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CRK Holdings Limited - Janelle Rest Home

Introduction

This 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 Q-Audit Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity: CRK Holding Limited

Premises audited: Janelle Rest Home

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 1 May 2018 End date: 2 May 2018

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 14

CRK Holdings Limited - Janelle Rest Home Date of Audit: 1 May 2018 of 28

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

consumer rights organisational management continuum of service delivery (the provision of services) safe and appropriate environment restraint minimisation and safe practice infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator Description Definition

Includes commendable elements above the required levels of performance

All standards applicable to this service fully attained with some standards exceeded

No short falls Standards applicable to this service fully attained

Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity

Some standards applicable to this service partially attained and of low risk


Indicator Description Definition

A number of shortfalls that require specific action to address

Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk

Major shortfalls, significant action is needed to achieve the required levels of performance

Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Janelle Rest Home provides rest home services for up to 21 residents. On the day of audit there were 14 residents receiving care. The owner/manager/registered nurse commenced in the role in June 2017 and is responsible for managing the service with the assistance and support of a registered nurse. The registered nurse has been at this facility for four years. All the residents and family members interviewed spoke positively about the staff, personalised care and the standard of services received.

This certification audit was conducted against the Health and Disability Services Standards and the provider’s contract with the district health board. The audit process included a review of policies and procedures, the review of residents’ and staff records, observations and interviews with residents, family, staff and the general practitioner.

There are no areas identified in this audit that required improvement.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs.

Standards applicable to this service fully attained.


The Health and Disability Commissioner`s Code of Health and Disability Services Consumers` Rights (the Code) is made available to residents. Opportunities to discuss the Code, consent and availability of advocacy services is provided at the time of admission and thereafter as required.

There were two residents that identified as Maori residing at the service at the time of the audit. There are no known barriers to Maori residents accessing the service. Services are planned to respect the individual culture, values and beliefs of the residents.

There is no evidence of abuse, neglect or discrimination and staff understood and implemented related policies. Professional boundaries are maintained.

Open communication between staff, residents and families is promoted and confirmed to be effective. There is access to formal interpreting service if required.

The service has linkages with a range of specialist healthcare providers which contributes to ensuring services provided to residents are of an appropriate standard.

Staff, residents and family members are aware of the complaints process. Complaints are being addressed in a timely manner.

Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner.


The organisation`s vision values and mission are documented in the business plan. There is also a quality and risk plan. The owner/manager is on site weekdays or if not present is on call for staff. The manager has attended more than eight hours of education on managing a residential care service as required to meet the providers` contract with the DHB.


The quality programme includes compliments, complaints management, incident reporting and policy and procedure review. The quality and risk plan has been developed by an external consultant and personalised to reflect the needs of Janelle Rest Home. Policies are current and available to staff. The manager is responsible for document control processes. The risk management plan evidences the organisations risks are being identified, managed and reviewed. Any new hazards are reported and the hazard register reviewed is up to date. Where improvements are required following quality activities this occurs in a planned manner. The manager and the registered nurse are aware of the events that require essential notification. Regular resident and staff meetings occur.

Staff recruitment includes the applicant completing a job application. Reference and police checks are conducted. Annual performance reviews are in place for all employees and records of this are maintained. Staff have access to relevant ongoing education.

The staffing and skill mix requirements are implemented to ensure the residents` care needs are met. The requirements align with the provider`s contract with the DHB. A staff member with a current first aid certificate is rostered on each shift. The registered nurse is on site four days a week. There is medical cover from the contracted general practitioner seven days a week and after hours cover is available.

Residents` information is accurately recorded, securely stored and not accessible to the public. Up to date, legible and relevant residents` records are maintained in the integrated records reviewed.

Continuum of service delivery

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.



Residents entry into the service is facilitated by the manager and the registered nurse (RN). Access processes are clearly documented in the facility brochure and are communicated to the residents, their family/whanau of choice, local communities and referral agencies.

Each stage of service provision is provided within the required timeframes that safely meet the needs of the residents. The RN is responsible for the development of care plans. Residents and or their family/whanau are involved in the assessment, planning, evaluation and review of residents’ care. Continuity in service delivery is promoted by team approach and multidisciplinary approach to the provision of care.

The service has electronic medicine management system which was recently implemented. The medicine management system implemented manages prescribing, administration and review of medication safely. Three monthly medication reviews are conducted by the GP and discontinued medication is signed off. Medication reconciliation is completed by the RN. Appropriate documentation that complies with current legislative requirements and guidelines was sighted on the medicine charts sampled. Management of controlled drugs onsite is safe and complies with current legislative requirements and guidelines. Medication administration training is completed annually and staff training records are current. All staff who administer medication have current medication administration competency.

