Care Alliance Limited - Waimarie

Transcription

1 Care Alliance Limited - Waimarie Current Status: 4 March 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified. General overview Care Alliance Waimarie is a private hospital with two rest home beds. The facility has 52 beds. On the days of the audit there are 42 hospital and two rest home level residents. The service is maintaining this number as renovations and redecorating are to commence shortly. The manager oversees the care service and reports to the business manager/director on a regular basis and is supported by a senior registered nurse, and multidisciplinary team is available. The manager advises that there have been no significant changes to the size and scope of the service and no significant events which have negatively impacted on the service delivery. There are no areas identified for improvement from this certification audit and all ARRC agreement requirements are effectively met. Audit Summary as at 4 March 2014 Standards have been assessed and summarised below: Key Indicator Description Definition Includes commendable elements above the required levels of performance All standards applicable to this service fully attained with some standards exceeded No short falls Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity A number of shortfalls that require specific action to address Major shortfalls, significant action is needed to achieve the required levels of performance Standards applicable to this service fully attained Some standards applicable to this service partially attained and of low risk Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk Some standards applicable to this service unattained and of moderate or high risk

2 Consumer Rights as at 4 March 2014 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. Organisational Management as at 4 March 2014 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. Continuum of Service Delivery as at 4 March 2014 Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Standards applicable to this service fully attained. Safe and Appropriate Environment as at 4 March 2014 Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Standards applicable to this service fully attained. Restraint Minimisation and Safe Practice as at 4 March 2014 Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service fully attained. Infection Prevention and Control as at 4 March 2014 Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. Standards applicable to this service fully attained. Audit Results as at 4 March 2014 Consumer Rights There is an open disclosure policy available which clearly defines the rights of residents to full and frank information and open disclosure from service providers. The key components of open

3 disclosure are emphasised and include openness and timeliness of communication, acknowledgement of regret and/or apology, recognition of the reasonable expectations of the resident and their support person, staff support and maintaining confidentiality. The service has an easily accessed and responsive complaints management system which is understood by staff, residents and family members. This documented complaints process is implemented to ensure all complaints are followed up and information is used as an opportunity to improve service delivery as appropriate. All complaints are documented and outcomes include corrective action management as appropriate to improve service delivery. A complaints register is maintained. There are no outstanding complaints at the time of the audit. Services are provided in a manner that respects the Code of Health and Disability Services Consumers Rights (the Code) and facilitates informed choice. The Code is clearly displayed. Residents and relatives interviewed express their satisfaction with services and believe staff are providing appropriate care and they are treated with respect and dignity. Interpreter and advocacy services are available. Residents and, where appropriate, the family/whanau are provided with information to assist them to make informed choices and give informed consent. The organisation has appropriate policies, procedures and a staff education programme to ensure the recognition of Maori values and beliefs. The service provides care that recognises and respects the resident s individual culture, values and beliefs. There is a documented and implemented policy on open disclosure and effective communication is evident and demonstrated between the manager, general practitioner and staff interviewed. The ARRC requirements and the obligations of the Code are met. Organisational Management The service has documented values, purpose and goals set out in the Strategic Direction which includes the quality improvement, business plan and risk and management plan for The plans identify objectives used to ensure that planning is co-ordinated to meet the individual needs of the residents. The day to day operation of the facility is undertaken by staff that are appropriately experienced and qualified. Documented quality and risk management systems are implemented to assist residents, visitors and staff safely. Internal audits are performed to measure the quality of service, inclusive of regular audits and analysis of collected data and ensuring corrective action planning is monitored for appropriate outcomes. Quality improvement data are used to improve the service delivery. Human resource management processes implemented reflect current good practice and meet legislative requirements. An education plan is developed and implemented for The service implements safe staffing levels and skill mix to ensure the contractual requirements and resident safety is promoted and maintained with team work and continuity of care. Continuum of Service Delivery The organisation has systems and processes implemented to assess, plan and evaluate the care needs of rest home and hospital residents in residential care. Staff are trained and qualified to perform their roles and deliver all aspects of service provision. The manager who is a registered nurse (RN) oversees the care and management of all residents along with the RN s in all service

4 areas. All residents are assessed on admission and assessment details are retained in the individual resident`s records. Two registered nurses have attended training on InterRAI assessments but this has not been implemented yet at Care Alliance Waimarie. The residents care plans are well documented and clearly identify the needs, outcomes and or goals and these are reviewed monthly or more often with resident and family being involved as required. Short term care plans are used as required to guide service delivery for residents who have short term needs. A general practitioner interviewed verifies that all residents are seen on admission and explains that full medical cover is provided for all residents 24 hours a day. The activities available are appropriate for residents requiring hospital or rest home residential care. These include community groups coming to the facility and external visits. Medication management systems comply with current legislation and all clinical staff involved in medicine management undergo competency assessment annually. The manager (RN) is responsible for all areas of medication management and works alongside a contracted pharmacy, who oversees controlled drugs and prescribed medication. The food service is prepared on site and there are two cooks who oversee this service. The menu plans have been reviewed by a contracted dietician to ensure they are suitable for the needs of the elderly. There is a four weekly menu cycle and daily menus are displayed in each area. Each resident is assessed by the registered nurse on admission for any identified needs in relation to nutritional status, weight, likes and dislikes. A copy of the nutritional profile is retained in the records and the kitchen is notified of any special food requests and diets can be accommodated. Visual inspection of the kitchen evidences compliance with current legislation and guidelines. All kitchen staff have completed food safety training. Meals are provided at appropriate times of the day. Residents and family/whanau interviewed report satisfaction with the food service provided. Safe and Appropriate Environment Residents are provided with safe, adequate, age appropriate facilities that are appropriately furnished. There are adequate toilets, shower and hand washing facilities. All bedrooms are spacious and furnished to meet the residents needs and likes. Residents can access safe outdoor areas. There is a reactive maintenance process and a long term maintenance programme in place. Safety is paramount and the health and safety co-ordinator manages effectively the safety for residents, staff and visitors for this service. Environmental checks are performed on a regular basis. Planning for an external disaster has occurred and there are provisions in case of such an emergency. A plan is available in each service area on the notice board to guide staff if and when required. Staff have had training in basic life support and first aid. Safe and hygienic cleaning and laundry services are provided for residents and the facility is clean. All chemicals are stored securely and safely. All residents areas have adequate light and ventilation with at least one open window or door to the outside. The home has adequate heating throughout.

5 Restraint Minimisation and Safe Practice The Restraint Policy reviewed defines all types of restraint and enablers in ways that are congruent with the standards. It clearly describes procedures associated with restraint use. The associated forms meet the intent of the standards. Enablers are used for residents as a least restrictive option and are voluntarily implemented to maintain independence and safety. Restraint minimisation is promoted at all times. There are no residents using restraint or enablers at this time. Infection Prevention and Control Care Alliance Waimarie has an infection prevention programme which meets legislative requirements. There is an Infection Prevention Control (IPC) Coordinator who is being trained by the manager (RN). There is a monthly meeting to report to the staff on any issues relating to IPC. Surveillance is occurring for residents who develop infections and these are reported to the IPC team monthly.

6 HealthCERT Aged Residential Care Audit Report (version 4.0) Introduction This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under 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). It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls. Audit Report Legal entity name: Certificate name: Designated Auditing Agency: Care Alliance Limited Care Alliance Limited - Waimarie The DAA Group Limited Types of audit: Certification Audit Premises audited: Care Alliance Waimarie Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric) Dates of audit: Start date: 4 March 2014 End date: 5 March 2014 Proposed changes to current services (if any): Total beds occupied across all premises included in the audit on the first day of the audit:

7 Audit Team Lead Auditor XXXXX Hours on site Other Auditors XXXXX Total hours on site Technical Experts Consumer Auditors Total hours on site Total hours on site 16 Hours off site 16 Total hours off site Total hours off site Total hours off site Peer Reviewer XXXXX Hours 2.5 Sample Totals Total audit hours on site 32 Total audit hours off site 22.5 Total audit hours Number of residents interviewed 7 Number of staff interviewed 15 Number of managers interviewed 2 Number of residents records reviewed Number of medication records reviewed Number of residents records reviewed using tracer methodology 8 Number of staff records reviewed 7 Total number of managers (headcount) 16 Total number of staff (headcount) 36 Number of relatives interviewed 3 2 Number of GPs interviewed 1 2

8 Declaration I, XXXXX, Managing Director of Wellington hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of The DAA Group Limited, an auditing agency designated under section 32 of the Act. I confirm that: a) I am a delegated authority of The DAA Group Limited Yes b) The DAA Group Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes c) The DAA Group Limited has developed the audit summary in this audit report in consultation with the provider Yes d) this audit report has been approved by the lead auditor named above Yes e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable g) The DAA Group Limited has provided all the information that is relevant to the audit Yes h) The DAA Group Limited has finished editing the document. Yes Dated Thursday, 27 March 2014

