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 44 0 5 1 0 0 Criteria 0 95 0 5 1 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
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. Criterion with desired outcome Attainment Rating Audit Evidence Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low There is a documented meeting schedule with meetings occurring at various intervals. Most are but these have not always occurred regularly. Despite recurring issues all facility meetings except restraint have only occurred three-monthly. Staff report not feeling well informed. The service has remained consistently above benchmarks in several areas through late 2016 and 2017 YTD. Corrective action plans, focussing on individual residents have not been reviewed and updated despite being ineffective. Ensure meetings are held at a frequency to ensure that issues are promptly addressed and that staff are well informed. Where quality data is evaluated and corrective actions initiated; ensure these are reviewed for effectiveness and amended where needed. 60 days
Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low Bupa Te Whanau has a roster where all staff are rostered to various shifts and specific area. The roster does not provide adequate cover of caregivers in the rest home. There are four casual caregivers employed and staff and management reported that agency staff are not used. Absent staff are frequently not replaced as sighted on the roster and confirmed by staff. There was no evidence of staffing being increased when acuity increases. (i) The ‘rest home’ includes eight hospital level residents) as evidenced by staff interviews and review of the roster does not always include sufficient staff to support the needs of residents. (ii) When illness or leave create gaps in the roster, staff are frequently not replaced. (iii) When acuity increases there is no evidence of an increase in staffing. This was particularly evident during the recent protracted outbreak. (iv) During the recent outbreak, when the rest home (which also houses hospital level residents) was fully isolated and locked down there was no registered nurse rostered to cover this isolated area. Ensure is sufficient staff with a correct skill mix to meet resident’s needs at all times. 30 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines. PA Low The service uses an electronic medication management system. Twelve of sixteen electronic medication signing charts reviewed aligned with the medication chart. Four medication charts and signing sheets reviewed of residents prescribed a dietary supplement, evidenced gaps in electronic medication signing sheets where the supplement had not been administered as prescribed. Ensure dietary supplements are documented as administered as prescribed. 30 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low Four rest home and four hospital level care plans were reviewed. All eight care plans had care plans that included most of the assessed needs; however, hospital care plans reviewed had not been Not all care reviewed included interventions to address all resident needs or had not been updated to reflect interventions currently being implemented. (i) One hospital file reviewed did not document management of constipation, or pain management; Ensure care plans are updated as resident need changes. 60 days