Residents who self-administer medication have been assessed to be competent by the GP. Self-medication administration competency is reviewed a regularly by the GP and the RN.

Food services are provided at the facility. All aspects of food procurement, preparation, storage, transportation and disposal comply with current legislation and guidelines. The cooks have relevant education.


Safe and appropriate environment

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.


The facility is well laid out with single rooms except for one double room. Some bedrooms have ensuite bathrooms and others are shared with additional showers and toilets being in close proximity to the residents` rooms. All rooms are of an adequate size to provide personal care.

Policies and procedures are available to guide staff in the safe disposal of waste and hazardous substances. Appropriate supplies of personal protective equipment are readily available for staff to use.

The building has a current building warrant of fitness. Clinical equipment in use has current calibration. Electrical safety checks of electrical appliances are current. The security arrangements and practices are appropriate and include security being maintained with surveillance cameras monitoring communal areas and the entrance. External areas are accessible, safe and provide shade and seating.

Laundry and cleaning is undertaken onsite and evaluated for effectiveness.

Staff are trained in emergency procedures, use of emergency equipment and supplies and attend regular fire drills held six monthly. Fire evacuation procedures are regularly practised. Residents reported a timely staff response to call bells.


Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation.


Janelle Rest Home has restraint minimisation and safe practice policies and procedures in place. Approved restraints/enablers are lap belts and bedsides. There were no restraints/enablers in use at the time of the audit. Restraint training for all staff is completed annually and this includes challenging behaviour management and de-escalation techniques. The RN is the restraint coordinator and has a current job description that was sighted.

Infection prevention and control

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme.


The infection prevention and control programme is led by the registered nurse and aims to prevent and manage infections. There are terms of reference for the infection control committee which meets quarterly. Specialist infection prevention and control advice is able to be accessed from the district health board, microbiologist and the general practitioner as required. The programme is reviewed on an annual basis.

Staff demonstrated good principles and practice around infection control which is guided by relevant policies and procedures and supported with regular education.


Aged care specific surveillance is undertaken, analysed, trended and results are reported and fed back to staff at the staff meetings. Follow-up action is taken when required.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating

Continuous Improvement

(CI)

Fully Attained(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)

Standards 0 45 0 0 0 0 0

Criteria 0 93 0 0 0 0 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome Attainment Rating

Audit Evidence

Standard 1.1.1: Consumer Rights During Service Delivery

Consumers receive services in accordance with consumer rights legislation.

FA Janelle Rest Home has developed policies and procedures and processes to meet its obligations in relation to the Code of Health and Disability Services Consumers` Rights (the Code). Staff interviewed understood the requirements of the Code and were observed demonstrating respectful communication, encouraging independence, providing options and maintaining dignity and privacy. Training on the Code is included as part of the orientation process for all staff employed and in ongoing training as was verified in the training records.

Standard 1.1.10: Informed Consent

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

FA A detailed informed consent policy is in place. The service ensures informed consent is part of the care plans and contact with families. Every resident has a choice to receive services, refuse services and withdraw consent for services. If a resident is cognitively alert they will decide on their own care and treatments unless they indicate they want representation. Informed consent is closely linked with the Residents` Code of Rights and Responsibilities.

The service provider ensures residents/family/enduring power of attorney (EPOA) understand documents that they are signing especially when English is their second language. Consent is obtained for photographs, outings and any procedures that may be required.


http://www.health.govt.nz/your-health/services-and-support/health-care-services/services-older-people/rest-home-certification-and-audits

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

The caregivers interviewed demonstrated their ability to provide information to residents required in order for the residents to be actively involved in their care and decision making. Staff interviewed acknowledged the residents’ right to make choices based on information presented to them. Staff were observed to gain consent for day to day care on an ongoing basis.

Standard 1.1.11: Advocacy And Support

Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice.

FA During the admission process residents are given a copy of the Code which also includes information on the advocacy service. Posters/pamphlets related to the Nationwide Advocacy Service were displayed in the entrance to the facility. Family members and residents interviewed were aware of the advocacy service and how to access this and their right to have a support person of their choice.

Staff are aware of how to access the advocacy service and education was provided as evidenced in the education plans and staff records reviewed.

Standard 1.1.12: Links With Family/Whānau And Other Community Resources

Consumers are able to maintain links with their family/whānau and their community.

