zilongwang/ReadingBank huggingface dataset:
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 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 Consumer Rights Day of Audit 23-Sep-13 Assessment 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. Some standards applicable to this service partially attained and of low risk Organisational Management Day of Audit 23-Sep-13 Assessment 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. All standards applicable to this service fully attained with some standards exceeded Continuum of Service Delivery Day of 23-Sep-13 Assessment 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. Some standards applicable to this service partially attained and of low risk Safe and Appropriate Environment Day of Audit 23-Sep-13 Assessment 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. Standards applicable to this service fully attained
Audit Report To: HealthCERT, Ministry of Health Provider Name Sprott Care Limited Premise Name Street Address Suburb City Sprott House 29 Messines Road Karori Wellington Proposed changes of current services (e.g. reconfiguration): Type of Audit Surveillance audit and (if applicable) Date(s) of Audit Date: 18-Sep-13 End Date: 18-Sep-13 Designated Auditing Agency Health and Disability Auditing New Zealand Limited Audit Team Audit Team Name Qualification Auditor on site Auditor Hours off site Auditor Dates on site Lead Auditor XXXXXXX RN, auditor certificate 9.00 6.00 18-Sept-13 Auditor 1 XXXXXXX RN, auditor certificate 9.00 5.00 18-Sept-13
Safe and Appropriate Environment Day of Audit 18-Oct-13 Assessment 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. Standards applicable to this service fully attained Restraint Minimisation and Safe Practice Day of Audit 18-Oct-13 Assessment Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Some standards applicable to this service partially attained and of low risk Infection Prevention and Control Day of Audit 18-Oct-13 Assessment 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. Some standards applicable to this service partially attained and of low risk
Audit Report To: HealthCERT, Ministry of Health Provider Name Howick Baptist Healthcare Limited Premise Name Street Address Suburb City Howick Baptist Home and Hospital 139 Union Road Howick Auckland Proposed changes of current services (e.g. reconfiguration): Required to report on the addition of two rest home care beds as per MOH letter dated 2 July 2012. Type of Audit Surveillance audit and (if applicable) Date(s) of Audit Start Date: 21-Oct-13 End Date: 21-Oct-13 Designated Auditing Agency The DAA Limited Team Audit Team Name Qualification Auditor Hours on site Auditor Hours off site Auditor Dates on site Lead Auditor XXXXXXXX BA, Lead Auditor NZQA 8086, RCN. 8.00 4.00 21-Oct-13
Auditor 1 XXXXXXXX RN, B.Nursing, RABQSA 8.00 4.00 21-Oct-13 Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor Peer Review Auditor XXXXXXXX RN,MBA,NZQA 8086 2.00 Total Audit Hours on site 16 Total Audit Hours off site (system generated) 10 Total Audit Hours 26 Staff Records Reviewed 10 of 188 Client Records Reviewed (numeric) 7 of 128 Number of Client Records Reviewed using Tracer Methodology 2 of 7 Staff Interviewed 14 of 188 Management Interviewed (numeric) 3 of 3 Relatives Interviewed (numeric) 3 Consumers Interviewed 8 of 128 Number of Medication Records Reviewed 14 of 128 GP’s Interviewed (aged residential care and residential disability) (numeric) 1
Standard 1.4.5 Communal for entertainment, recreation, and dining Not Applicable 0 0 0 0 0 3 Standard 1.4.6 Cleaning and laundry services Not Applicable 0 0 0 0 0 3 Standard 1.4.7 Essential, emergency, and security systems Not Applicable 0 0 0 0 0 7 Standard 1.4.8 Natural ventilation, and heating Not Applicable 0 0 0 0 0 3 Safe and Appropriate Environment Standards (of 8): N/A:5 CI:0 FA: 3 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0 Criteria (of 36): CI:0 FA:3 PA:0 UA:0 NA: 0 Restraint Minimisation and Safe Practice Attainment CI FA PA UA NA of Standard 2.1.1 Restraint minimisation FA 0 1 0 0 0 6 Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3 Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2 Standard 2.2.3 Safe restraint use FA 0 1 0 0 2 6 Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3 Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 0 1 Standard 2.3.1 Safe seclusion use 0 0 0 0 0 5 Standard 2.3.2 Approved seclusion rooms 0 0 0 0 0 4 Restraint Minimisation and Safe Practice Standards (of 6): N/A: 4 CI:0 FA: 2 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0 Criteria (of 21): CI:0 FA:2 PA:0 UA:0 NA: 2
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 Consumer Rights Day of 22-Oct-13 Assessment 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 Organisational Management Day of Audit 22-Oct-13 Assessment 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. Standards applicable to this service fully attained Continuum of Service Delivery Day of Audit 22-Oct-13 Assessment 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. All standards applicable to this service fully attained with some standards exceeded Safe and Appropriate Environment Day of Audit 22-Oct-13 Assessment Includes 8 standards that support an outcome 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 Restraint Minimisation and Safe Practice Day of Audit 22-Oct-13 Assessment
