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 4 September 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. Some standards applicable to this service partially attained and of low risk. Organisational Management as at 4 September 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 4 September 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 4 September 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 4 September 2014 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 4 September 2014
choice are provided with the information they need to make informed choices and give informed consent. HDS(C)S.2008 Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. PA Low ‘Not all resuscitation’ records are recorded and GP sign off is not consistently recorded on the resuscitation orders. ‘Not for resuscitation’ orders are not consistently signed by GPs (four of eight files, two rest home and two hospital) and one of eight files (one rest home) evidences the ‘not for resuscitation’ record is not completed. The facility policy states the GP verifies if a resident is competent to make a resuscitation decision. Provide evidence the GP assesses and documents the resident is competent to make resuscitation decisions. 90 HDS(C)S.2008 Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. PA Low HDS(C)S.2008 Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low In seven of eight files reviewed, there are inconsistent recordings of time of entry in progress notes and inconsistent recording of Ensure that all entries in progress include the time of entry and designation of person making the entry. 90
designation of person making the entry. HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. PA Low HDS(C)S.2008 Criterion 1.3.3.1 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. PA Low The initial care plan is completed by an enrolled nurse (EN) and not checked and countersigned by registered nurse (RN), as per ARC contract D16.2b and D16.3b. Provide evidence the initial care plan completed by an enrolled nurse is reviewed and countersigned by a RN. 90 HDS(C)S.2008 Standard 1.3.4: Assessment Consumers' support requirements, and preferences are gathered and recorded in a timely manner. PA Low HDS(C)S.2008 Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Low The initial care plans do not include spiritual and cultural aspects of care (ARC contract D16.2a). Risk assessments are not consistently conducted when required. Seven of eight resident files (three hospital and four rest home) with Provide evidence of a full assessment process for all residents. 90
pain issues do not evidence completion of pain assessments. Respite care resident’s file does not evidence completion and documentation of any risk assessments. 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 1.3.8.3 progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Low term care plans are not consistently conducted for short term problems. Two of five short term care plans reviewed do not evidence detailed planned intervention related to the short term problem. Provide evidence short term care plans are recorded for short term problems and interventions are detailed to guide care relating to the short term problems. 60 HDS(C)S.2008 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. PA Low HDS(C)S.2008 Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines. PA Low Decanted foods are not dated. Provide evidence decanted foods are dated. 90
Standard 1.3.10: Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10) Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. ARC D21 ARHSS D21 Attainment and Risk: FA Evidence: The residents’ files evidence appropriate communications between family and other providers and demonstrate transition, exit, discharge or transfer plan is communicated to all relevant providers, when required. Transition, exit, discharge, or transfer form / letters / plan are located in residents' files. The policy and procedures describes guidelines for death, discharge, transfer, documentation and follow up. One resident’s file where the resident had been transferred to hospital acutely, evidences appropriate transfer documentation. All relevant information is documented and communicated to the receiving health provider or service. Criterion 1.3.10.2 (HDS(C)S.2008:1.3.10.2) Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives. 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.) Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12) Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d Attainment and Risk: FA Evidence: The medication area in the facility evidences an appropriate and secure medicine system, free from heat, moisture and light, with medicines stored in original dispensed packs. The controlled drug storage area is secure. The controlled drug register is maintained and evidences weekly checks and six monthly stock takes. The medication fridge temperature checks are conducted and recorded.