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. Citerion with desired outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.10.4 The service is able to demonstrate that written consent is obtained where required. PA Low Information about the advance directive is available to residents and their family. There is a process regarding the use of the enduring power of attorney (EPOA) for residents who are not assessed as competent. A copy of the signed EPOA was not sighted in two of five resident files. Evidence of signed EPOA’s has not been maintained. Maintain a record of the signed EPOA. 180 days Criterion 1.1.4.3 The organisation to ensure Māori receive services commensurate with their needs. PA Low Documentation on cultural considerations was limited to cultural considerations for the management of hazardous waste. Documents related to the care of Maori residents were not sighted, for example a Maori health plan/policy and tikanga practices. Provide staff with documentation related to the care of Maori residents. 180 days Criterion 1.1.8.1 The service provides an environment that encourages good practice, which PA Areas requiring improvement in service delivery resulted in a high risk finding. This included two areas regarding medication management and staff competencies (refer criteria 1.3.12.3 and Evidence of consistent good Provide consistent good practice.
should include evidence-based practice. 1.3.12.6) There was also insufficient evidence that care planning meets all requirements (refer criteria 1.3.7.1 and 1.3.8.2) and that clinical policies and procedures have been developed in line with best practice (refer 1.2.3.3). practice has not been maintained. 90 days Criterion 1.2.1.3 The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services. PA Low The facility manager is suitably qualified. The facility manager’s job description outlines authority, accountability and responsibility. The facility manager has been in the position since February 2015 and is yet to access the required training for this role. It was stated by the facility manager that training needs had not been discussed. Annual training requirements for the role of the facility manager have not been maintained. Maintain annual training requirements for the person in the role of facility manager 90 days Criterion 1.2.2.1 During a temporary absence a suitably qualified and/or experienced person performs the manager's role. PA The deputising role had been discussed with the clinical manager however the clinical manager had not agreed to perform this role and a formal arrangement was not in place. There is no suitably qualified and/or experienced person to perform the facility manager’s role during a temporary absence. Appoint a suitably qualified person to perform the manager’s role during the facility manager’s temporary absence. 60 days Criterion 1.2.3.3 The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. PA Low New policies and procedures have been developed. Policies include the the date and who authorised the policy. As policies are received they are printed and placed in the appropriate section in the policy manuals and made available to staff in the nurses’ station. A few electronic policies had not been made available to staff and there had been insufficient time following the receipt of the policies to train staff about their content. A document control process is in place however policy manuals did not have an index that was easy to follow. Not all the requirements of policies and procedures have been met. Ensure all the requirements of policies and procedures are met. This includes the appropriateness, accessibility and maintenance of documents and references to best practice/legislation. 90 days
Policies did not consistently reference best practice documents or legislation and some policies were not relevant to the level of care required for residents, for example the oxygen policy. Criterion 1.2.3.7 A process to measure achievement against the quality and risk management plan is implemented. PA Low Internal audits have been implemented as per the internal audit schedule. Records of internal audits are maintained. This was a previous area requiring improvement. A business and risk management plan is in place. This was developed after the last audit. The plan includes methods for monitoring achievement against business and risk goals, however the required review against the plan was yet to occur. Achievement against the business and risk management plans had not occurred. Monitor progress against the business and risk management plans. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low A corrective action process has been implemented. This was identified as a previous area requiring improvement, however not all corrective actions sampled included documented evidence that corrective actions had been addressed, or that the corrective actions has been closed. There was insufficient evidence that all corrective actions had been addressed and/or closed. Document actions taken and close all corrective actions. 90 days Criterion 1.2.9.7 Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable. PA Low Hard copy files storage is secure. Some electronic security was in place, however electronic security procedures, for example backup, could not be confirmed. The security procedures for electronic resident records could not be confirmed. Implement a process which ensures the security, and accessibility, of electronic resident records at all times. 180 days Criterion 1.3.12.3 Service providers responsible for medicine management are competent PA High All staff administering oral medications have current medication competencies. The CM, RN and a healthcare assistant (HCA) had followed Medication competencies have not been maintained. Ensure that all staff administering insulin have the required competencies.
to perform the function for each stage they manage. medication administration policies and procedures as evidenced in the three observed lunchtime medication rounds. There is a medication competency process which requires sign off by the registered nurse. All 14 staff administering insulin have no insulin competencies completed by the registered nurses 30 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines. PA The medication charts are generated by the pharmacy and these are all signed and dated by the GP. All discontinued medications were also signed by the GP. The staff had reported that they reduce the dose of the insulin to be administered for the two out of four residents receiving insulin therapy. These will depend on the resident’s glucose level and when the residents have finished the meals. The medication charts generated by the pharmacy have confirmed this. The GP’s instructions regarding insulin administration do not have clear instructions to ensure safe insulin administration i.e. timing of administration and the actual dose to be administered Medication administration instructions have not been fully documented. Fully document medication administration instructions. 30 days 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 All food is cooked on-site. The kitchen is situated in the dementia unit. Cooked meals are transported to the rest home unit on a covered trolley and the meals are heated in the oven before serving to the residents. The two cooks have completed a course on safe food handling. HCAs assist with the serving of food. They were observed wearing hats and gloves when serving food. The relief cook has not completed safe food handling training. Not all food safety requirements have been maintained Maintain all food safety requirements. For example, food and fridge temperatures and food safety training for all kitchen staff. 180 days
close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use. Monthly hot water monitoring occurs throughout the two buildings, however there are several small kitchen areas and shower rooms throughout the lodge and the hot watering monitoring records did not include the location from which the checks were made. did not include the location from which the water was tested. checked for hot water temperature. 60 days Criterion 1.4.7.3 Where required by legislation there is an approved evacuation plan. PA Low The fire evacuation plan was approved on 19 September 2013. A copy could not be located during the audit. A copy of the approved evacuation plan was not sighted. Retain a copy of the approved evacuation plan 90 days Criterion 1.4.8.1 Areas used by consumers and service providers are ventilated and heated appropriately. PA Low Bedrooms were heated by free standing oil column heaters. Some bedrooms were not warm enough for residents. Adequate heating has not been consistently maintained in bedroom Provide heating that meets the needs of the residents. 60 days