Audit Team Lead Auditor XXXXXX Hours on site 8 Hours off site 4 Other Auditors XXXXXX Total hours on site 8 Total hours off site 4 Technical Experts hours on site hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXX Hours 3 Sample Totals Total audit hours on site 16 Total audit hours off site 11 Total audit hours 27 Number of residents/patients interviewed 3 Number of staff interviewed 7 Number of managers interviewed 1 Number of residents’/patients’ records reviewed 3 Number of staff records reviewed 5 number of managers (headcount) 2 Number of medication records reviewed 6 Total number of staff (headcount) 10 Number of relatives interviewed 1 Number of residents’/patients’ records reviewed using tracer methodology 1 Number of GPs interviewed (Residential Disability providers only) 1
HDS(C)S.2008 Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low The CPU is not yet provided to the service. Ensure that there is a CPU prior to occupancy. Prior to occupancy Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards Outcome 1.2: Organisational Management Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1) The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5 Attainment and Risk: FA Evidence: Tui House Limited is governed by the owner/general manager/director who is an experienced registered nurse with a current APC - sighted (referred to in the report as general manager - GM). Tui House is one of two age care facilities owned by the GM. Tui House currently has 54 beds including 23 designated rest home and 31 swing beds. On the day of the audit, there are 44 rest home residents and nine hospital residents. The audit verifies an additional 24 as rest home beds in a purpose built building separate to the existing building (same site). The newly purpose-built rest home building verified through this audit is completed including furnishings, call bells etc and ready for residents to move into. The building is expected to open as soon as the report is finalised. The service intends to eventually convert nine to 18 of the rest home rooms in the new building to hospital beds in 2014. The GM develops the annual business plan 2013-14 and goals with the support of the management team. The current business plan is sighted and includes goals around
Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8) Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature. ARC D15.2f ARHSS D15.2g Attainment and Risk: FA Evidence: The facility is light and airy. There is underfloor heating throughout and oil heaters. There are also four heat boxes in the new facility that can be adjusted thermostatic controls. Smoking is only allowed outside away from residents' rooms and communal areas noting that the service is trying to become smokefree. All rooms have an individual window/s with one room retaining the original stained glass window. ARC requirements are met. Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1) Areas used by consumers and service providers are ventilated and heated appropriately. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2) All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light. Attainment and Risk: FA Evidence: Finding:
Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 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. PA Moderate HDS(C)S.2008 Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Moderate The service does not currently have a training and education plan to guide internal and compulsory training and education opportunities for staff. Medicine management competency programme for RN’s is not current and there is no evidence of medicines management training having occurred within the last year The service to a) have a system for identifying, planning, facilitation and recording of ongoing education of staff, b) All staff members responsible for medicines management to maintain competencies, c) medicines management training to be completed annually. 60 HDS(C)S.2008 Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Low HDS(C)S.2008 Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and PA Low Rest home and hospital short term care plans do not show the degree of achievement or response to care and b) observation charts Short term care plans to reflect the degree of achievement to care and b) observations to be recorded. 90
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 Consumer Rights as at 20 November 2013 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. Organisational Management as at 20 November 2013 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. Standards applicable to this service fully attained. Continuum of Service Delivery as at 20 November 2013 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. Some standards applicable to this service partially attained and of low risk. Safe and Appropriate Environment as at 20 November 2013 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. Standards applicable to this service fully attained. Restraint Minimisation and Safe Practice as at 20 November 2013 Includes 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. Infection Prevention and Control as at 20 November 2013
Audit Team Lead Auditor XXXXXX Hours on site 13 Hours off site 6 Other Auditors hours on site hours off site Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site hours off site Peer Reviewer XXXXX 2 Sample Totals Total audit hours on site 13 audit hours off site 8 Total audit hours 21 Number of residents interviewed 3 Number of interviewed 10 Number of managers interviewed 3 Number of residents’ records reviewed 5 Number of staff records reviewed 5 Total number of managers (headcount) 3 Number of medication records reviewed 15 Total number of staff (headcount) 50 Number of relatives interviewed 4 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed 0
