Audit Team Lead Auditor XXXXX Hours on site 16 Hours off site 8 Other Auditors Total hours on site 16 Total hours off site 4 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer Hours 0 Sample Totals Total audit hours on site 32 Total audit hours off site 12 Total audit hours 44 Number of residents interviewed 10 Number of staff interviewed 21 Number of managers interviewed 3 Number of residents’ records reviewed 10 Number of staff records reviewed 9 number of managers (headcount) 3 Number of medication records reviewed 20 number of staff (headcount) 76 Number of relatives interviewed 14 Number of residents’ records reviewed using tracer methodology 3 Number of GPs interviewed 1
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2) Consumers are informed of rights. ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii Attainment and Risk: FA Evidence: A registered nurse discusses the Code, including the complaints process with residents and their family on admission. Discussions relating to the Code are also held at during the monthly residents' meetings (meeting minutes sighted). Residents and family interviewed including 10 residents (six rest home and four hospital) and 11 family members (three rest home, four hospital and four dementia unit) confirm their rights are being upheld by the service. Information regarding the Health and Disability Advocacy Service is clearly displayed in multiple locations throughout the facility and in a brochure that is held at reception. Pamphlets around the Code are available at the front entrance of the service with posters in English and Maori in all areas including the dementia unit. If necessary, staff will read and explain information to residents as stated by the health care assistants and registered nurses interviewed. Information is also given to next of kin or enduring power of attorney (EPOA) to read to and discuss with the resident in private. Ten residents and 11 family members interviewed are able to describe their rights and advocacy services particularly in relation to the complaints process. An audit of the Code and advocacy in June 2014 shows that the audit achieved 96%. The District Health requirements are met. Criterion 1.1.2.3 (HDS(C)S.2008:1.1.2.3) Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service. Attainment and Risk: FA Evidence:
being Criterion 1.1.7.3 (HDS(C)S.2008:1.1.7.3) Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or of the consumer. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8) Consumers receive services of an appropriate standard. ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c Attainment and Risk: CI Evidence: Takanini Lodge implements Oceania policies to guide practice. These policies align with the health and disability services standards and are reviewed annually. There is a quality framework that that supports an internal audit programme. Benchmarking occurs across all the Oceania facilities with Takanini Lodge actively reviewing the data and making improvements as a result. There is a comprehensive training programme and managers complete management training. The training programme for all staff includes extra topics outside of those identified on the Oceania standard training plan in response to needs identified and projects taking place. The staff interviewed including the seven health care assistants describe sound practice based on policies and procedures, care plans and information given to them via the registered nurses, clinical and business and care managers. Specialised training and related competencies are in place for the registered nursing staff. There is a comprehensive programme of meetings at a national, regional and service level and this ensures that the quality improvement and risk management programme is monitored with data used to improve service delivery. Projects are undertaken to improve the lives of residents with these evaluated to ensure that outcomes have improved. Residents and families interviewed expressed a high level of satisfaction with the care delivered. The general practitioner reports a high standard of care is provided at the service and the registered nurses demonstrate good clinical assessment skills. Consultation is available through the organisation’s management team that includes registered nurse, dietician and others as required. A physiotherapist is available for two days a week with a physiotherapist assistant implementing plans. The service has been given a rating of continuous improvement for good practice.
The District Health Board contract requirements are met Criterion 1.2.9.1 (HDS(C)S.2008:1.2.9.1) Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting. 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 1.2.9.7 (HDS(C)S.2008:1.2.9.7) Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable. 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.)
The CM and RNs verbalise that medications are not crushed in the service. The CM reports that there are two residents who self-administer inhalers. There are processes in place for self-administration. The medicine self-administration policy is sighted and the CM is able to discuss the self-administration procedure. The inhalers are kept inside a locked cupboard in the resident’s room. The medication competencies for all the 14 RNs and one health care assistant are current and evidence in the documentation. The District Health Board requirements D1.1g, D19.2d are not met Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1) 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. 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 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each stage they manage. 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.)