HDS(C)S.2008 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 Moderate (i)Six of six resident records reviewed did not evidence resident/ family/whanau involvement in the care plan process. (ii) of six care plans do not reflect the current needs of the residents; a) there are no alternative strategies/activities documented in the care plan for the management of disturbing behaviours for two hospital level residents and one rest home resident. b) There is no diabetic management plan for one rest home resident on insulin and one hospital resident on oral diabetic medication, and c) There is no management plan for one hospital resident with seizures. (i)Ensure there is documented evidence of resident/family/whanau involvement in the care planning process. (ii) Ensure long term care plans describe the required support and interventions to meet the resident’s needs. 90 HDS(C)S.2008 Criterion 1.3.5.3 Service delivery demonstrate service integration. PA Low Activity plans are not integrated into the resident files. Ensure activity are integrated into the resident files. 90 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, PA Moderate Staff have used dittos on five of 12 non-packaged medication signing sheets. The dose of fentanyl patch is not Ensure administration documentation complies with legislative requirements. 30
review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. documented when applied. HDS(C)S.2008 Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Low HDS(C)S.2008 Criterion 1.4.2.4 The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group. PA Low Gardening chemicals and turpentine were sighted on a shelf, outdoors, at the rear of the facility in an area that is accessible to the residents. Ensure all chemicals, including chemicals used outdoors, are stored in a secure area. 30 HDS(C)S.2008 Criterion 1.4.2.6 Consumers are provided with safe and accessible external areas that meet their needs. PA Low The outdoors area includes tables and chairs but there is a lack of available shade for the residents. Ensure there is adequate shading outdoors for the residents. 180 HDS(C)S.2008 Standard 1.4.4: Personal Space/Bed Areas Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. PA Low HDS(C)S.2008 Criterion 1.4.4.1 Adequate is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area. PA Low There are 12 rooms that have been certified as suitable for dual purpose (rest home or hospital). However, these rooms are only suitable to provide rest home care. Ensure that these identified rooms are only used for residents assessed as rest home care once the temporary accommodation is not required. 180