9 Executive Summary of Audit General Overview Care Alliance Waimarie is a private hospital with two rest home beds. The facility has 52 beds. On the days of the audit there are 42 hospital and two rest home level residents. The service is maintaining this level for some renovations and redecorating to commence soon. The manager oversees the care service and reports to the business manager/director on a regular basis and is supported by a senior registered nurse and all of the multidisciplinary team being available. The manager advises that there have been no significant changes to the size and scope of the service and no significant events which have negatively impacted on the service delivery. There are no areas identified for improvement from this certification audit and all ARRC agreement requirements are effectively met. Outcome 1.1: Consumer Rights There is an open disclosure policy available which clearly defines the rights of residents to full and frank information and open disclosure from service providers. The key components of open disclosure are emphasised and include openness and timeliness of communication, acknowledgement of regret and/or apology, recognition of the reasonable expectations of the resident and their support person, staff support and maintaining confidentiality. The service has an easily accessed and responsive complaints management system which is understood by staff, residents and family members. This documented complaints process is implemented to ensure all complaints are followed up and information is used as an opportunity to improve service delivery as appropriate. All complaints are documented and outcomes include corrective action management as appropriate to improve service delivery. A complaints register is maintained. There are no outstanding complaints at the time of the audit. Services are provided in a manner that respects the Code of Health and Disability Services Consumers Rights (the Code) and facilitates informed choice. The Code is clearly displayed. Residents and relatives interviewed express their satisfaction with services and believe staff are providing appropriate care and they are treated with respect and dignity. Interpreter and advocacy services are available. Residents and, where appropriate, the family/whanau are provided with information to assist them to make informed choices and give informed consent. The organisation has appropriate policies, procedures and a staff education programme to ensure the recognition of Maori values and beliefs. The service provides care that recognises and respects the resident s individual culture, values and beliefs. There is a documented and implemented policy on open disclosure and effective communication is evident and demonstrated between the manager, general practitioner and staff interviewed. The ARRC requirements and the obligations of the Code are met. Outcome 1.2: Organisational Management The service has documented values, purpose and goals set out in the Strategic Direction which includes the quality improvement, business plan and risk and management plan for The plans identify objectives used to ensure that planning is co-ordinated to meet the individual needs of the residents. The

10 day to day operation of the facility is undertaken by staff who are appropriately experienced and qualified. Documented quality and risk management systems are implemented to assist residents, visitors and staff safely. Internal audits are performed to measure the quality of service, inclusive of regular audits and analysis of collected data and ensuring corrective action planning is monitored for appropriate outcomes. Quality improvement data are used to improve the service delivery. Human resource management processes implemented reflect current good practice and meet legislative requirements. An education plan is developed and implemented for The service implements safe staffing levels and skill mix to ensure the contractual requirements and resident safety is promoted and maintained with team work and continuity of care. Outcome 1.3: Continuum of Service Delivery The organisation has systems and processes implemented to assess, plan and evaluate the care needs of rest home and hospital residents in residential care. Staff are trained and qualified to perform their roles and deliver all aspects of service provision. The manager who is a registered nurse (RN) oversees the care and management of all residents along with the RN s in all service areas. All residents are assessed on admission and assessment details are retained in the individual resident`s records. Two registered nurses have attended training on InterRAI assessments but this has not been implemented yet at Care Alliance Waimarie. The residents care plans are well documented and clearly identify the needs, outcomes and or goals and these are reviewed monthly or more often with resident and family being involved as required. Short term care plans are used as required to guide service delivery for residents who have short term needs. A general practitioner interviewed verifies that all residents are seen on admission and explains that full medical cover is provided for all residents 24 hours a day. The activities available are appropriate for residents requiring hospital or rest home residential care. These include community groups coming to the facility and external visits. Medication management systems comply with current legislation and all clinical staff involved in medicine management undergo competency assessment annually. The manager (RN) is responsible for all areas of medication management and works alongside a contracted pharmacy, who oversees controlled drugs and prescribed medication. The food service is prepared on site and there are two cooks who oversee this service. The menu plans have been reviewed by a contracted dietitian to ensure they are suitable for the needs of the elderly. There is a four weekly menu cycle and daily menus are displayed in each area. Each resident is assessed by the registered nurse on admission for any identified needs in relation to nutritional status, weight, likes and dislikes. A copy of the nutritional profile is retained in the records and the kitchen is notified of any special food requests and diets can be accommodated. Visual inspection of the kitchen evidences compliance with current legislation and guidelines. All kitchen staff have completed food safety training. Meals are provided at appropriate times of the day. Residents and family/whanau interviewed report satisfaction with the food service provided. Outcome 1.4: Safe and Appropriate Environment

11 Outcome 2: Restraint Minimisation and Safe Practice The Restraint Policy reviewed defines all types of restraint and enablers in ways that are congruent with this standard. It clearly describes procedures associated with restraint use. The policy and its associated forms meet the intent of this standard. Enablers are used for residents as a least restrictive option and are voluntarily implemented to maintain independence and safety. Restraint minimisation is promoted at all times. There are no residents using restraint or enablers at this time. Outcome 3: Infection Prevention and Control Care Alliance Waimarie has an infection prevention programme which meets legislative requirements. There is an Infection Prevention Control (IPC) Coordinator who is being trained by the manager (RN). There is a monthly meeting to report to the staff on any issues relating to IPC. Surveillance is occurring for residents who develop infections and these are reported to the IPC team monthly. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days)

12 Continuous Improvement (CI) Report Code Name Description Attainment Finding

13 NZS :2008: Health and Disability Services (Core) Standards Outcome 1.1: Consumer Rights 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, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Standard 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1) Consumers receive services in accordance with consumer rights legislation. ARC D1.1c; D3.1a ARHSS D1.1c; D3.1a Consumer Rights policy and procedure sighted acknowledges how the service will ensure residents rights are fulfilled and states a copy of the Health and Disability Commissioner`s (HDC) Code of Health and Disability Services Consumers` Rights (the Code) is provided in the information pack and this will be discussed at admission and on display. The Code is displayed both in Maori and English versions and pamphlets are readily accessible. The manager (RN) interviewed states that the service is held annually to ensure compliance with the Code (evidence sighted). All new employees undergo a service orientation and the Code is covered. The service has an advocacy service which is readily available for residents or family and the Health and Disability Advocacy Service pamphlets with relevant contact numbers are displayed at reception and in all service areas around the hospital. Staff interviewed have a good understanding of the Code. Clinical staff ensure that this understanding of consumer rights is incorporated as part of their everyday practice and care of the residents. Criterion (HDS(C)S.2008: ) Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice..

14 Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2) Consumers are informed of their rights. ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii The policy relating to Consumer Rights identifies that staff are provided with in-service education that relates to the Health and Disability Commissioner`s (HDC) Code of Health and Disability Consumers` Rights (the Code). Policy and procedures identify that all service information brochures include information relating to the Code upon admission to the service. Information about the Nationwide Health and Disability Advocacy Service is available and accessible for residents/family/whanau and information will be sited at audit. A consumer rights policy and procedure states the Code will be discussed on admission to this service. Opportunities will be provided for explanations, discussions and clarification about the Code and information about the Nationwide Health and Disability Advocacy Service will be made available. This is evident with posters clearly displayed in both English and Maori. Pamphlets are readily available on the Code and advocacy services. The Health and Disability Commissioner s office website has the Code information available in multiple languages. Interpreter services are available through the Auckland District Health Board. The Nationwide Health and Disability Advocacy Service is available and the contact numbers are documented on the reverse of the advocacy pamphlet or alternatively the numbers are documented on the reverse of the Code information pamphlet since this was reviewed in The manager (RN) is trained to talk to residents family/whanau/representatives as needed. The seven residents and three family interviewed report they are aware of their rights and whom to contact. Criterion (HDS(C)S.2008: ) Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service.

15 Criterion (HDS(C)S.2008: ) Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers. Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3) Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4 There are adequate policies and procedures documented and reviewed which ensure residents are treated with respect and dignity and that residents are able to maintain personal privacy and maintain their independence as much as possible. There is a policy and procedure for abuse and neglect that clearly defines these and the different forms of abuse. Staff training is provided and the training records sighted during the audit. Policy provides guidance for staff identifying risk factors and/or possible abuse when providing cares. The action required and appropriate reporting system is in place. Legislative requirements to meet are referenced and clearly documented to guide staff. There is one chaplain and an advocate who are available at all times for staff, residents, family/whanau as required. Posters are displayed in all service areas of the facility as appropriate. All staff interviewed are very well informed and acknowledged the importance of being respectful towards all residents and maintaining confidentiality and privacy at all times. On the tour of the facility it is observed that there are doors to close, signage, curtains to be pulled and locks are available on the bathroom doors. Security is maintained at all times. Security systems are in place for ensuring the residents are protected and entrance doors are locked after hours. Contractors sign in when visiting this residential aged care service.