FA Residents are assisted to maximise their potential for self-help and to maintain links with their family and the community by attending outings, activities and entertainment. Visitors are welcome and the facility has unrestricted visiting hours. Family members interviewed stated they felt welcome when they visited and comfortable in their dealings with staff and management.

Standard 1.1.13: Complaints Management

The right of the consumer to make a complaint is understood, respected, and upheld.

FA The complaints policy and associated forms meet the requirements of the Right 10 of the Code. The information is provided to residents and family on admission and there is a complaint information and forms available at the entrance to the facility.

The complaints register showed that seven verbal complaints in ten months have been received and that actions were taken as required through to an agreed solution. All complaints are documented and completed within the required timeframes specific in the Code. Action plans reviewed show any required follow up and improvements have been made where possible.

All residents and family members interviewed confirmed being aware of the complaints process. The residents and family identified they were happy with the services provided.

The manager is responsible for complaints management and follow up. All staff interviewed reported a sound understanding of the complaint process and what actions are required.


Standard 1.1.2: Consumer Rights During Service Delivery

Consumers are informed of their rights.

FA Residents interviewed repored being made aware of the Code and the Nationwide Health and Disability Advocacy Service through information provided and discussed with the registered nurse on admission. The Code is displayed at reception together with information on advocacy services and how to make a complaint and feedback forms.

Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect

Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence.

FA The residents and families confirmed that they receive services in a manner that has regard for their dignity, privacy, sexuality, spirituality and choices.

Staff understood the need to maintain privacy and were observed doing so throughout the audit such as: when attending to personal cares and ensuring information is held securely and privately. All residents have a private room except for one resident who occupies a double room.

Residents are encouraged to maintain their independence by participating in clubs of their choosing, community activities and arranging visits to the doctor off site if family able to take them.

Resident records reviewed confirmed that each resident`s individual cultural, religious and social needs, values and beliefs had been identified, documented and incorporated into their care plan.

Staff understood the service`s policy on abuse and neglect including what to do should there be any signs. Education on abuse and neglect is part of the orientation programme for staff and is then provided on an annual basis as confirmed in staff and training records.

Standard 1.1.4: Recognition Of Māori Values And Beliefs

Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs.

FA Staff support the two residents in the service that identify as Maori to integrate their cultural values and beliefs. The principles of the Treaty of Waitangi are incorporated into day to day practice as is the importance of whanau to Maori residents. Whanau are encourage to visit. There is a current Maori health plan developed with input from cultural advisors.

Current access to resources includes the contact details of local cultural advisers with the district health board (DHB). Guidance in tikanga best practice is available and is supported by staff who identify as Maori in the facility. The two Maori residents and their whanau interviewed reported that staff acknowledge and respect their individual cultural needs and these are reflected on the care plans reviewed. There are no identified barriers for Maori to access this facility and services provided.

Standard 1.1.6: Recognition And Respect Of The Individual's Culture,

FA The residents verified that they were consulted on their individual culture, values and beliefs and that staff respect these. Residents’ personal preferences, required interventions and special needs were


Values, And Beliefs

Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs.

included in the care plans reviewed. A resident survey includes valuation of how well residents` cultural needs are met and this is supported that individual needs are being met. This is also reflected in the interRAI re-assessment process and the care plan evaluations six monthly or more often if needed.

Standard 1.1.7: Discrimination

Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation.

FA The residents and family members interviewed stated that residents were free from any type of discrimination, harassment or exploitation and felt safe. A general practitioner also interviewed expressed satisfaction with the standard of services provided to residents.

All new staff receive education during the orientation process related to maintaining professional boundaries and expected behaviours. The two registered nurses have records of completion of the required training on professional boundaries. The individual employment agreements for all staff reviewed contain a segment on Code of Conduct that staff are to respect and abide by as part of their individual agreement.

Ongoing education is also provided on an annual basis which was confirmed in staff training records. Staff are guided by policies and procedures and when interviewed demonstrated a clear understanding of what would constitute inappropriate behaviour and the processes they would follow should they suspect this was occurring.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

FA The service encourages and promotes good practice through evidence based policies, input from a quality consultant and allied health professionals such as the gerontology nurse specialist from the DHB and services for older people who visit regularly.

The GP confirmed the service sought prompt and appropriate medical intervention when required and were responsive to medical requests.

Staff reported they receive in-service education on a regular basis. The registered nurse interviewed stated that the support of the manager was appreciated for external education opportunities to support contemporary practice.