Kingswood Healthcare Morrinsville Limited Current Status: 10 December 2013 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified. General overview Kingswood Rest Home, located in Morrinsville, provides rest home and specialist dementia care service. The service also has separate independent living apartments, which are not included as part of this certification audit. One of the strengths of the service is the implementation of the ‘Spark of Life’ approach to care in the specialist dementia service. The Spark of Life is a practical implementation of person centred care to support people living with dementia. There is one area requiring improvement relating to the documentation of advance directives identified at this audit. Audit Summary as at 10 December 2013 Standards have been assessed and summarised below: Key Indicator Description Definition Includes commendable elements the required levels of performance All standards applicable to this service fully attained with some standards exceeded No falls Standards applicable to this service 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 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
Audit Team Lead Auditor XXXXX on site 16 Hours off site 8 Other Auditors XXXXX Total hours on site 16 Total hours off site 8 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXX Hours 3 Sample Totals Total audit hours on site 32 Total audit hours off site 19 Total audit hours 51 Number of residents interviewed 6 Number of staff interviewed 10 Number of managers interviewed 1 Number of residents’ records reviewed 6 Number of staff records reviewed 5 Total number of managers (headcount) 1 Number of medication records reviewed 12 number of staff (headcount) 15 Number of relatives interviewed 4 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed
Consumer Rights as at 15 January 2014 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. Organisational Management as at 15 January 2014 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. Some standards applicable to this service partially attained and of low risk. Continuum of Service Delivery as at 15 January 2014 Includes 13 standards that support an outcome 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 medium or high risk and/or unattained and of low risk. Safe and Appropriate Environment as at 15 January 2014 Includes 8 standards that support an outcome 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. Restraint Minimisation and Safe Practice as at 15 January 2014 Includes 3 standards that support outcomes consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service attained. Infection Prevention and Control as at 15 January 2014 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. Standards applicable to this service attained.
No short falls Standards applicable to this service fully attained Some 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 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 Consumer Rights as at 27 November 2013 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. Some standards applicable to this service partially attained and of low risk. Organisational Management as at 27 November 2013 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. Standards applicable to this service fully attained. Continuum of Service Delivery as at 27 November 2013 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. Standards applicable to this service fully attained. Safe and Appropriate Environment as at 27 November 2013 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. Standards applicable to this service attained.
The Kawerau Social Services Trust Board Current Status: 28 January 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified. General overview Mountain View Rest Home continues to provide rest home and hospital care to a maximum of 50 older people. On the day of audit there are a total of 43 residents, 16 in the rest home and 27 in the hospital. There have been no changes to the service scope or size of the facility or significant changes to staff. Building improvements have occurred since the previous certification audit in 2012. This unannounced audit revealed three areas requiring improvement. One relates to the analysis of clinical quality indicators and the other two are ongoing improvements required to restraint practice. Six of the eight areas identified for improvement at the previous audit are now resolved. Audit Summary as at 28 January 2014 Standards have been assessed and summarised below: Key Indicator Description Definition Includes commendable elements 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 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
with staff). Documents sighted and staff interviewed (eg, registered nurses (RN)s, caregivers, and administrators’) demonstrate that processes are appropriately adhered to. Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1) The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3) An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Outcome 1.2: Organisational Management Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.