16 The five RN s interviewed report they ensure the cultural values and beliefs are taken into consideration when planning individual care for each resident. Consents, choices and options are discussed with the residents/family/whanau/representative when providing appropriate cares while at the same time maintaining residents independence. All four healthcare assistants interviewed have received education (sighted) and have a good understanding of abuse and neglect and how to report any suspected incidences to the RN in their respective service areas. All eight care plans reviewed reflect the identified needs and wishes of residents, inclusive of social and spiritual needs. The seven residents and three family report they are treated with respect and privacy is upheld at all times. Criterion (HDS(C)S.2008: ) The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times. Criterion (HDS(C)S.2008: ) Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies.

17 Criterion (HDS(C)S.2008: ) Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer. Criterion (HDS(C)S.2008: ) Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect. Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4) Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i The Care Alliance Waimarie Maori Health Plan has been reviewed in November 2013 by a Maori health consultant. A clear philosophy is documented for this service and comprehensive information is provided. The Treaty of Waitangi is clearly defined in relation to cultural awareness and cultural sensitivity. Cultural safety is defined as an outcome of education that enables safe service to be defined by those who receive this service. It includes actions which recognise, respect and nurture the unique

18 cultural identity of tangata whenua, to safety and to meet the needs, expectations and rights of older persons. The Maori Health Plan includes the cultural safety policy, access to services, spiritual, cultural and social support available. Interpreter services are utilised as required through Health Interpreting and Translation Services Auckland City Hospital. The Maori Health Plan identifies the cultural, spiritual, and social needs of Kaumatua. Clearly the Maori Health Plan meets the ARRC service provider agreement obligations and requirements for a Maori health plan which includes: A Maori Health Strategy Plan identifies processes and procedures for the availability and access to services for Maori residents, acceptance of cultural values and implementation of dispute, resolution procedures, effectiveness of service to respond to Maori residents cultural, spiritual and social needs, efficiency in providing services within a reasonable and sustainable budget, cultural safety is acknowledging certain customs that will ensure a culturally safe environment for all residents and consultation with tangata whenua and staff that have been accepted during the consultation process. The appointment of the Maori consultant ensures Maori residents culture and spiritual needs are effectively met in accordance with the Treaty of Waitangi. The four cornerstones of health concept are adopted by this service provider: te whanau, te wairua, te hinengara and te tiana. Kaupapa are acknowledged. As part of the assessment documentation process the resident is given to the opportunity to identify with the Māori culture. There are services available should the resident wish to participate in their culture. Evidence is seen of education in the annual in service programme. There are no residents who wish to have Māori culture recognised on the day of the audit. Criterion (HDS(C)S.2008: ) Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated. Criterion (HDS(C)S.2008: ) The organisation plans to ensure Māori receive services commensurate with their needs.

19 Criterion (HDS(C)S.2008: ) The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers. Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6) Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d The cultural awareness policy provides guidelines for Maori residents and those from other ethnicities The culture, values and care policy outlines the expectations of services which meet individual residents cultural personal requirements, preferences and beliefs. Additional references and information are accessible and can be obtained from the ADHB and Asian health website. Staff interviewed (one management, twelve clinical and three non-clinical staff) display awareness of the needs of many cultural groups in relation to food service requirements and support person presence and/or understanding cultural rituals in the case of death in the different services. The photographs of all staff in each area visited evidence staff employed represent many different cultures. The seven residents and three family members report they are given the opportunity to have their individual beliefs and values respected.

20 Criterion (HDS(C)S.2008: ) The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs. Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7) Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. ARHSS D16.5e The discrimination, coercion, sexual harassment and exploitation policy is compliant. Policy and procedures related to discrimination ensure residents receive services free from any discrimination and that residents are not subjected to any form of coercion, harassment, sexual or other exploitation. Professional boundaries of staff are maintained for the well-being of the residents. All registered nurses are required to completed compulsory Code of Conduct training for the New Zealand Nursing Council (NZNC) by 2015, so many staff have already completed this as part of their mandatory education for registration in Staff interviewed (twelve clinical and three nonclinical) are well informed and fully aware of the processes to follow if an incident arises and whom the incident should be reported to. Criterion (HDS(C)S.2008: ) Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.

21 Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8) Consumers receive services of an appropriate standard. ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c The service identifies actions taken to ensure residents receive appropriate services in an environment that encourages good practice. This includes evidence based practice as per policies and procedures. Evidenced-based practice is observed, promoted and encouraged for good practice, as evidenced in interviews with the manager, RN s, staff in all services. This is also reflected in the comprehensive education programme available for all staff and the excellent attendance records maintained and sighted. Competencies for health care assistants and registered nurses are also maintained and all relevant information is current and up to date. Policies, procedures and information sheets are examples sighted of evidence based practice and go through a quality process when developed, reviewed and prior to approval and implementation. All sources of information are referenced on the policies sighted. The clinical quality improvements/outcomes are displayed on the staff notice boards also for staff/residents/family to view in each service. Evidenced-based practice is observed as documented, promoted and encouraged across all services by the manager and quality management team. Criterion (HDS(C)S.2008: ) The service provides an environment that encourages good practice, which should include evidence-based practice.

22 Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9) Service providers communicate effectively with consumers and provide an environment conducive to effective communication. ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 ARHSS A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3 Policy fully describes that open disclosure is part of everyday practice. Residents have a right to full and frank information and open disclosure from staff. The five registered nurses interviewed understand about open disclosure and providing appropriate information when required. The policy outlines staff responsibilities in relation to open disclosure. The key principles of open disclosure are documented to guide staff, such as openness and timeliness of communication, acknowledgement of regret and apology, recognition of the reasonable expectations of the resident and their support person, support for staff and maintaining confidentiality. Interpreter services are available through the Counties Manukau District Health Board (MDHB), Middlemore Hospital interpreter and translation services available to services in the community. The service offers translation for 80 different languages. Contact details are readily available and accessible. Criterion (HDS(C)S.2008: ) Consumers have a right to full and frank information and open disclosure from service providers.

23 Criterion (HDS(C)S.2008: ) Wherever necessary and reasonably practicable, interpreter services are provided. Standard : Informed Consent (HDS(C)S.2008:1.1.10) Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. ARC D3.1d; D11.3; D12.2; D13.1 ARHSS D3.1d; D11.3; D12.2; D13.1 There is a documented Informed Consent Policy reviewed in The policy is compliant with the Code requirements. Families/whanau/residents are provided with explanations and information and/or the resident is given choices as appropriate prior to consenting to care and treatment and/or investigations if required. Appropriate forms are used depending on the circumstances. Signed consent forms are retained in the individual resident`s records reviewed. The service has an advanced care policy with clear directions documented by the resident or family. Advance directives sighted comply with legislative requirements. The resuscitation policy is sighted. Advance care planning has been implemented and it is noted that a sticker is placed on the files if this is in place. This is a new process and one hospital record sighted has an advanced care plan completed. The seven residents and three family report that they are made aware of all care and are asked for their permission when and if required.

24 Criterion (HDS(C)S.2008: ) Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making. Criterion (HDS(C)S.2008: ) The service is able to demonstrate that written consent is obtained where required. Criterion (HDS(C)S.2008: ) Advance directives that are made available to service providers are acted on where valid.

25 Standard : Advocacy And Support (HDS(C)S.2008:1.1.11) Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f Advocacy and support service information is shown in the policy and procedures reviewed. How to access an independent advocate is described. The Nationwide Health and Disability Advocacy Service brochure along with contact details is readily available for residents/family/whanau/representatives in the information pack provided and in the pamphlet stand at reception and in all service areas. The `Your Rights Posters` are displayed in both English and Maori. The staff interviewed including RNs, health care assistants, cooks and cleaner understand the investigation process for this organisation and the complaints process when required which recommends an advocate and/or support person. The organisation also has links with New Zealand Aged Concern and contact details are readily available. A photo of the resident advocate and contact details are on the notice board. Residents and family report they are aware of the advocacy service but the service has not been needed. They report that the manager (RN) is always available. Criterion (HDS(C)S.2008: ) Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.

26 Standard : Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12) Consumers are able to maintain links with their family/whānau and their community. ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f The service has clear links with family/whanau and visitors are very welcome to this facility and to special events organised with residents, their families and friends. Visiting times are very flexible but arrangements can be made with the managers. The four RN s are available to families as well as the managers for each care setting. Family members are informed of reviews and are notified of any changes as they occur. Evidence is seen of family having input into the care planning and the activities programme to meet the needs of the individual resident concerned. Links are maintained with activities in the community being encouraged as part of the activities programme. Van outings into the community or attendance at church services at local churches are encouraged. Chaplain service is available and visitors come to the rest home and hospital on a regular basis. Residents can be taken for outings in the community and this is sighted on the activities/recreational programme. Criterion (HDS(C)S.2008: ) Consumers have access to visitors of their choice. Criterion (HDS(C)S.2008: ) Consumers are supported to access services within the community when appropriate.