Standard 1.1.9: Communication

Service providers communicate effectively with consumers and provide an environment conducive to

FA Family members stated they were kept well informed about any changes in their relative`s health status and were advised in a timely manner about any incidents or accidents and outcomes of regular and any urgent medical reviews. This was supported in the residents` records reviewed. There was evidence of resident/family input into the care planning process.


effective communication. Staff understood the principles of open disclosure which is supported by policies and procedures that meet the requirement of the Code.

Interpreter services are available through DHB when required. Staff knew how to access this service although reported this was rarely required due to staff being able to provide interpretation as and when needed. Family/whanau were available if required for those residents where English is their second language.

Standard 1.2.1: Governance

The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

FA Janelle Rest Home has a documented mission statement and philosophy on care that is focused around the provision of individualised resident focused care that maximises independence. The manager monitors the progress in achieving these goals via the internal audit process and review of resident and family satisfaction at review meetings. A number of goals/objectives are set for the forthcoming year and these are monitored and documented once completed.

The day to day operations and ensuring the wellbeing of residents is the responsibility of the registered nurse (RN) who reports to the manager. The current owner/manager has owned this rest home since June 2017. The owner/manager is on site most days but still currently works at a district health board (DHB) as a registered nurse in acute care and assessment and rehabilitation. The manager has completed approved education in age related care and management to meet the provider`s contract with Counties Manakau District Health Board (CMDHB). The manager is supported by an experienced registered nurse who has worked in aged care for seven years. The registered nurse works twenty hours a week and is responsible for the clinical services provided. Both the manager and the registered nurse have current and valid annual practising certificates which were sighted.

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.

FA An experienced registered nurse who has worked at this facility for four years and has been in New Zealand for seven years is available to perform the manager`s role as required. The registered nurse interviewed has a good understanding of aged residential care and resides in close proximity to the facility. The manager and the registered nurse provide the after-hours cover for the rest home seven days a week. The registered nurse covers Monday to Friday and the manager covers the weekend. There is some flexibility as long as cover is provided.

Standard 1.2.3: Quality And Risk FA There is a documented quality and risk plan and this was sighted.


Management Systems

The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

Policies and procedures are available to guide staff practice. The policies are developed by an external consultant and then reviewed and localised to reflect Janelle Rest Home by the manager. Changes in policy are discussed at staff meetings as verified by staff interviewed and is referenced in applicable meeting minutes. Document control processes are set up and implemented. Policies were all newly implemented June 2017 and are current and up to date.

A review of the quality and risk programme is undertaken three monthly via the review meetings. The last month minutes sighted involved the medication system training as well. The meetings have set agenda. All key components of service delivery are included and reported to the quality meeting. The meeting covers complaints and compliments, changes to any policies/practices, the results of any audits, staffing and education. Restraint minimisation, infection prevention and control and any reported incidents are also discussed. The owner/manager has an `open door` to staff and residents/families.

Internal audits have been undertaken and are conducted using a template audit form. A schedule sighted details the audits to be undertaken and when. Audits sampled identified compliance by staff in meeting the requirements of the organisation`s policy and the audit criteria. Where improvements were required these improvements have been documented, implemented and monitored.

An annual survey has not been completed as yet as the service has only been operating for 10 months. Residents meetings are held two monthly. Minutes sighted reflected discussion on food, the activities programme, staff and the laundry service. Resident compliments were recorded and communicated to staff. Education has been provided to residents on infection prevention and control topics during the resident meetings.

A risk management plan is in place. Organisation risks are categorised and documented and mitigation strategies noted. The owner/manager and the RN were able to discuss changes in organisation risk. Staff confirmed that they report any new hazards and the hazard register reviewed was up to date.

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.

FA Policy and procedure details the required process for reporting incidents and accidents. Staff are provided with education on the responsibilities for reporting and managing accidents and incidents during orientation and as a component of the ongoing education programme and as a discussion topic at staff meetings.

Applicable events are being reported in a timely manner and also disclosed to the resident and or designated next of kin. This was verified by residents and family members interviewed. The incident form includes an area to record that family were informed and who else was notified about the reported event (e.g. where applicable the RN and the resident`s GP). A summary of the number and


type of reported events is maintained in each resident`s clinical record. A review of a near miss incident and other incidents demonstrated that incident forms are appropriately completed, investigated and responded to in a timely manner.

Changes were made to the resident`s care plan where applicable or a short term care plan developed. Staff communicated incidents and events to oncoming staff via the shift handover. Individual events are discussed with staff monthly at the staff meetings and also reviewed at the service review meetings held six monthly. Any themes or trends over time are monitored and evaluated.

