Restraint minimisation and safe practice The organisation has policies and procedures that support the minimisation of restraint. No enablers and four restraints were in use at the time of audit. A comprehensive pre-assessment is undertaken prior to restraint being implemented. Policy identifies approval and monitoring process to ensure safe restraint use and to meet best practice. Use of enablers is voluntary for the safety of residents in response to individual requests. Staff demonstrated knowledge and understanding of the restraint and enabler processes. Infection prevention and control The infection prevention and control programme, led by a trained infection control coordinator, aims to prevent and manage infections. The programme is reviewed annually. Specialist infection prevention and control advice is accessed when needed. Staff demonstrated good principles and practice around infection control, which is guided by relevant policies and supported with regular education. Aged care specific infection surveillance is undertaken, and results reported through all levels of the organisation. Follow-up action is taken as and when required. 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 0 36 0 10 3 1 0 Criteria 0 83 0 14 3 1 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
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 is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.13.3 An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. PA Low The service has a complaints/complements register in place which identifies the complaint made, the dates and actions taken. Complaints forms can be easily accessed from a holder located at the nurses’ station. Documentation shows that appropriate actions are taken when dealing with complaints, however, not all complaints are entered into the complaints register. The facility manager located documentation related to two complaints which have occurred since the last entry was made in the complaints register which identify the actions taken to date to manage the complaints. Both these complaints remain open at the time of audit. The last recorded complaint documented in the complaints register is dated August 2016. Two recent complaints are not identified in the complaints register, one of which is related to a serious issue and remains open under police investigation. Provide evidence that all complaints are entered into the complaints register. 180 days Criterion 1.1.4.3 The organisation plans to ensure Māori receive services commensurate with their needs. PA Low One of one files reviewed evidenced an initial assessment at time of admission of a resident in the dementia unit whom affiliated with their Maori culture. The short term and long term care plan evidenced interventions and the Maori Health plan was not implemented. English was documented as the A resident whom affiliates with their Maori culture does not have a Maori Health plan Ensure all residents who affiliate with their Maori culture are supported by a Maori Health plan.
residents’ primary language however when interviewed the resident responded in Maori. Documentation evidenced regular communication with family/whanau. Family were unable to be contacted on the day of audit. 180 days Criterion 1.2.1.1 The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. PA The organisation has a strategic and business plan in place (February 2015). The objectives and goals documented have not been reviewed since they were put in place. Policy outlines the purpose, values, and scope of the organisation. No reporting occurs between the facility manager and the current owner. The current facility manager was unaware that regular review of the documented goals and objectives set was a requirement. The organisation’s strategic and business plan was last reviewed in February 2015. The current owner/director stated they were unaware that they were required to monitor the set objectives and goals. Provide evidence that the organisational planning processes are overseen by the governing body and regularly reviewed to allow monitoring of planned, coordinated and appropriate service delivery to meet the needs of residents. 60 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 overall day to day service is managed by a facility manager who has been a registered nurse since 2013. They maintain their required educational hours to meet Nursing Council requirements. They have worked at the facility since July 2016, firstly as the clinical nurse manager and then as the facility manager since November 2016. This is their first role as a facility manager. The facility manager confirmed knowledge of the sector, regulatory and reporting requirements and maintains currency through attendance at ongoing clinical education sessions, via two post graduate papers related to the health field. They have also commenced attendance at aged care professional development seminars. The facility manager is new to the role and they have no established localised networks or support from the current owner. The current owner had very limited knowledge of what is expected as the owner of an aged care facility. There are no formalised lines of communication between the facility manager and the current owner. Provide evidence that the facility manager is supported into their role to allow them to gain confidence and experience to complete all required tasks. 180 days
put in place to ensure best practice for safe administration of medication and safe disposal of used needles/syringes is followed. Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low All residents admitted to the facility had written initial assessments, short term and long term care plans and evaluations provided with required timeframes. It was evident from staff interviewed that they knew the residents well. Family/whanau interviewed stated that they were happy with the care and communication provided. However, one resident admitted in January 2017 via the hospital for respite care has not been admitted by a GP, all other GP assessments are within required timeframes. 18 of 23 residents did not have an up to date interRAI assessment. Two of 23 interRAI assessments were last completed in 2015, 11 interRAI assessments were last completed in 2016. The clinical nurse manager stated that interRAI assessments were not up to date due to high staff turn-over. No corrective action plan is in place at time of audit however a registered nurse employed recently at the facility is interRAI trained and awaiting permission and to have access to the facility database. Not all residents had an up to date interRAI assessment or GP admission. Ensure that all residents have an interRAI assessment and are admitted by a GP to meet contractual requirements and time frames. 180 days 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 All residents admitted to the facility had assessment tools completed. It was evident from staff interviewed that they knew the residents well. Family/whanau interviewed stated that they were happy with the care and communication provided. Two of seven residents’ files were reviewed, one resident did not have documented in their short and long term care plans evidence to support the use of a moon boot supporting a fracture. One resident had evidence to show the need for a restraint, however this was not reflected in the resident’s short or long term care plan. Not all residents had identified needs documented in the support care plan. Ensure the needs of all residents are identified in the service delivery planning. 180 days