27 Standard : Complaints Management (HDS(C)S.2008:1.1.13) The right of the consumer to make a complaint is understood, respected, and upheld. ARC D6.2; D13.3h; E4.1biii.3 ARHSS D6.2; D13.3g There is a comprehensive complaints management process which is clearly documented in policy. The manager and all five registered nurses interviewed confirm that complaints management is discussed as part of the admission process. A copy of the complaints form is available at the entrance of the facility and is included in the information pack given to all family/whanau upon entry to the facility. Interviews with three family members and seven of seven residents confirm their understanding of the right to make a complaint. Management is available to listen to any concerns or issues they may have. Interviews with staff inclusive of one diversional therapist, one physiotherapist, five registered nurses, one occupational therapist, four health care assistants, one cleaner and two cooks confirm they all implement complaints management processes to meet policy requirements. The manager of the facility is responsible for maintaining the complaints register and this is available and sighted. The complaints register identifies that complaints and concerns are responded to by the manager and any complainants will be fully informed of the investigation results and follow-up corrective action as appropriate. There have been no complaints lodged with the Health and Disability Commissioner or Coroner`s Office since the previous audit. The director is kept well informed if a complaint is lodged with the service. The last complaint was followed through and has been documented and managed effectively by management. The residents have regular monthly meetings and minutes identify any issues or concerns as well as things they like. Resident interviews confirm they can discuss anything they wish at the meetings and they are always responded to by management. Criterion (HDS(C)S.2008: ) The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.

28 Criterion (HDS(C)S.2008: ) An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. Outcome 1.2: Organisational Management Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1) The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5 The service has a strategic plan and business plan to identify the purpose, values, priorities and objectives of the service. The service has clear visions and values. The mission statement is documented as are the scope and limitations of the service. The values reflect on the organisation s mission, philosophy, service objectives, planning and the service motto. The annual monitoring is planned and the annual audit schedule for 2014 is sighted. The type of audit, frequency, by whom it is carried out, the month, average percentage and minimum target are documented.

29 The manager interviewed ensures this schedule is managed effectively for each area of service delivery, for example, for health and safety, infection control, clinical, environmental, resident rights and satisfaction and human resources. An organisation chart is available in the quality manual to guide staff. The results of satisfaction survey and interviews with three of three family and residents identify services are delivered in a manner to meet residents` needs. Very positive comments are made by everyone spoken to including the contracted general practitioner about the overall management of the facility. The service is managed by a suitably qualified and experienced person with authority, accountability and responsibility for the provision of service. The manager has been in this role for five years. The manager is a registered nurse who has a Postgraduate Diploma in Health Sciences graduating in 2013 with a specialisation in Advanced Nursing. The manager reports to the business manager/director on a regular basis and documents an annual report reviewed. Criterion (HDS(C)S.2008: ) The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. Criterion (HDS(C)S.2008: ) The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.

30 Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2) The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers. ARC D3.1; D19.1a; E3.3a ARHSS D3.1; D4.1a; D19.1a During the temporary absence of the manager, a senior registered nurse is available to cover in this role. The registered nurse has been trained and mentored by the manager to ensure the registered nurse is able to cover the role as required. The personal record for the registered nurse was reviewed and the individual education records verify that the registered nurse has undertaken appropriate education in care of the elderly for this role. Criterion (HDS(C)S.2008: ) During a temporary absence a suitably qualified and/or experienced person performs the manager's role.

31 Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3) The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. ARC A4.1; D1.1; D1.2; D5.4; D10.1; D17.7a; D17.7b; D17.7e; D19.1b; D19.2; D19.3a.i-v; D19.4; D19.5 ARHSS A4.1; D1.1; D1.2; D5.4; D10.1; D16.6; D17.10a; D17.10b; D17.10e; D19.1b; D19.2; D19.3a-iv; D19.4; D19.5 The Care Alliance Strategic Direction includes the quality improvement, business plan and risk and management plan for This documents the management framework, inclusive of the strategic, risk, quality and business operational plans. This clearly identifies the objectives and action planning and support needed to reach identified objectives. The overall objective is to meet the needs of the residents and enhance satisfaction with support/care and service provided. The quality plan covers all aspects of service delivery with actions showing how to minimise identified risks, who is responsible and the timeframe required to implement. The business risk plan covers being a good employer, responsible planning safe environment, internal audit and succession planning. Policies are reflective of good practice and all policies are being reviewed as per the review schedule developed and implemented. The health and safety co-ordinator interviewed takes responsibility for reviewing the policies and procedures for this area of service delivery in consultation with the manager and the health and safety committee. Obsolete documents are archived in a locked filing cabinet in the manager`s office and can be accessed as required. Document control is well managed. The service has a confidential disposal bin available on site. The risk plan is reviewed annually. The manager has in depth knowledge in the management of risk and ensures quality controls are implemented by the service to meet resident needs. This is informed by information gathered from incidents, accidents, adverse events (health and safety), infection control, restraint/enablers, complaints, and data reporting. Identified risks are categorised via a risk matrix system to identify the level of risk related to the event. Staff interviews confirm that staff understand the quality and risk management systems and that they are involved in reporting, audits, and undertaking corrective actions that are put in place. The manager explains the quality improvement tool utilised for specific quality improvement projects. Three projects are identified and clearly documented for increasing the registered nurse hours for resident centred care and management (completed July 2013), medication management consent (August 2013) and for managing the personal clothing laundry service which have all been closed out (October 2013), each of which has had a significant and positive impact on service delivery for the respective areas concerned. Other quality projects have included improving social dining for residents and the implementation of the flash meetings held every morning. InterRAI training (a comprehensive clinical assessment for people living in aged residential care) and implementation is also on the agenda for Feedback is provided to staff at staff monthly meetings and minutes of the meetings for 2013 are sighted. The minute folder is accessible to all staff. Quality improvements, results of audits and graphs are displayed in the staff room in the courtyard area to update and keep staff well informed. As previously mentioned, daily Flash Meetings are held at 9.30am and a staff member from each of the areas inclusive of One Tree Hill/Waiatarua Place, Wanaka Court, Hauraki Drive and Waitakere Avenue discuss with the manager the present status of each area in relation to staffing and the well-being of residents and/or any incidents. This is ed to all staff to ensure all staff are updated and teamwork is encouraged at all times.

32 Criterion (HDS(C)S.2008: ) The organisation has a quality and risk management system which is understood and implemented by service providers. Criterion (HDS(C)S.2008: ) The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. Criterion (HDS(C)S.2008: ) There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.

33 Criterion (HDS(C)S.2008: ) Key components of service delivery shall be explicitly linked to the quality management system. Criterion (HDS(C)S.2008: ) Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

34 Criterion (HDS(C)S.2008: ) A process to measure achievement against the quality and risk management plan is implemented. Criterion (HDS(C)S.2008: ) A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.

35 Criterion (HDS(C)S.2008: ) Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and implemented. Standard 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4) All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. ARC D19.3a.vi.; D19.3b; D19.3c ARHSS D19.3a.vi.; D19.3b; D19.3c Policies and procedures are in place which identify that all adverse, unplanned or untoward events are recorded and followed up by the service. There is an open disclosure policy to identify family/whanau are informed. Policy states that serious accidents will be reported to the appropriate government departments, HealthCERT (MOH) and the Auckland District Health Board (ADHB). Corrective action planning is put in place to prevent the reoccurrence of an incident where possible. All incident and accident reports are analysed and trended via the quality team and the manager. The manager, the health and safety co-ordinator and registered nurses interviewed verbalise their knowledge and understanding of statutory and regulatory obligations in relation to essential notification reporting. All incidents or accidents are recorded on a specific form. The service has an incident/accident form for residents and one for staff. The resident form has been reviewed and signed off by management and the staff form is currently being reviewed. Both forms reviewed are very comprehensive. Adverse event data are collected and trended against previously collected data. Incident and accident information is used to identify areas of improvement and data are identified under specific sections to assist in the identification and cause of the incident or the accident. This includes the time of day, types of incident such as falls, injury, medication error, the degree of risk and any corrective actions put in place. All data are reported per 1000 occupied bed days. Staff are informed at handover, during the monthly staff meetings and through the communication book, s and results displayed in various forms such as graphs, diagrams or in written form sighted on the wall in the staff room. The information is supported in meeting minutes and management reports reviewed. Follow-up is undertaken and demonstrates how the actions put in place are outcome-focused to assist in improvement of health and safety and care delivery of all residents.

36 Staff interviews with registered nurses, the health and safety co-ordinator and manager identify knowledge and understanding of the need to document all incidents and accidents. Four of four healthcare assistants clearly understood the importance of reporting all incidents and accidents. Staff are familiar with how to complete the relevant form used by the service provider and reporting to the registered nurse as required. The incident form identifies that family/whanau are informed as well as documenting this in the progress records of the individual resident involved. Family interviews confirm there is good communication and that they are informed of all incidents or concerns the service may have related to their relative. Criterion (HDS(C)S.2008: ) The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. Criterion (HDS(C)S.2008: ) The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.

