West Otago Health Limited - Ribbonwood Country Home Introduction This report records the results of a Certification 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 here. The specifics of this audit included: Legal entity: West Otago Health Limited Premises audited: Ribbonwood Country Home Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care) Dates of audit: Start date: 8 July 2016 End date: 8 July 2016 Proposed changes to current services (if any): Addition of Hospital - medical to the their current certification Total beds occupied across all premises included in the audit on the first day of the audit: 11
Consumer rights 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. Standards applicable to this service fully attained. Ribbonwood home provides care in a way that focuses on the individual resident. Cultural and spiritual assessment is undertaken on admission and is documented in care plans. Policies are implemented to support individual rights such as privacy, dignity, abuse/neglect, culture, values and beliefs, complaints, advocacy and informed consent. Residents and family interviewed verified ongoing involvement with community. Information about the Code and related services is readily available to residents and families. Care plans accommodate the choices of residents and/or their family. Complaints processes are implemented and managed in line with the Code. Organisational management 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. Standards applicable to this service fully attained. Ribbonwood home is implementing a quality and risk management system that supports the provision of clinical care. Quality activities are conducted and corrective actions have been developed and implemented. The service has a culture of health and safety. There are human resources policies including recruitment, job descriptions, selection, orientation and staff training and development. The service has an orientation programme that provides new staff with relevant information for safe work practice. The staffing policy aligns with contractual requirements and includes appropriate skill mixes to provide safe delivery of care.
providers, and visitors. This shall be appropriate to the size and scope of the service. infection data and provides education and support to staff. The infection control programme is not yet due for review. Visitors are asked not to visit if they have been unwell. There are hand sanitisers throughout the facility and adequate supplies of personal protective equipment. There have been no outbreaks. The infection control team is included as part of the quality and staff meetings. Standard 3.2: Implementing the infection control programme There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation. FA The infection control coordinator (registered nurse) manages infection control. The infection control coordinator has maintained current knowledge of infection prevention and control. The infection control coordinator has access to infection control personnel within the district health board, laboratory services and the GP. Standard 3.3: Policies and procedures Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe, and appropriate/suitable for the type of service provided. FA The infection control manual outlines a comprehensive range of policies, standards and guidelines and includes the infection control programme, responsibilities and oversight, training and education of staff. The policies have been reviewed. Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers. FA The infection control coordinator is responsible for coordinating/providing education and training to Infection control education has been provided in the past year. Staff receive education on orientation and as part of the training schedule. Infection control was provided as part of the orientation of staff prior to opening. Resident education occurs during the course of daily cares. Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. FA The surveillance policy describes and outlines the purpose and methodology for the surveillance of infections. The infection control coordinator uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. Surveillance data is available to all staff. Corrective actions are established where trends are identified.