Little Sisters of The Poor Aged Care New Zealand Limited - St Joseph's Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008). The audit has been conducted by Health and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health. The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008). You can view a full copy of the standards on the Ministry of Health’s website by clicking . The specifics of this audit included: Legal entity: Little Sisters of The Poor Aged Care New Zealand Limited Premises audited: St Joseph's Home & Hospital Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care) Dates of audit: Start date: 12 November 2014 End date: 12 November 2014 Proposed changes to current services (if any): None Total beds occupied across all premises included in the audit on the first day of the audit: 30
Internal audit of infection control is included in the annual programme and occurs monthly. Definitions of infections are described in the infection control manual. Infection control policies are in place appropriate to the complexity of service provided. The surveillance policy describes the purpose and methodology for the surveillance of infections including risk factors and needs of the consumers and service providers. Communication between the facility, primary and secondary services regarding infection control is reportedly responsive and effective. GP's are notified if there is any resistance to antimicrobial agents. There is evidence of G.P involvement and laboratory reporting. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA There is a restraint minimisation procedure. This includes definitions of restraints and enablers, cultural safety, privacy and dignity, approved restraints, use of enablers, the role of the restraint coordinator, alternative interventions, implementing restraint, assessing risk, consent, monitoring, evaluation, quality review and education. The restraint coordinator is a registered nurse. The restraint coordinator interviewed was able to clearly describe the minimisation strategies used. There is a restraint committee which meets three monthly or as necessary. Meeting notes were sighted. There is a restraint register. There is also a register for hi-lo beds and anti-roll mattresses. All staff receive education on restraint minimisation at orientation and as part of in-service training. There are currently four enablers and one restraint in use. Four enabler and one restraint file were reviewed. All had signed consents. The restraint had the risks associated with restraint identified and documented on the assessment and consent form. Alternative strategies had been tried before restraint was applied. The service has addressed a previous audit finding ensuring the use of enablers is voluntary and the least restrictive option is used to promote or maintain resident independence and safety.