37 Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7) Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. ARC D17.6; D17.7; D17.8; E4.5d; E4.5e; E4.5f; E4.5g; E4.5h ARHSS D17.7, D17.9, D17.10, D17.11 The service has a documented process related to human resource management to ensure good employment practice is undertaken and that all legislative requirements are met. There is a system in place to record annual practising certificates for staff who require them and these are sighted for the two general practitioners, the pharmacy and all pharmacists, one podiatrist, two physiotherapists, one occupational therapist and the ten registered nurses and the contracted dietitian for this service. Seven of seven staff records and interviews of 15 of 15 staff (one occupational therapist, one physiotherapist, five registered nurses, one diversional therapist, four healthcare assistants, one cleaner and two cooks) confirm that the orientation process prepares staff for the roles they undertake. All health professionals work within their scope of practice. The GP interviewed speaks positively about the care and management of this service and the high calibre of staff. Documented orientation covers all aspects of service relevant to the role the employee undertakes. All records contain signed employment contracts, job descriptions, orientation workbooks (one for registered nurses and enrolled nurses and one for healthcare assistants are sighted) covering all essential aspects of service delivery, up to date annual staff appraisals and clinical staff medication competencies. Staff members` education is individualised and interviews with 15 of 15 staff confirm they are satisfied with the amount and type of education offered. The training planner for 2014 is available. Education is offered on site and off site and staff are encouraged and supported to attend education related to care of the elderly. There are 18 health care assistants who are very qualified and all but two have completed level four of a (NZQA) New Zealand recognised aged care qualification. InterRAI training is planned for 2014 and registered nurses are enrolled in this programme as this is compulsory and to be completed before Interviews with residents and families confirm they are pleased with the care delivery and that staff perform their roles in a professional and competent manner. All comments made are positive of the team approach and the staff working in one area getting to know each individual resident and their respective families. This approach is welcomed by the residents and the families. The manager states continuity of care is promoted at all times and this is clearly evidenced during the audit Criterion (HDS(C)S.2008: ) Professional qualifications are validated, including evidence of registration and scope of practice for service providers.

38 Criterion (HDS(C)S.2008: ) The appointment of appropriate service providers to safely meet the needs of consumers. Criterion (HDS(C)S.2008: ) New service providers receive an orientation/induction programme that covers the essential components of the service provided.

39 Criterion (HDS(C)S.2008: ) A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8) Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. ARC D17.1; D17.3a; D17.3 b; D17.3c; D17.3e; D17.3f; D17.3g; D17.4a; D17.4c; D17.4d; E4.5 a; E4.5 b; E4.5c ARHSS D17.1; D17.3; D17.4; D17.6; D17.8 A review of the rosters identifies staffing numbers exceed the numbers of the ADHB contractual requirements. Planned and unexpected leave is covered and replacement staff are shown on the rosters sighted. The manager works fulltime and covers on call with the senior registered nurse. The rosters identify the increase in registered nurses (RN) employed in this service and an RN is on duty in each designated area for the morning shift. One or two registered nurses are rostered to cover the night shift. Staff undertake twelve hour shifts and this is working effectively. There are adequate healthcare assistants rostered on every shift. Most healthcare assistants have worked at this facility for some time (two to twenty years) and all but two have competed level four (aged care related training) and have certificates in their personal records sighted to verify this has occurred. Two healthcare assistants are awaiting their certificates for their records. The manager has a record of all education completed by all staff employed. Interviews with 15 of 15 staff confirm they have adequate numbers of staff to complete all required resident centred care. Staff have completed first aide or are completing first aide if up skilling. There is a first aider on every shift. The success of the new graduate programme has resulted in Care Alliance Waimarie recruiting two new graduate registered nurses and the service continues to support Auckland University of Technology (AUT) nursing students in their placement to gain practical experience. There are four intakes a year for two student nurses at any one time. The manager states students continue to be a valuable and useful addition to the team: they bring vibrancy and up to date knowledge enhancing the skill mix. Goldstar Institute did not place any students in 2013 but the manager explains that they will be placing students in Interviews with seven of seven residents and three of three families confirm all their needs are met and staff are always available when required.

40 Criterion (HDS(C)S.2008: ) There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. Standard 1.2.9: Consumer Information Management Systems (HDS(C)S.2008:1.2.9) Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. ARC A15.1; D7.1; D8.1; D22; E5.1 ARHSS A15.1; D7.1; D8.1; D22 The document control policy identifies how health information meets the legislative requirements and relevant professional sector standards. All eight residents records reviewed (six hospital and two rest home) are legible and show the date, time, name and designation of the staff member entering the information. The progress records are current and up to date. The medication records (16 of 16) reviewed evidence all entries are appropriate and accurately documented with discontinued medications ruled through and signed off by the GP and reviews occur timely. All residents individual records are integrated with coloured dividers between each section. Staff records are stored in the manager`s office, locked in the filing cabinet, are well maintained and confidentiality is maintained and respected by the manager. Staff interviewed ensure confidentiality is maintained and residents records are stored appropriately in the nurse stations on the two levels sighted. Records are accessible to staff. The nurse stations are lockable. Information on resident name boards are out of sight of the public. The resident register is maintained by the manager. Document audits of residents records are performed as part of the quality improvement system reviewed.

41 Criterion (HDS(C)S.2008: ) Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting. Criterion (HDS(C)S.2008: ) Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable. Criterion (HDS(C)S.2008: ) All records are legible and the name and designation of the service provider is identifiable.

42 Criterion (HDS(C)S.2008: ) All records pertaining to individual consumer service delivery are integrated. Outcome 1.3: Continuum of Service Delivery Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Standard 1.3.1: Entry To Services (HDS(C)S.2008:1.3.1) Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified. ARC A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2; E3.1; E4.1b ARHSS A13.2d; D11.1; D11.2; D13.3; D13.4; D14.1; D14.2 The organisation has a clearly identified process for pre-entry and entry to this service. The requirements for all residents to be assessed prior to admission or transfer to another service is made known to staff. The information pack is provided and pre-entry and entry requirements are highlighted. Entry to all services is facilitated in a competent, suitable and respectful manner. An 'Admissions Policy' includes the procedure to be followed when a resident is admitted to Care Alliance Waimarie. Policy identifies that entry screening processes are documented and communicated to the resident and their family/whanau or representative. The seven residents and three family members report that prior to admission meetings are held with the manager (RN) regarding the admission agreement to ensure they have full understanding of the requirements. The documentation is given to

43 residents and family in and follow up is undertaken with them to ensure they understand the information given. The four RN s interviewed each have a role which they undertake with new residents. Criterion (HDS(C)S.2008: ) Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies. Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2) Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate. ARHSS D4.2 There is a statement in the admission process that if the manager feels that the service cannot meet the needs of the resident then this is explained to the prospective resident/family and information is provided in relation to the options available. Barriers to admission are identified and minimised including cultural, physical access, being able to meet the needs of the prospective resident or if an existing resident condition changes and cannot be managed a re-assessment may be required and a referral would be sent off for this to occur. The manager reports on interview that she visits a prospective resident in hospital if there is a concern regarding the ability to provide the care required. This is then discussed with the family or referee as required.

44 Criterion (HDS(C)S.2008: ) When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services. Standard 1.3.3: Service Provision Requirements (HDS(C)S.2008:1.3.3) Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. ARC D3.1c; D9.1; D9.2; D16.3a; D16.3e; D16.3l; D16.5b; D16.5ci; D16.5c.ii; D16.5e ARHSS D3.1c; D9.1; D9.2; D16.3a; D16.3d; D16.5b; D16.5d; D16.5e; D16.5i Service delivery documentation is overseen or completed by the RNs. Documentation is completed and reviewed within required timeframes. In the eight files reviewed (six hospital and two rest home) there is evidence of initial assessments and care plans being completed and clinical risk tools being reviewed in the required timeframes. Care Alliance Waimarie does not use the InterRAI computer programme for assessments yet (two RN s have attended training). The long term care plan template is personalised, reviewed and amended within required timeframes. The clinical risk assessments and follow up times for documentation reviews are all completed. The manager (RN) reports there is no formal process for multidisciplinary reviews but evidence is seen of families being contacted after monthly review by the GP. There is evidence in the eight files reviewed that the family/whanau are involved.handover at the beginning of each shift is undertaken in the nurses station for privacy. Care Alliance Waimarie have the services of two GP s but both of them belong to the one surgery. One of these GP s is always on call and or on site as required. The nine clinical staff interviewed (five RNs and four health care assistants) report that external services from the ADHB are used as required (e.g. dietitian). The seven residents interviewed are very positive about the staff, GP and all aspects of care. The nine clinical staff interviewed (five RNs and four health care assistants) report that they are kept up to date with all clinical changes. Tracer methodology Hospital: XXXXXX This information has been deleted as it is specific to the health care of a resident..

45 resi Methodology Rest Home: XXXXXX This information has been deleted as it is specific to the health care of a resident. Criterion (HDS(C)S.2008: ) Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. Criterion (HDS(C)S.2008: ) 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.

46 Criterion (HDS(C)S.2008: ) The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4) Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. ARC D16.2; E4.2 ARHSS D16.2; D16.3d; D16.5g.ii There are appropriate policies and procedures to guide staff in the full assessments required on admission to this service. The needs assessment service coordinators assessment completed prior to the admission is used as the basis of service delivery planning. Additional care related policies are well documented and available. There are clearly set out policy and procedures related to management of challenging behaviour, skin care management and continence management. The policy clearly states how the continence programme is coordinated and evidences a continence and product management flow chart on how to meet management goals. Other recognised assessment tools are used as part of good practice management and these include determining falls risk, pressure area risk, wound-care and pain management. All assessments are retained in the resident`s record. The eight records (six hospital and two rest home) sighted evidence that assessments are conducted within the specified timeframes. Short term care plans are used for residents as required. The manager reports that she operates an open door policy with the families to ensure all the residents assessed needs are what the family and resident want. The RN s and HCA s report they have a discussion regarding all new residents to ensure they have all the information they require to ensure safe service delivery.