The manager and the RN are able to identify the type of events that must be reported to external agencies. An essential notification was made to HealthCERT. This was reported on a Section 31 notice and was managed effectively. A copy of this communication and subsequent acknowledgement was sighted.

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.

FA The copy of the annual practising certificates (APCs) for the registered nurse, manager who is a RN, the general practitioners (GPs), the contracted pharmacy and the pharmacists involved and a podiatrist were reviewed and all annual practising certificates were current.

The recruitment/employment policy aligns with current accepted practices. This includes staff completing an application form and completing a health declaration, police vetting, interviews being conducted and reference checks being obtained and retained. Staff have a signed individual employment agreement and confidentiality/privacy agreement on file. Performance appraisals are conducted at least annually and these were sighted in the relevant staff records reviewed.

Records evidencing completion of the orientation programme were present in the staff records. Staff interviewed reported orientation included being buddied with a senior staff member. The orientation included the facility, policy/processes, facility routines, staff tasks and the individual resident`s care needs.

Individual records of education are maintained by the manager for each staff member and copies of education certificates are present in the staff records reviewed. All caregivers have completed level two except for three staff who are completing level 1 and two staff who are completing level 3 (Careerforce) New Zealand Quality Authority aged care related qualifications. In-service education and attendance records were sighted showing staff had access to regular ongoing education relevant to their roles and the service provided.


Standard 1.2.8: Service Provider Availability

Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

FA A policy details staffing levels and skill mix requirements and this aligns with the requirements of the provider`s contract with the DHB.

The current roster and three weeks of rosters reviewed demonstrated that there is at least one senior caregiver on each shift. The registered nurse covers 9am to 2pm four days a week (week days). The manager (a registered nurse) covers during the week with flexible hours and takes residents to appointments if family are unable to do this and also ensures any maintenance is attended to and/or arranged with the maintenance person as needed.

There is an after-hours service with the registered nurse covering the weekdays and the manager/registered nurse covering the weekends. The contracted general practitioner for this service is also on-call twenty four hours a day seven days a week.

Additional staff are rostered for the activities programme and the food service. Staff complete the cleaning and the laundry. All caregivers interviewed reported that there is adequate staff available and that they are able to get through their work. The staff confirmed the RN and the manager are available out of hours if required. All staff members have a current first aid certificate and these were sighted.

Residents and family members interviewed confirmed staffing meets their needs.

Standard 1.2.9: Consumer Information Management Systems

Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

FA The resident`s name, date of birth and National Health Index (NHI) number is used on all records reviewed as the unique identifier. All necessary demographic, personal and health information was fully completed in the residents` records sampled for review. Clinical records were current and integrated with the GP and allied health professional records. Records are legible with the name and designation of the person making the entry identifiable.

Archived records are held securely on site and confidentiality is maintained. The records are retrievable. Residents` records are held for the required period before being destroyed. No personal or private information was on public display during the audit.

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

FA Access processes and entry criteria are clearly documented and communicated to the consumers, their family of choice where appropriate, local communities and referral agencies in the facility brochure. Services provided are clearly stated. The RN, manager and the GP are involved in the admission process. Out of hours contact information is made available. Facility welcome pack and the Code information is provided on admission.


identified.

Standard 1.3.10: Transition, Exit, Discharge, Or Transfer

Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services.

FA There is a planned and coordinated transition, exit, discharge or transfer managed by the manager and the RN. Yellow envelopes are used for transfers to the local DHB using the DHB transfer forms. Sighted transfer documents in sampled files demonstrated safe transfer process for residents. To minimise risks associated with transfers, contact is established with the next service before transfer and at times follow up to ensure that the resident is safe.

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.

FA Medicine management policies and procedures clearly outline the service provider`s responsibilities in relation to all stages of medicine management. The use of electronic medication management system was recently implemented. Pre-packaged medication is in use. The staff who are responsible for medicine management are competent and have current medication administration competencies. Allergies or sensitivities are recorded on the residents’ medication entries. Sighted medication entries have residents’ photo for identification and consent forms were sighted. The GP reviews medication charts three monthly.

Medication reconciliation is completed by the RN. There is a process in place for expired/unwanted medication return to the pharmacy. Medication is stored safely in locked and secure cupboards. There was no expired medication in the cupboards. There are controlled drugs onsite. Controlled medication checks are completed weekly and six monthly. A pharmacist is involved in the six-monthly controlled medication stocktakes. Controlled medication administration complies with current legislative requirements and safe practice guidelines.

There are residents who self-administer their medication. Medication self-administration policy is in place and medication self-administration assessment process is being conducted as per policy. The GP, resident and the RN are involved in the process of assessment and authorisation of medication self-administration. Assessment forms sighted. Reviews of medication self-administration is conducted every three months.

Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

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

FA Food services are provided at the facility. The kitchen services are going to go with an arrangement developed by the Care Association New Zealand (CANZ) and will have a combined agreement for meeting the food development and safety plan requirements. There are two permanent cooks and one casual cook. All cooks have completed food handling training, certificates sighted. Kitchen staff were observed using appropriate infection control procedures as per current legislation and guidelines. Special diets are catered for per rising need and personal food preferences of residents are met where appropriate. Food allergies are recorded on the diet profile that is shared with the


kitchen staff on admission and whenever there are changes made. Interviewed residents and family/whanau reported satisfaction with the food services.

There is a process for food procurement in place managed by the manager and the cook. Cooked food was dated, covered and labelled. The pantry had adequate supplies and no expired food in stock. There was no food touching the floor. The fridges and freezers are packed and clean. Food, fridge and freezer temperatures are monitored and recorded and records were reviewed.

The kitchen was clean and there is a cleaning schedule in place. Cleaning records were sighted.

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.

FA A process is in place for declining entry to services as and when required and the immediate risk to consumer and or their family/whanau is managed by the organisation. Consumers and where appropriate their family/whanau of choice are informed of the reason for the decline and are advised of other options or alternative services. A register is utilised to document enquiries and referrals to other health agencies.

Standard 1.3.4: Assessment

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

FA Risk assessments are completed on admission using facility owned assessment forms. Medical admission is completed by the GP within 48 hours of resident admission. InterRAI assessments are completed within the required timeframes and information gathered from the assessment is incorporated in the care plans. The identified needs, outcomes and goals of the residents are documented and serve as a basis for service delivery.

Standard 1.3.5: Planning

Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

FA Care plans are individualised and residents’ personal preferences, individual habits and routines are taken into consideration. All care plans sampled are accurate and up to date. The care plans have detailed information of the required support and interventions to achieve the desired outcomes. Residents and their family/whanau participate in the care plan review meetings at regular times. Documentation sighted in sampled files. Care plans demonstrate service integration. A multidisciplinary approach is adopted in the care planning process.

Standard 1.3.6: Service Delivery/Interventions

FA Residents are encouraged to maintain or redevelop their level of independence to meet their everyday living needs with support as needed. Interventions are consistent and contribute to meet the residents’ assessed needs and desired outcomes. Appropriate links with other external services


Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

and organisations working with the residents are maintained and consulted when required.

Standard 1.3.7: Planned Activities

Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service.

FA Activities assessments are completed on admission by the activities coordinator with the support of the RN. There are individualised activities plans for each resident and these are evaluated six monthly and changes are made when required. The activities reflect ordinary patterns of life and family/whanau of choice and community groups are involved where appropriate. In the sampled files, residents’ preferences are sought and they are involved in the development of the planned activities. Daily activities attendance register was sighted. On the days of the audit, residents were observed participating in a variety of activities. Interviewed residents and family reported that they are satisfied with the activities programme.

Standard 1.3.8: Evaluation

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

FA Care plans are evaluated six monthly and whenever required if there are any changes to residents’ condition. The RN is responsible for evaluating the care plans using outcomes from interRAI assessment, input from other nursing staff, residents and family. Evaluations in residents’ care plans are resident focused and indicate the degree of achievement or response to interventions. In sampled files, amendments were made to ensure interventions remain relevant to address the residents’ current identified needs. Short-term care plans are evaluated regularly and signed off when conditions are resolved.

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.

FA Residents are given the choice and advised of their option to access other health and disability services where indicated or requested. Referral forms to other health providers sighted in sampled files. Residents and or their family/whanau are kept informed in a timely manner as reported by the interviewed family members.

Standard 1.4.1: Management Of Waste And Hazardous Substances

FA Policies were sighted to detail how waste was to be segregated and its disposal. The policy content aligns with current accepted practice.

Chemicals sighted were stored in designated and secure areas. Material data sheets detailing


Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.

actions to take in the event of exposure were sighted for chemicals in use. All care staff have been provided with training on chemical safety and handling.

Appropriate personal protective equipment (PPE) was available on site including: disposable gloves; hats; masks and aprons. An emergency kit with PPE is also available in the event of an outbreak or other significant event. The staff interviewed on this topic detailed what PPE was required to be worn by staff and when in order to minimise risk of exposure to blood and other body fluids and contaminated items/equipment.

Staff advised they would report inadvertent exposures to hazardous substances and/or body fluids via the incident reporting system.

