station when not attended (refer 1.4.2 below). The documentation of PRN medicines is now well managed with the introduction of a GP who comes on site as required and the implementation of tighter management controls for other general practitioners who provide services. There has been an increase in residents choosing to use the GP who does onsite visits. A key pad lock has been installed on the door to the nurses station (refer 1.4.2). ARRC A 5.1 Bupa are aware that when they secure an agreement with Auckland DHB to provide care to government subsidised and assessed residents. The admission agreement will be changed to reflect these obligations when the facility enters into an agreement with Auckland DHB. 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 The food service is established. The kitchen will be able to accommodate the proposed reconfiguration. The facility employs two and three kitchen hands. The head cook works fulltime and she alternates shifts with another second cook. Summer and winter menus are organised on a six weekly cycle and are used on a weekly rotational basis and the menus are available on the intranet. The national menus have been audited and approved by an external dietitian. The menus were last reviewed in March 2013. Food requirements can be accommodated. The kitchen staff are currently providing soft diets to some residents. Food is procured from commercial suppliers. The kitchen supplies all meals and most food served is cooked onsite. Meals for residents wishing to eat in their rooms are plated up by kitchen staff and staff then pick up the food and deliver at the same time to ensure the food remains hot. Kitchen fridge, food and freezer temperatures are monitored and documented daily and daily in other areas. The kitchen is included in the internal audit programme (last audit conducted 11 August 2014 which showed 94 percent compliance. CARS were identified and have been addressed). Each resident has a nutritional profile developed on admission which identifies their dietary requirements and their likes and dislikes. This information is provided to the kitchen staff and reviewed six monthly as part of the care plan review. Changes to residents’ dietary needs are communicated to the kitchen. Special diets can be catered for as needed (eg, vegetarian and soft/pureed diets).
Specific results for criterion where corrective actions are required 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 outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low The facility employs RNs and has access to a bank of trained RNs who have been orientated to the site. The facility is in the process of recruiting additional registered nurses in order to ensure they have a registered nurse on duty 24 hours a day, 7 days a week. A pre-requisite for appointment is that the registered nurses are InterRAI trained. These nurses will receive a comprehensive orientation/induction, which is standardised across all Bupa sites. The service is in the process of employing registered nurses. Advised they will complete an onsite induction, which will include fire safety. Ensure newly employed registered nurses who will be providing care for hospital level residents complete an orientation and onsite induction. Prior to occupancy Criterion 1.2.8.1 There is a clearly documented and implemented process which PA Low The proposed roster reflects the anticipated of residents in both levels of care from the day the service commences. The proposed roster will accommodate anticipated growth in hospital level resident numbers as the facility moves toward capacity. Hospital level residents will be provided with services from one of The facility is in the process of recruiting and has access to a bank of RNs who hold Bupa competencies. Ensure there is 24 hour registered nurse cover in place
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.