Audit Team Lead Auditor XXXXXX Hours on site 4 off site 4 Other Auditors Total hours on site Total hours off site Technical Experts hours on site hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXX Hours 1 Sample Totals Total audit hours on site 4 Total audit hours off site 5 Total audit hours 9 Number of residents interviewed Number of staff interviewed 2 Number of managers interviewed 2 Number of residents’ records reviewed Number of staff records reviewed 7 Total number of managers (headcount) 2 Number of medication records reviewed Total number of staff (headcount) 40 Number of relatives interviewed Number of residents’ records reviewed using tracer methodology Number of GPs interviewed
Criteria 0 0 0 0 0 0 0 77 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Low HDS(C)S.2008 Criterion 1.4.2.4 The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group. PA Low The environment is generally safe, but currently access toTui wing is via reception in the main home. All this area will become a secure area once the reconfiguration occurs, so there needs to be a separate/independent and suitable entry/access for rest home level residents and their families. Create a safe and readily accessible entry point for residents and their visitors, to and from the wing which will be designated as the rest home. to occupancy HDS(C)S.2008 Criterion 1.4.2.6 Consumers are provided with safe and accessible external that meet their needs. PA Low The external areas around Tui wing (which is currently designated and designed for secure care), are grassed without pavements and only contain 'safe' and suitable planting and outside furniture. This requires some modification to make it more attractive for use Upgrade and modify the external areas of Tui wing (the wing which is currently designed for dementia care) to make this area more appropriate and suitable for rest home level care residents. There is also a requirement to carry out the minor modifications required Prior to occupancy
Entertainment, Recreation, And Dining adequate, age appropriate and accessible areas to meet their relaxation, activity, and dining needs. HDS(C)S.2008 Criterion 1.4.5.1 Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers. PA Low Each wing has its own lounge and dining room and these are located within easy walking distance from the resident’s bedrooms. The two dining rooms and lounges in Kahikatea and Pukeko wing will stay as separate areas with clear and separate demarcation between lounge and dining rooms. The lounge and dining areas in Tui wing are not as spacious or provide enough seating for 15 rest home level care residents (there are only 14 armchairs and 14 dining room chairs). This requires improvement. The provider has undertaken to convert one or two existing bedrooms into a separate quiet lounge. Ensure there is adequate seating and space for entertainment, relaxation. Recreation and dining in the area proposed for rest home level care. Prior to occupancy