47 Criterion (HDS(C)S.2008: ) 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. Standard 1.3.5: Planning (HDS(C)S.2008:1.3.5) Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. ARC D16.3b; D16.3f; D16.3g; D16.3h; D16.3i; D16.3j; D16.3k; E4.3 ARHSS D16.3b; D16.3d; D16.3e; D16.3f; D16.3g All resident care plans are resident focused, integrated and promote continuity of care. There is documented evidence of resident or family/whanau input in the development of the care plan. One resident stated that full consultation and involvement was encouraged when the care plan was developed. Family are involved as well. The care plans reflect clear interventions and the support required being documented to achieve the desired outcomes as identified by the ongoing assessment process. The eight care plans are well documented and the name of the registered nurse responsible for the resident is clearly signed and dated. The multidisciplinary approach is observed with input encouraged and this is evident in the assessments and in the integrated progress records sighted. In all eight files (six hospital and two rest home) reviewed evidence is sighted of interventions related to the desired outcomes. Risks identified on admission are included in the care plan and these include falls risk, pressure area risk and mental capacity. All health professionals document in the resident's individual clinical file and have access to care plans and progress notes. Documentation in all eight files reviewed include nursing notes, medical reviews and hospital correspondence. The RN accompanies the doctor on their rounds and the doctor documents in the residents notes and the RN updates in the progress notes or on the care plan if changes occur. Evidence is also seen of letters from ADHB clinics. The care plan is written in a language that is user friendly and able to be understood by all staff. In all eight residents' files reviewed there is evidence to demonstrate involvement in care planning of the family/whanau. The nine clinical staff (five RN and four HCA s) report they receive in house education on all the clinical risk tools used as part of the compulsory education hours provided. The three relatives and seven residents report that they are involved with all the care planning and contacted if there are any changes.

48 Criterion (HDS(C)S.2008: ) Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. Criterion (HDS(C)S.2008: ) Service delivery plans demonstrate service integration. Standard 1.3.6: Service Delivery/Interventions (HDS(C)S.2008:1.3.6) Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. ARC D16.1a; D16.1b.i; D16.5a; D18.3; D18.4; E4.4 ARHSS D16.1a; D16.1b.i; D16.5a; D16.5c; D16.5f; D16.5g.i; D16.6; D18.3; D18.4 There are numerous policies in place for managing service delivery and to provide optimum care delivery and to meet the needs of all residents accessing this service and the many services provided. The policies document, for example, wound care management, death of a resident, skin management, pain management, personal grooming, challenging behaviour, continence management and others relevant to promoting service delivery and appropriate interventions as required. The policies

49 reviewed clearly meet the requirements of the ARRC agreement. In the eight files reviewed (six hospital and two rest home) ) there is documented evidence that the interventions relating to the residents' assessed needs and desired outcomes are assessed at required timeframes to ensure they are being met. The nine clinical staff interviewed report they are informed of any care plan changes at hand over and have relevant in-service education as required. The seven residents and three family report they are notified of changes and interventions are discussed. Criterion (HDS(C)S.2008: ) The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. Standard 1.3.7: Planned Activities (HDS(C)S.2008:1.3.7) Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service. ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h There is one diversional therapist (DT) and one contracted occupational therapist (OT) who provide activities for the residents. The Eden Philosophy is going to be implemented and this includes services being in separate areas. There is a lounge and dining room in each area and programmes are designed with this in mind. The planned activities reflect ordinary patterns of life and take into consideration the assessed needs of residents. During interview the OT and DT report that it is important to have activities at similar times each day as the residents get into a routine. This includes morning exercises in a group and socialisation within the facility. They reinforce that physical activities are best in the morning as this is the residents more alert time. External visits for residents include the shopping and community events. Activities held at the facility include sensory games and exercise classes. The three relatives and

50 seven residents report on interview the activities are positive and include walking and music. Criterion (HDS(C)S.2008: ) Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer. Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8) Consumers' service delivery plans are evaluated in a comprehensive and timely manner. ARC D16.3c; D16.3d; D16.4a ARHSS D16.3c; D16.4a In all eight files reviewed (six hospital and two rest home) evidence is seen of documentation if an event occurs that is different from expected and requires changes to service. Individual short term care plans are used for wound care, infections and challenging behaviours. These are transferred to the long term care plan if the issues has not resolved within 28 days. Long-term care plans are reviewed monthly or earlier as required. Evidence of this is sighted in eight files reviewed. Progress notes are signed each duty by the RN. Evidence is seen of the family/whanau involvement in the care planning and review. The three relatives report that they are involved in any changes to care of their relative. The nine clinical staff interviewed have knowledge of the care plan documentation requirements.

51 Criterion (HDS(C)S.2008: ) Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. Criterion (HDS(C)S.2008: ) Where progress is different from expected, the service responds by initiating changes to the service delivery plan. Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) (HDS(C)S.2008:1.3.9) Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs. ARC D16.4c; D16.4d; D20.1; D20.4 ARHSS D16.4c; D16.4d; D20.1; D20.4 Referral processes are documented and in place to guide staff. Residents are supported and referrals are appropriately facilitated to meet the needs of residents receiving services in this organisation.

52 Residents have the option to use their own GP or use the resident doctors. Referrals to other providers is evident in the five of the eight resident records reviewed mostly for ongoing specialist assessments. Transport is provided for residents to attend external appointments in the community if required. Family/whanau are always given the first option to transport their family/whanau member to external appointments. The gerontology nurse specialist from ADHB often comes to the hospital if ongoing re-assessments are required and especially if the resident is frail. If a resident wishes to change facilities to another health and disability service, the NASC service is contacted and the service provider assists as much as possible with arranging the transfer once approved by the NASC service co-ordinator concerned. Criterion (HDS(C)S.2008: ) Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained. Standard : Transition, Exit, Discharge, Or Transfer (HDS(C)S.2008:1.3.10) Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. ARC D21 ARHSS D21 A transfer policy and transportation are sighted for this service. Safety is paramount and processes are to be followed by staff. A transfer form is available and the yellow bag system is used when transferring a resident to the ADHB. Accurate information is forwarded to the receiving facility and/or service. Appropriate policies and procedures are provided for transition, exit, discharge or transfer from the services provided for residents ensuring safety is paramount and who to contact is detailed. The RN interviewed verifies the process for transfer to ADHB. The GP rings the direct line to the registrar health services for older people to discuss

53 the transfer. Once authorised the transfer details are completed with all relevant information being provided to the receiving hospital. Any risks or alerts are identified. A copy of the medication sheet is attached and/or placed in the yellow transfer envelope. Family are contacted. Transportation is arranged safely. Family can escort the resident or a staff member if required. Clinical staff report they are aware of the requirements for resident transfer and work with the manager or RN to ensure this is a safe process for the resident. Criterion (HDS(C)S.2008: ) Service providers identify, document, and minimise risks associated with each consumer's transition, exit, discharge, or transfer, including expressed concerns of the consumer and, if appropriate, family/whānau of choice or other representatives. Standard : Medicine Management (HDS(C)S.2008:1.3.12) Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d The Safe Management of Medicines policy is reviewed. This is a comprehensive policy which clearly defines the purpose and policy documented. Legislative requirements are referenced and are inclusive of legal documentation, standards, organisations and guidelines. The policy states that standing orders are not used at this facility. Three monthly review of the medication records is enforced and a requirement for the service agreement. There is a clear statement regarding staff competency requirements. Fourteen day robotic system is utilised and blister packs as required. The contracted pharmacy provides comprehensive services and a medication reconciliation process and flowchart is available and included also in the policy. Medication reconciliation processes are documented. If residents require their medication to be crushed documentation is seen of pharmacy, GP and staff approval for this to occur.this includes which food preparation is to be used for the medication to be mixed. All processes comply with the legislative requirements.

54 Evidence is seen of a process of stock being returned to the pharmacy when it is out of date or not required. The RN reports that the GP s work with the pharmacy but he/she is responsible for all medicines administered to his residents. If medicine is brought in by family this is approved by the GP and he charts on the medication sheet. The RNs or EN s are responsible for medication rounds. Evidence is seen of the designated staff having up to date competency for medicine management and administering medicines. There is no self-administration of medicines on the day of the audit. Medicine sheets are signed in ink as required following administration. All 14 files reviewed comply with legislation requirements. Criterion (HDS(C)S.2008: ) A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. Criterion (HDS(C)S.2008: ) Service providers responsible for medicine management are competent to perform the function for each stage they manage.

55 Criterion (HDS(C)S.2008: ) The facilitation of safe self-administration of medicines by consumers where appropriate. Criterion (HDS(C)S.2008: ) Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.

