging behaviours. There are currently no residents requiring restraint and enablers. Specific results for criterion where corrective actions are requiredWhere a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded.Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights.If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit.Criterion with desired outcomeAttainment RatingAudit EvidenceAudit FindingCorrective action required and timeframe for completion (days)Criterion 1.1.10.7Advance directives that are made available to service providers are acted on where valid.PA LowAll long-term rest home residents had copies of EPOA on their file. One of four dementia care files had an activated EPOA. One resident was under the Mental Health Act. Two residents had an EPOA, however these had not been activated. Two dementia care residents did not have the EPOA activated. Ensure EPOAs are activated for dementia care residents. 90 daysCriterion 1.2.4.3The 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.PA LowAll adverse events are documented on an electronic register and included registered nurse input, however not all events included full investigation and opportunities to minimise future events. Fifteen of twenty (7 rest home and 13 dementia) incident forms reviewed did not include investigation and opportunities to minimise future events. Ensure investigation is completed and opportunities to minimise future events are identified. 90 daysCriterion 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 LowFour dementia level resident files reviewed evidenced that interventions aligned with the residents’ assessed needs including behaviour charts and behaviour management plans including the use of activities for de-escalation of behaviours. Three of five rest home resident care plans did not have documented/implemented interventions. There were five dementia care residents with skin tears and three rest home residents with wounds (one skin tear, one graze and one non-healing lesion). Wound care documentation was in place for all wounds including photos, however there were no measurements/sizes of wounds documented for rest home residents with wounds. 1) There were no documented pain interventions for two long-term rest home residents; a) The pain management plan did not identify the type and location of pain as per the pain assessment and b) there were no documented interventions for another rest home resident with pain following a fall requiring GP intervention and c) the respite care resident had not been weighed on admission and there were no documented interventions for the signs/symptoms and diabetic management for the respite resident who was an insulin dependent resident. 2) There were no wound measurements/sizes for three of three rest home wounds.1) Ensure that all cares and interventions are documented/implemented for residents assessed needs. 2) Ensure that wound assessments and evaluations include the wound measurement/size. 60 daysSpecific results for criterion where a continuous improvement has been recordedAs well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded.As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit.Criterion with desired outcomeAttainment RatingAudit EvidenceAudit FindingCriterion 1.3.7.1Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.CIThere have been several quality improvement initiatives set up in consultation with the manager and DT team. Initiatives which have been successful is the pet friendly Hillview dementia care unit, development of a sensory unit, wall hangings around the facility that enhance the environment and buffet breakfast in Hillview. 1) The Hillview dementia care unit is the facility pet friendly area. There is a chicken coup in the back area of the courtyard and residents collect the eggs and feed the chickens. Two large rabbits also live in the courtyard and were in the lounge (within their play pen) entertaining the residents on the day of audit. The latest addition to the pet family is a lorikeet named by residents as “Sammy”. Sammy comes out of his cage each day and loves to sit on residents’ shoulders. He has been taught several words and the residents enjoy chatting to Sammy. The pet therapy plan has been successful as many residents had pets and they now participate in caring for the pets. 2) A sensory room was developed within the smaller dementia care unit where the residents require more one-on-one time including distraction and low stimulus environment. The sensory room (viewed) focuses on the senses and provides a soothing and calming environment. The room is set up with soft lighting, relaxing chair, music, and an outlook onto rose gardens. Sensory frames have been developed with many textures. The files of two residents who regularly spend time with the DT in the sensory room evidenced a positive effect on the resident with reduction of behaviours. 3) The manager trialled a purchase of several wall hangings that are displayed using curtain rods. The wall hangings are able to be changed and reflect seasons, events and celebrations such as autumn and poppies for the upcoming ANZAC day celebrations. Changing of the wall hangings effectively changed the look of the environment and prompted discussion and reminiscing among residents and their families.The 2018 resident survey for activities was 100% and relative survey result for activities was 94%.End of the report. ................
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