information was provided to residents prior to consents being sought and they were able to decline or withdraw their consent. D13.1 There were eight of eight admission agreements sighted. D3.1.d Discussion with nine family (one from the rest home, three from the dementia unit and four from the hospital) identified that the service actively involves them in decisions that affect their relative’s lives. Policies and training support staff in providing care and support so that residents can make choices and be involved in the service. There is an informed consent policy and procedure that directs staff clearly in relation to the gathering of informed consent. Interviews with five caregivers, one registered nurse and one enrolled nurse identify that consents are sought in the delivery of personal cares and this is confirmed by eight residents interviewed (four rest home, four hospital). Resuscitation policy is implemented and there are signed forms in all resident files reviewed. Resuscitation forms are reviewed annually. D13.1: There were eight admission agreements sighted and all eight had been signed on the day of admission. D3.1.d: Discussion with nine of nine family/whanau identified that the service actively involves them in decisions that affect their relative’s lives. Criterion 1.1.10.2 (HDS(C)S.2008:1.1.10.2) Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.1.10.4 (HDS(C)S.2008:1.1.10.4) The service is able to demonstrate that written consent is obtained required. Attainment and Risk: FA Evidence: Finding: Corrective Action:
towards meeting the desired outcome. HDS(C)S.2008 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. PA Low HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Low Two medication charts do not have photo identification. ii) A short course of topical medication does not have a signing sheet. Ensure all medication charts have photo identification. ii) Ensure signing sheets are in place for topical medications. 30 Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards Outcome 1.1: Consumer Rights 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, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs.
Criteria 0 0 0 0 0 0 0 60 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Low HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low (i)One hospital resident reviewed by the psychiatrist for challenging behaviour does not have a behaviour assessment in place documenting alternative strategies/activities for the de-escalation of challenging behaviours as per the psychiatrist letter. ii) Two hospital residents with reports of a) wound pain and b) exacerbation of a chronic pain do not have pain assessments completed. One rest home resident on regular and prn analgesia for breakthrough pain does not have a pain assessment or monitoring of the effectiveness of pain. The initial assessment (i)Ensure alternative strategies/activities for the de-escalation of challenging behaviours are documented in the care plan/behavioural assessment. ii) Ensure pain assessments are completed for all residents who identify with chronic, breakthrough or new pain episodes. Ensure there is monitoring of the effectiveness of pain relief. iii) Ensure chronic wounds are documented on the chronic/complex wound care plan and linked to the long term care plan. 60
for one rest home resident does not identify a high pressure area risk as per the nursing discharge summary. iii) Two wounds have become chronic. They are written onto the wound short term care plan. The chornic wounds are not linked to the long term care plan. HDS(C)S.2008 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. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Moderate Three out of 12 medication signing sheets have “am” documented as the time given for medications. One resident has an inhaler prescribed twice daily, which is being administered daily. Ensure the time is entered for administration of medications. Ensure the right doses are administered as prescribed on the medication chart. 7 HDS(C)S.2008 Standard 1.3.13: Nutrition, Safe Food, And Management A consumer's individual food, fluids and nutritional needs are met where this service is a PA Low
cellulitis and on another occasion same resident suffered an acute cholecystitis. HDS(C)S.2008 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. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Moderate (i)It was noted that three of 12 medication signing sheets reflect a failure to include a signature after medication administration; (ii) Two eye drop containers on the hospital medication trolley reflect no date and time of opening on the container; (iii) weekly controlled drug stock checks have not been conducted; (iv) controlled drug administration records do not (i) Ensure that all medications administered are signed for; (ii) ensure that eye drop medications are dated at time of opening; (iii) conduct weekly controlled drug checks as per guidelines; (iv) ensure that controlled drug administration sheets evidence two staff signatures. 60
evidence two staff signatures. HDS(C)S.2008 Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate It is noted that annual competency for caregivers has not been maintained and that registered nursing staff have not completed medication competency. Ensure that all staff with medication administration responsibilities are assessed as competent to do so. 60 HDS(C)S.2008 Standard 1.4.6: Cleaning And Laundry Services Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in the service is being provided. PA Moderate HDS(C)S.2008 Criterion 1.4.6.3 Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals. PA Moderate Not all bottles containing chemicals were clearly labelled. The sluice room is unlocked and two bottles with cleaning chemicals were on the bench. Ensure chemicals are clearly labelled and stored correctly. 30 Continuous Improvement (CI) Report Code Name Description Attainment Finding
Audit Team Lead Auditor XXXXX Hours on site 8 off site 6 Auditors XXXXX hours on site 8 Total hours off site 6 Technical Experts Total hours on site hours off site Consumer Auditors Total hours on site hours off site Peer Reviewer XXXXX Hours 2 Sample Totals Total audit hours on site 16 Total audit hours off site 14 Total audit hours 30 Number of residents interviewed 8 Number of interviewed 6 Number of managers interviewed 2 Number of residents’ records reviewed 5 Number of staff records reviewed 5 Total number of managers (headcount) 2 Number of medication records reviewed 10 Total number of staff (headcount) 18 Number of relatives interviewed 5 Number of residents’ records reviewed tracer methodology 1 Number of GPs interviewed 1
Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 40 0 5 0 0 0 Criteria 0 88 0 5 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 5 Criteria 0 0 0 0 0 0 0 8 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 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. PA Low HDS(C)S.2008 Criterion 1.1.10.2 Service providers demonstrate ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making. PA Low D13.1- Five out of five files reviewed showed that admission agreements were not signed by the resident or enduring power of authority. Some of these files reviewed showed that the residents were admitted to the service before the business was transferred to the new owners. The facility manager reports that new contract will be Ensure that admission agreements are signed on the day of admission. 180
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 Consumer Rights as at 31 March 2014 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 attained. Organisational Management as at 31 March 2014 Includes 9 standards that support an outcome 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 medium or high risk and/or unattained and of low risk. Continuum of Service Delivery as at 31 March 2014 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. Some standards applicable to this service partially attained and of low risk. Safe and Appropriate Environment as at 31 March 2014 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. Standards applicable to this service fully attained. Restraint Minimisation and Safe Practice as at 31 March 2014 Includes 3 standards that support outcomes consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. All standards applicable to this service fully attained with some standards exceeded Infection Prevention and Control as at 31 March 2014 trial
noted in criteria 1.3.3.3 and 1.3.4.2 evaluation updates are not always informed by assessment processes). ARRC requirements are met. Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2) Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.3.8.3 (HDS(C)S.2008:1.3.8.3) Where progress is different from expected, the service responds by initiating changes to the service delivery plan. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.3.4 (HDS(C)S.2008:1.2.3.4) There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5) Key components of service delivery shall be explicitly linked to the quality management system. Attainment and Risk: FA Evidence: Finding: Corrective Action:
Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1) Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. ARC D19.3c.v; ARHSS D19.3c.v Attainment and Risk: FA Evidence: The service has waste management policies and procedures for the safe disposal of waste and hazardous substances such as decontamination procedure; blood and body fluid spill management procedure; blood accident procedure. Chemicals are labelled and there is appropriate protective equipment and clothing for staff. There is an incident reporting system that includes investigation of these types of incidents. The service has a health and safety management system. There is a hazard register and on-going hazard control plans. Management of waste and hazardous substances is covered during orientation of new staff. In-service education in management of chemicals, waste and hazardous substances was last delivered by in 2013. Six health care assistants, one registered nurse, the senior coordinator and the manager interviewed are familiar with policies and the appropriate practices. Material Safety Data Sheets are available to staff (sighted). General waste is removed by the council and sharps are removed in an approved container by the pharmacy. Staff were observed to use appropriate personal protective equipment (PPE). Gloves, aprons, and goggles are available for staff. Infection control policies state specific tasks and duties for which protective equipment is to be worn. PPE was observed in use. The staff working on the day of audit demonstrate good knowledge of the appropriate use of protective equipment and clothing. The staff interviewed including six health care assistants, one registered nurse and the senior coordinator interviewed are knowledgeable about the reasons for use of protective equipment and clothing and utilise this. Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1) Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
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 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 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
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 Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low Four of seven long term care plans detail interventions required to meet the needs of the residents. Two dementia care plans lacked interventions to support management of behaviours that challenge. Monitoring of restraints and enablers is guided by policy and assessment tools. Not all monitoring forms had been completed as per requirements. (i). Two dementia care plans lacked interventions to support management of behaviours that challenge. (ii). Monitoring of the lap belt restraint for one hospital resident was not undertaken for three days. (i).Ensure behaviour management strategies are clearly documented in the long term care plan. (ii).Ensure restraint monitoring documentation is completed. 90 days Criterion 1.3.9.1 Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of PA Low There is evidence of medical review and psychogeriatrician involvement in two rest home residents with challenging behaviour. The GP and the pychogeriatrician have documented the residents require referral for higher level of care. Referrals for for two residents have not been initiated for two rest home residents with challenging behaviour as per medical notes. Ensure re-assessments for higher level of care is initiated as per medical advice and within a timely manner. Referrals for needs assessments for both rest home
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 1 15 0 1 0 0 0 Criteria 1 40 0 1 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