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
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. All standards applicable to this service fully attained with some standards exceeded. Policies and procedures adhere with the requirements of the Code of Health and Disability Services Consumers’ Rights (the Code). Residents and families are informed regarding the Code and staff receives ongoing training about the Code. The personal privacy and values of residents are respected. There is an established Māori health plan in place. Individual care plans reference the cultural needs of residents. Discussions with residents and relatives confirmed that residents and where appropriate their families are involved in care decisions. Regular contact is maintained with families including if a resident is involved in an incident or has a change in their current health. Families and friends are able to visit residents at times that meet their needs. Examples of good practice were provided. is an established system for the management of complaints, which meets guidelines established by the Health and Disability Commissioner. 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. Standards applicable to this service fully attained. Services are planned, coordinated, and are appropriate to the needs of the residents. An assistant village manager and care lead are responsible for the day-to-day operations. Goals are documented for the service with evidence of regular reviews. A quality
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 2 47 0 1 0 0 0 Criteria 5 95 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