56 Standard : Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13) A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery. ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c Food service policies are documented and have been reviewed. Food safety is paramount. Training is to be provided for all kitchen staff. Care Alliance Waimarie operates a four weekly menu cycle approved by a dietitian (sighted). An individual dietary assessment is completed on admission which identifies individual needs and preferences. Morning and afternoon teas are prepared in the kitchen and snacks are available over 24 hours. Residents are weighed on admission and evidence is seen of a process to monitor unexplained weight loss. This includes contacting the GP, notifying the kitchen of extra dietary requirements and changes to care plans. There are two cooks who work over seven days. Both have up to date food safety certificates (sighted). Evidence is seen of attendance at annual update on infection control and first aid. The cook reports that she is well supported by management on food supplies and listens to residents at the resident meetings on any concerns or requests. Evidence of this is sighted. Food monitoring occurs with foods being labelled clearly and expiry dates observed on a regular basis. Food temperature monitoring occurs and the cook is responsible for recording the findings. Fridge/freezer temperatures are maintained daily and recorded by the kitchen hand. If residents require assistance with feeding a staff member is available to assist. Criterion (HDS(C)S.2008: ) Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.

57 Criterion (HDS(C)S.2008: ) Consumers who have additional or modified nutritional requirements or special diets have these needs met. Criterion (HDS(C)S.2008: ) All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines. Outcome 1.4: Safe and Appropriate Environment Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.

58 Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1) Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. ARC D19.3c.v; ARHSS D19.3c.v The waste management policy is sighted. The policy is located in the Infection Control Manual and is linked to health and safety. The health and safety co-ordinator explains the waste management system and health and safety generally for this service. Service providers, visitors and residents are protected from harm at all times. There are adequate policies and procedures available for managing infectious and/or hazardous substances to guide staff. Legislative requirements and local body obligations are referenced on the policies and procedures. A contracted company collects rubbish three times a week on Monday, Wednesday and Fridays. Additional pickups can be arranged if and when required. The Auckland City Council collects the recycling rubbish each Wednesday from the appropriate bins provided. The collection point is at the gate or entrance to this property. There are approved containers for sharps which are collected when full. Approved yellow sharp bins are sighted in locked areas for the correct disposal of sharps. The service uses approved cleaning chemicals and safety data sheets are available in all areas where chemicals are stored. The main storage area for bulk supplies is in the garage. Staff education related to safe chemical handling occurs annually and is provided as part of the induction process as appropriate. Cleaners are employed but the laundry service is maintained by the healthcare assistants, all of whom have been trained and have certificates to verify this has occurred in their personal records sighted. Personal protective equipment/clothing (PPE) sighted includes disposable aprons, gloves, goggles and masks. Interviews with 15 of 15 staff confirm they can access PPE at any time and they can verbalise appropriate use. Staff are observed wearing disposal gloves and aprons as required. Hand hygiene is promoted and antibacterial gel is located at every hand basin throughout the facility. Care importer wipes are used for resident hygiene and there are adequate stocks available. The cleaner`s trolley is stored appropriately in a locked room when not in use. The service undertakes appropriate storage of waste, infectious and/or hazardous substances to comply with current legislation. The business manager/director undertakes the maintenance management programme but employs a contractor to undertake the maintenance required. Staff document in the communication book if any maintenance or equipment requires attention and this is signed off and dated when completed. Alternatively the health and safety co-ordinator, when completing the environmental checks monthly, reports to the manager if any maintenance is needed. Criterion (HDS(C)S.2008: ) Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.

59 Criterion (HDS(C)S.2008: ) Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers. Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2) Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a; D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4 The health and safety co-ordinator explains that regular audits are undertaken to ensure the physical environment and facilities remain safe and fit for their purpose. All processes are undertaken as required to maintain the service building warrant of fitness. The current warrant of fitness expires on 30 June There is a documented reactive maintenance process implemented for this service. A contracted service provider is responsible for any maintenance and the business manager/director oversees the programme. Electrical testing occurred on 25 February Calibration of all equipment occurred on 15 and 21 January 2014 by the contracted company. All electrical equipment was checked in accordance with Australian and New Zealand Standards (AS/NZS ) and meets the Health and Safety in Employment legislation Act Regular checks for the washing machines, dryer and the dishwasher in the kitchen are performed. Equipment is safely stored such as oxygen being correctly stored in a locked cupboard which is clearly labelled by the nurses` station on the second level. There are two lifts available in the facility which are checked on a regular basis and

60 records are maintained. Residents are always assisted when transferred in the lifts. The physical environment minimises the risk of harm and safe mobility by ensuring the flooring is in good condition, the correct use of mobility aids and walking areas not being cluttered. The facility has good storage space available. Hallways have safety handrails as do all bathrooms to assist residents to mobilise safely. Residents who have mobility difficulties are assessed by a physiotherapist and occupational therapist and appropriate walking aids are obtained as required. Residents have access to a safe and well maintained courtyard with even surfaces; seating is available and in the warmer months umbrellas are utilised for shade. The area is safe and enclosed. The property has a fence around for safety of the residents. There is an additional outside area available and a sunny lounge/dining/sunroom where residents can sit and enjoy the sun. Interviews with three of three family members and seven of seven residents confirm the environment is suitable to meet their needs. There is wheelchair access into the courtyard and outside of Hauraki Drive and the front entrance to the facility. An ambulance can access this location if and when required. Criterion (HDS(C)S.2008: ) All buildings, plant, and equipment comply with legislation. Criterion (HDS(C)S.2008: ) The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.

61 Criterion (HDS(C)S.2008: ) Consumers are provided with safe and accessible external areas that meet their needs. Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3) Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements. ARC E3.3d ARHSS D15.3c There are four designated areas in the facility. All residents rooms are personalised to meet their needs with enough room to allow residents with or without mobility aids to move freely around safely. Every doorway has double doors to allow for ease of furniture or equipment movement. All rooms are appropriate for hospital level care and rest home care (two rooms only). Seven of seven residents and three of three family confirm they are happy with their rooms. Hauraki Drive has five individual toilets inclusive of three bathroom/toilets together. One Tree Hill/Waiatarua Place (upstairs) has two separate bathroom/toilets. Courtyard has ten rooms with ensuites off each individual room. Wanaka Court has one separate toilet and three bathroom/toilet facilities available. Each area has adequate toilet/shower facilities and privacy is respected and maintained when staff are attending to the personal cares of each resident. There are separate staff and visitor toilets.

62 Criterion (HDS(C)S.2008: ) There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use. Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4) Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii There are 52 beds available at this facility and forty four are currently occupied. One Tree Hill/Waiatarua area has one three bedded room with screening curtains available. Two large spacious rooms are also available and sighted. These rooms are appropriate and all three beds are occupied by residents. A lift is available for family and staff to access this level of the facility. Any residents would be accompanied by a staff member. An internal staircase is available to access this level of the hospital. All other rooms throughout the facility vary in size and are suitable for single occupancy. All beds are hospital beds. A room is available for activities and is appropriate for this use. The lounge near the courtyard is used for activities and is designed appropriately for when the service implements the Eden Philosophy. Residents with walking aides can walk freely around their own room and the facility. Safety is paramount and staff assist residents as required. A physiotherapist is available to assess all residents on admission and for ongoing care and management. Resident independence is maintained and encouraged by staff interviewed.

63 Criterion (HDS(C)S.2008: ) Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area. Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5) Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs. ARC E3.4b ARHSS D15.3d The physical environment provides safe, age appropriate and accessible areas to meet residents` needs. The lounge areas range in size and some are used as quiet rooms. Most lounge areas are used for activities as observed on the days of the audit. There are five lounges available. One of the two downstairs dining areas is set up as an open plan area with lounge and dining in readiness for the implementation of the Eden philosophy to be introduced. There are two lounges in Hauraki Drive, one of which is a dining area as well. A separate lounge for activities and for physiotherapy assessments to be performed is available. A large photo-board is mounted on to the wall with photographs of activities and special occasions celebrated. An area near the kitchen is set up for fine dining for four residents to enjoy. All areas are appropriately furnished. Residents can relax and sit in any area they choose as observed during the days of the audit. Family can visit and sit in the lounge areas if they wish with the residents or in the residents` own room. Criterion (HDS(C)S.2008: ) Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.

64 Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6) Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided. ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e Cleaning and laundry policies and procedures are documented and available to guide staff. Staff are employed at this facility for cleaning and maintaining the inside of the facility to a high standard. There is a job description for the two cleaners to abide by which clearly outlines their responsibilities for this area of service delivery. The laundry is managed by all staff employed. All personal clothing is done on site as well as all other linen used for beds, towels and facecloths and tea towels from the kitchen. Staff are responsible for the laundry for their own areas. The cleaner interviewed is able to verbalise understanding and knowledge related to outbreak management of a resident in isolation. The cleaners have received training in chemical and products used at this facility and the education records evidence training has been provided. Additional cleaning internally and externally is contracted as required. Product data sheets/ fact sheets are available and accessible to staff in the laundry and cleaners/chemical storage areas which are locked at all times. Containers can be refilled from a pump system installed and the cleaning trolley stored when not in use in the laundry/sluice room. All containers sighted are correctly labelled. The laundry has commercial dryers and washing machines available. Audit are performed regularly for cleaning and laundry processes to monitor effectiveness as per the audit schedule. The cleaning, laundry and hygiene results rated highly overall when audits were performed. Linen quality and availability resulted in the service purchasing more linen to meet requirements. Adequate linen resources sighted are available in all areas. The laundry is set up with a clean and dirty flow, with adequate equipment for the size of the facility. The manager collates the results and reports to the business manager/director and feedback is provided to staff at the staff meetings. Results of the audits are displayed in the staff room to ensure staff are updated.