Standard 1.4.2: Facility Specifications

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

FA There is a current building warrant of fitness (BWOF). Ongoing checks to maintain the BWOF are occurring. An external company undertakes performance monitoring and electric safety checking (where applicable) of clinical equipment. Maintenance requests are identified and documented during the facility inspections or if observed by staff and reported to the manager. Requested tasks have been signed off as completed or are in progress. The hot water temperature is monitored monthly. The temperatures are within required range and this included hot water tested at several outlets during the audit.

Grab rails are present in the residents’ showers. There are handrails in the hallways in each wing. The bathroom floors have non slip linoleum floor covering.

The residents and family members interviewed confirmed the facility is appropriately furnished to create a home like environment. Furniture and fixtures were appropriate to the service setting. The front entrance is at ground level. There are also exits where there are ramps. Residents have personalised their rooms as observed.

The facility vehicle has a current registration and warrant of fitness.

Residents were observed to be mobilising independently or with the use of a mobility device in their bedrooms and in communal areas.

Standard 1.4.3: Toilet, Shower, And Bathing Facilities

Consumers are provided with adequate toilet/shower/bathing

FA One wing has all shared facilities with four shared ensuites between each resident`s room. In addition there are four separate shower units in close proximity to the residents` rooms. The other wing of the facility has rooms with their own ensuites with a shower, vanity and toilet facilities. There is one double room which is in close proximity to bathroom/toilet facilities (only one resident in this room). The caregivers interviewed confirmed there are enough bathroom and shower facilities for the


facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.

residents` use as they assist or provide supervision for residents when showering. Privacy locks are present on the bathroom and shower doors that are accessible/utilised by residents.

There are separate bathroom facilities for staff/visitor use. Key pad access is available.

Standard 1.4.4: Personal Space/Bed Areas

Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.

FA Residents` bedrooms are single occupancy, except one double room that has one resident in this room. The rooms contain space for the residents` personal possessions and use of mobility aides/devices if required. Residents were sighted mobilising inside the rest home independently including while using a mobility aid.

The staff interviewed advised there is sufficient space for the residents to mobilise including when assistance was required. The residents and family members interviewed confirmed this.

Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining

Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.

FA There are three small dining areas of which two are situated close to the kitchen. Two comfortable lounges are used for residents/families. There is also one quiet visitor/whanau lounge (multi-purpose function) with a storage room off the lounge for activities resources. This lounge is also used for in-service education provided for staff.

Standard 1.4.6: Cleaning And Laundry Services

Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.

FA Policies and procedures detail how the cleaning and laundry services are to be provided. Resident’s personal clothing is washed by staff and returned daily. There is a separate sluice room for sluicing laundry. The residents and family members interviewed confirmed the rest home is normally kept clean and tidy and residents` laundry is washed and returned in a timely manner.

Audit of cleaning and laundry services were undertaken as scheduled and reports demonstrated a high level of compliance with the rest home policy and service requirements and prompt remedial action where improvements were requested/identified. Chemicals are stored in a designated secure utility room. The containers are refillable by staff and all containers are clearly labelled. The staff described the chemicals used for environmental cleaning during interview and these were aligned to the wall mounted instructions. Instructions for a chemical spill was readily available to staff and a kit was sighted. The cleaner`s trolley was stored in another sluice room when not in use.


Standard 1.4.7: Essential, Emergency, And Security Systems

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

FA The fire evacuation policy to guide staff was reviewed. The fire evacuation plan has been approved by the Manukau Fire District Fire Safety Department of the New Zealand Fire Service (NZFS) in a letter dated 21 November 2001. A fire evacuation drill was conducted in November 2017 and is due in May 2108 and records were sighted.

Policy documents provide guidance for staff on responding to other events including (but not limited to) earthquake, flooding and volcanic eruptions.

A review of the staff records and training records verified all staff have current first aid certificates. The caregivers interviewed detailed their responsibilities in the event of an emergency.

There are sufficient supplies available of dated dry food, drinking water, lighting, a radio and batteries and other clinical supplies for use in an emergency. Spare blankets are available. There is a gas cooker and gas bottle available if needed. There is gas cooking available in the kitchen. There is no emergency power for this small rest home. The manager and the cook advised the food is regularly rotated through to the kitchen and replaced to ensure it remains of appropriate quality. Food items are dated when purchased.

Call bells are present in all bathrooms and residents` bedrooms. The call bells alert audibly and the room is displayed on the board in the newer wing. Staff use a pager system and the room number is also reflected onto the pager system when activated. Staff were observed to answer the call bells promptly.

