Audit Team Lead Auditor XXXXX on site 16 Hours off site 8 Auditors XXXXX hours on site 16 Total hours off site 4 Technical Experts hours on site Total hours off site Consumer Auditors hours on site hours off site Peer Reviewer XXXXX Hours 3 Sample Totals Total audit hours on site 32 Total audit hours off site 15 audit hours 47 Number of residents interviewed 8 Number of staff interviewed 17 Number of managers interviewed 4 Number of residents’ records reviewed 9 Number of staff records reviewed 10 number of managers (headcount) 4 Number of medication records reviewed 20 Total number of staff (headcount) 97 Number of relatives interviewed 2 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed 1
The business and care manager advises there have been no complaint investigations by the Ministry of Health, Health and Disability Commissioner, District Health Board, Accident Compensation Corporation (ACC) or Coroner since the previous audit at this facility. Complaints policies and procedures are compliant with Right 10 of the Code. Systems are in place to ensure residents and their family are advised on entry to the facility of the complaint processes and the Code. Residents (four hospital and four rest home) and family (one hospital and one rest home) interviewed demonstrate an understanding and awareness of these processes. Resident meetings are held two monthly and residents are able to raise any issues they have during these meetings and this is confirmed during interview of residents and review of meeting minutes. A visual inspection of the facility provides evidence that the complaint process is readily accessible and/or displayed. Review of quality and staff meeting minutes and the business and care manger’s monthly reports provides evidence of reporting of complaints to the governing body and staff. Care staff interviewed confirm this information is reported to them via their staff meetings and that graphs of this data is displayed on the noticeboard in the staff room. The district health board contract requirements are met. Criterion 1.1.13.1 (HDS(C)S.2008:1.1.13.1) The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. 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 1.1.13.3 (HDS(C)S.2008:1.1.13.3) An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. Attainment and Risk: FA Evidence: Finding:
including competency assessments (as appropriate). Care staff also confirm their attendance at on-going in-service education and currency of their performance appraisals. The district health board contract requirements are met. Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2) Professional qualifications are validated, including evidence of registration and of practice for service providers. 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 1.2.7.3 (HDS(C)S.2008:1.2.7.3) The appointment of appropriate service providers to safely meet the needs of consumers. 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.)