65 Criterion (HDS(C)S.2008: ) The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. Criterion (HDS(C)S.2008: ) Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals. Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7) Consumers receive an appropriate and timely response during emergency and security situations. ARC D15.3e; D19.6 ARHSS D15.3i; D19.6 Essential emergency and security systems are described in the Health and Safety policies and procedures and include evacuation processes and the service emergency plan. The approved emergency evacuation plan signed off by the New Zealand Fire Service is dated 15 August There have been no changes to the facility since this time. Six monthly fire evacuations are conducted; last undertaken 3 March 2014, with no corrective actions required. A record is maintained of all fire drills by the

66 manager. A folder is available for ensuring all records are accessible if and when required. The fire equipment was last serviced June 2013 and is current. Records are kept for the monthly checks required. Training is provided and emergency plans that have been reviewed in 2013 are available in each of the four areas of the service and are accessible to staff. The manager and senior registered nurses provide training regularly for staff and all staff receive emergency management training as part of the orientation/induction process at commencement of employment. There is a points to remember flow chart available to guide staff in the health and safety manual. Civil defence and emergency supplies are checked regularly. This is kept at the main nurses station at Hauraki Drive. There are emergency food and water supplies available and a gas barbecue that can be used for cooking in case of an emergency. Emergency lighting is available. No generator is available on this site. There is no security company contracted to provide security services. Staff confirm that they are required to ensure doors and windows are securely closed at night. The main doors are locked and visitors can ring a bell and staff respond after hours. Call bells are sighted in all resident areas. When the call bell is activated a display board shows where the bell has been activated from and staff respond. Residents and staff interviewed stated they feel safe. There have been no incidents of security being breached. Criterion (HDS(C)S.2008: ) Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. Criterion (HDS(C)S.2008: ) Where required by legislation there is an approved evacuation plan.

67 Criterion (HDS(C)S.2008: ) Alternative energy and utility sources are available in the event of the main supplies failing. Criterion (HDS(C)S.2008: ) An appropriate 'call system' is available to summon assistance when required.

68 Criterion (HDS(C)S.2008: ) The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting. Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8) Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature. ARC D15.2f ARHSS D15.2g All resident areas have at least one opening window and/or door which provides natural light and ventilation. The facility is totally heated by gas heating. The facility is warm on the day of the audit. Provision for electric heaters is available if required in the winter months. There are wall heaters in the bathrooms and in all residents rooms sighted. Criterion (HDS(C)S.2008: ) Areas used by consumers and service providers are ventilated and heated appropriately.

69 Criterion (HDS(C)S.2008: ) All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light. NZS :2008: Health and Disability Services (Restraint Minimisation and Safe Practice) Standards Outcome 2.1: Restraint Minimisation Services demonstrate that the use of restraint is actively minimised. Standard 2.1.1: Restraint minimisation (HDS(RMSP)S.2008:2.1.1) Services demonstrate that the use of restraint is actively minimised. ARC E4.4a ARHSS D16.6 The Restraint Policy reviewed defines all types of restraint and enablers that are congruent with this standard. It clearly describes procedures associated with restraint use. The policy and its associated forms meet the intent of this standard. Enablers are used for residents as the least restrictive option and are voluntarily implemented to

70 maintain independence and safety. Restraint minimisation is promoted at all times. There are no restraints or enablers in use. Interviews with clinical staff confirm their knowledge and understanding related to restraint versus enablers and how they are managed. Staff education covers de-escalation techniques, such as calming, redirection, activities and understanding cue signs of residents. The manager is the restraint co-ordinator and states that the service actively works at keeping the environment restraint free by talking to family and residents about the use of alternatives. There are appropriate policies and procedures in place to guide staff actions related to restraint and enabler use. Restraint is one of the key components of quality management and risk for the organisation. A restraint register is maintained by the manager. Criterion (HDS(RMSP)S.2008: ) The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety. NZS :2008: Health and Disability Services (Infection Prevention and Control) Standards

71 Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1) There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service. ARC D5.4e ARHSS D5.4e The infection prevention and control manual was submitted and there are excellent policies and procedures in relation to infection control management. The infection control programme is well documented and appropriate for the size and complexity of this facility. The aim is to minimise the risk of infection to residents, staff family/whanau and visitors to this service. There are clear lines of accountability and reporting systems in place. Any trends or issues are identified and information is fed back to staff at staff meetings. There is a surveillance programme available. Care Alliance Waimarie infection control programme identifies that the IPC programme is developed by the manager and the IPCC with input from staff. Evidence is seen of the programme being reviewed at least annually. The programme is evaluated to assess the progress in achieving the 2013 goals and objectives and establish priorities for 2014 (evidence sighted). The roles and responsibility for the infection control coordinators are defined in a position description (sighted). Fifteen staff( five RNs, four HCA, one cleaner, one physiotherapist, one occupational therapist, one diversional therapist and two cooks) interviewed confirm that they are required to report residents who are suspected of having infections to the RN and manager promptly. All staff interviewed are able to identify the importance of hand hygiene and using standard precautions. Criterion (HDS(IPC)S.2008:3.1.1) The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.

72 Criterion (HDS(IPC)S.2008:3.1.3) The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. Criterion (HDS(IPC)S.2008:3.1.9) Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious. Standard 3.2: Implementing the infection control programme (HDS(IPC)S.2008:3.2) There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation. ARC D5.4e ARHSS D5.4e The manager reports that she takes overall responsibility for the IPC programme. Resources of IPCC and RN s are available on site and she ensures all staff are aware of their responsibilities. The in service programme is sighted and includes external courses and in-house education.

73 In the case of an outbreak, advice will be sought from the GP, laboratory services, an external consulting company and experts at the ADHB. The manager and the IPCC are responsible for gaining infection control/infectious disease/microbiological advice and support, where this is not available within the organisation. There have been no reported outbreaks since the last audit. Evidence is sighted of the 2014 programme. Education is also provided by the nurse specialist at ADHB and staff are given the opportunity to attend these in-services. The 15 staff interviewed report good knowledge of infection control, standard precautions and outbreak management. The seven residents and three families are informed of any infections and notices are put on the door when required. Criterion (HDS(IPC)S.2008:3.2.1) The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard. Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3) 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. ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a Policies and procedures comply with relevant legislation and current accepted good practice. The 15 staff interviewed report they are informed of any policy changes as part of the education programme. They are also given the opportunity to attend ADHB in service education on infection control. The manager and the IPCC are given the opportunity to attend an IPC conference annually or when it is held.

74 Criterion (HDS(IPC)S.2008:3.3.1) There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice. Standard 3.4: Education (HDS(IPC)S.2008:3.4) The organisation provides relevant education on infection control to all service providers, support staff, and consumers. ARC D5.4e ARHSS D5.4e Staff orientation covers infection control education relevant to practice within the organisation. Infection prevention and control education was provided to all staff in This included standard precautions and management of incontinence. A record of attendance is maintained and a copy of the presentations held on file (sighted). The 15 staff interviewed confirm attending these in-service educations. The education plan for 2014 is sighted and includes infection control sessions. Education is provided to residents (and/or family members) related to hand hygiene and isolation, if there is an infection outbreak. This is confirmed in interview with residents and families members. Criterion (HDS(IPC)S.2008:3.4.1) Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.

75 Criterion (HDS(IPC)S.2008:3.4.5) Consumer education occurs in a manner that recognises and meets the communication method, style, and preference of the consumer. Where applicable a record of this education should be kept. Standard 3.5: Surveillance (HDS(IPC)S.2008:3.5) Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. The type and frequency of surveillance is clearly stated in policy and is appropriate to the complexity of the organisation. Surveillance methods, analyses and responsibilities are clearly described within the infection control policy. Policy states that surveillance will be presented at staff meetings. An annual summary of the number and type of infections per month is maintained and sighted for A register is kept of all residents who develop infections, the type of infections, results of cultures (where obtained) and details of treatment provided. The register notes whether further follow-up is required. The data are entered into the computer each month and reports of surveillance data are presented at monthly staff meetings. The data are benchmarked through an external consultancy company. Evidence is sighted of surveillance data from the initial completion of the infection notification form and the process that this becomes part of the quality system.

76 Staff report they are notified of any infections at handover and families are contacted as required. Criterion (HDS(IPC)S.2008:3.5.1) The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation. Criterion (HDS(IPC)S.2008:3.5.7) Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.