The caregivers interviewed advise the external door and windows are checked and locked in the evening. All external windows and doors are also checked and secured at this time. A door bell is present at the front door entrance for family/visitors to ring after this time in order to gain access. A number of security cameras are in use monitoring the entrance and the communal areas. The images display on a screen in the manager`s office and in the small lounge and are electronically archived for a period of time. The screen has pass word access only.

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.

FA All residents` rooms have an external window and a door that opens directly onto the deck. There are wall mounted electric heaters present in each bedroom and in the hallways and communal areas. Residents and family members interviewed verified that the facility is kept suitably warm and ventilated.


Standard 3.1: Infection control management

There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service.

FA The RN is the infection control nurse and has a job description that was sighted. The infection control policies and procedures clearly define the lines of accountability and responsibilities for infection control matters in the facility leading to the senior management.

The service is aware of processes for prompt notification of serious infection control related issues. There is an infection control programme that is reviewed and evaluated annually. Annual report sighted. The infection control committee is appropriate for the size and complexity of the service and monitors the progress of the infection control programme. There are infection control posters at the front entrance of the facility and throughout the facility for visitors, staff and residents’ awareness of infection control procedures to minimise the risk of infection. The service works in collaboration with the local DHB and infection control advice is sought as required. There were no infection outbreaks reported since the last audit.

Standard 3.2: Implementing the infection control programme

There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation.

FA The infection control nurse has received external infection control training and certificates were sighted. Expert advice is sought through the local DHB. Referral forms to external infection control experts were sighted. The infection control nurse facilitates the implementation of the infection control programme. Interviewed staff reported that infection control issues are discussed in monthly quality meetings. The infection control nurse and the manager have access to records and diagnostic results of residents.

Standard 3.3: Policies and procedures

Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided.

FA Infection control policies and procedures comply with relevant legislation and current accepted good practice. The policy folders are readily accessible to all personnel. The policies and procedures are reviewed regularly and current. On the audit days, staff were observed performing hand hygiene and using appropriate products for infection control. Interviewed staff reported that there are adequate infection control resources and equipment for use. Adequate quantities of personal protective equipment was sighted on audit days. Interviewed staff demonstrated awareness of infection control procedures.

Standard 3.4: Education FA Annual infection control training is conducted by the infection control nurse or external educators at


The organisation provides relevant education on infection control to all service providers, support staff, and consumers.

times. Staff training records sighted.

Individual resident infection control education is conducted per rising need in a manner that recognises and meets the residents’ communication method, style and preference. Documentation on short term care plans sighted. Education on flu vaccines was conducted before the flu immunisation for individual residents. Signed consent forms sighted. Interviewed staff reported that infection control is discussed at orientation for all staff and ongoing per rising need.

Standard 3.5: Surveillance

Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme.

FA The surveillance for infection control is completed as specified in the infection control programme. Infection control audits are completed six monthly. The type of surveillance carried out is suitable to the type of services provided and the size of this facility. All staff participate in surveillance activities managed and monitored by the infection control nurse. Standardised definitions are used for identification and classification of infection events, indicators or outcomes, copy sighted in the infection control folder. Surveillance findings and specific recommendations or interventions required to achieve infection reduction and prevention are recorded and shared in staff quality meetings and at shift handover times. Interventions are evaluated regularly on short term care plans and signed /closed off when infection is resolved. Where the expected outcome is not achieved changes are made to the interventions. Staff meeting minutes and short-term care plans sighted.

Monthly infection control data is collected and results and interventions are shared with the staff in monthly staff meetings. Interviewed staff demonstrated awareness of infection statistics and interventions in place to manage the infections.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The facility promotes a policy of restraint minimisation and restraint is used as a last resort. Alternative strategies are considered and used before restraint intervention is used. The restraint coordinator is responsible for the decision to use restraint in consultation with the GP, resident and their family/whanau or representative.

A policy and procedure is in place that shows the process for restraint use and safety considerations. The policy states that enabler use is voluntary. There was no restraint/enabler is use on the days of the audit. Restraint assessment and evaluation forms were sighted as part of the restraint policies and procedures. Interviewed staff reported that restraint is discussed in staff meetings monthly. Interviewed staff including the restraint coordinator have demonstrated knowledge about restraint and enablers and processes to be followed if there is need for restraint use. All staff receive restraint training annually and training records were sighted.


Specific results for criterion where corrective actions are required

Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded.

Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 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.

No data to display


Specific results for criterion where a continuous improvement has been recorded

As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded.

As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 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.

No data to display

End of the report.


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