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Kiwiannia Care Limited - Granger Hose & Richard Seddon Hospital Date of Audit: 15 March 2016 Page 1 of 36

Kiwiannia Care Limited - Granger Hose & Richard Seddon Hospital

Introduction

This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted by Health Audit (NZ) Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity: Kiwiannia Care Limited

Premises audited: Granger House Rest Home & Richard Seddon Hospital

Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit: Start date: 15 March 2016 End date: 16 March 2016

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 61

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards


Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

consumer rights organisational management continuum of service delivery (the provision of services) safe and appropriate environment restraint minimisation and safe practice infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

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 Standards applicable to this service fully attained

Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity

Some standards applicable to this service partially attained and of low risk


Indicator Description Definition

A number of shortfalls that require specific action to address

Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk

Major shortfalls, significant action is needed to achieve the required levels of performance

Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Granger House and Richard Seddon Hospital can provide care for up to 69 residents requiring care at rest home or hospital level. There were 61 residents on the day of the audit. This surveillance audit has been undertaken to establish compliance with a sub-set of the relevant Health and Disability Services Standards and the district health board contract.

The audit process included the review of policies and procedures, the review of residents and staff files, observations and interviews with residents, family, management, staff and a medical officer.

The facilities manager is responsible for the overall management of the facility and is supported by the clinical manager.

The previous certification audit identified number of areas requiring improvement. The appointment of a permanent manager and clinical manager met one requirement. The areas requiring improvement that remain open are quality and risk management documentation; timeliness of advising the Ministry of Health of an essential notification; staff in-service education; resident documentation including care planning documents and advance directives.

The Ministry of Health and district health board undertook an unannounced inspection in September 2015 and identified partially attained standards related to: best practice; complaints management; governance; quality and risk framework including incident reporting; human resource management; staffing; clinical record documentation; assessment and care planning; medication management; safe restraint practice and availability of equipment. The areas identified as requiring improvement that have been


met following this surveillance audit relate to: governance (appointment of a facilities manager and a clinical manager) and safe restraint practice. The remaining areas requiring improvement remain open.

New areas identified at this surveillance audit relate to: open disclosure; hazard registers; the orientation programme; job descriptions; staff performance reviews; skill mix policy; first aid; short term care plans and medication competencies. There is one area identified as a high risk finding relating to pressure injuries and wound care plans.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs.

Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk.

Information regarding the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code), Nationwide Health and Disability Advocacy Service, is accessible and is brought to the attention of residents’ and their families on admission to the facility.

Residents and family reported time is provided if further discussions and explanations are required. There was positive feedback from residents and family members on care provided at the facility.

Improvements are required around: good practice; open disclosure; advance directives and the complaints management system.


Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner.


Kiwiannia Care Limited is the governing body and is responsible for the service provided at Granger House and Richard Seddon Hospital. An organisational structure indicates one overall facilities manager for both sites (Granger House and Richard Seddon Hospital and Kowhai Manor) and a clinical manager at each of the two sites. Some aspects of the quality framework have been centralised to Granger Home and Richard Seddon Hospital.

The current facilities manager is a registered nurse with many years of experience in aged care management. They are supported by the clinical manager, registered nurse with three years’ experience in aged care.

Areas identified as requiring improvements at certification and Ministry inspection and remaining open relate to: the quality and risk management system; analysis and evaluation of the quality improvement data; development and implementation of corrective action plans; adverse event reporting; human resource management. In addition, the Ministry inspection identified policies and procedures require review to meet current best practice, and this also remains open.

New areas requiring improvement are review of the skill mix policy, staff to have current first aid and hazard registers to be up to date.


Copies of annual practising certificates were reviewed for all staff that required them and were current. Staff are supported to complete the New Zealand Qualifications Authority approved aged care education modules and these commenced in December 2015.

Continuum of service delivery

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.


The registered nurses are responsible for each stage of service provision at Granger House. Referral to other health and disability services occurs as required. Families and residents interviewed were supportive of the care provided. There is an activities coordinator who facilitates the provision of a range of activities that are suitable for rest home and hospital residents. There are policies and procedures to guide staff in the safe implementation of all medicine management system. Nutrition and safe food systems are appropriately managed on site.

Safe and appropriate environmentIncludes 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.


There is a current building warrant of fitness. Residents and family interviewed describe the environment as appropriate with indoor and outdoor areas that meet their needs.

Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation.


There are restraint minimisation and safe practice policies applicable to the service. Guidelines of the use of restraints policy ensures that enablers are voluntary, the least restrictive option and allows residents to maintain their independence. There are currently four hospital residents using restraint and seven hospital residents using enablers.

Infection prevention and controlIncludes 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.


The infection control surveillance data was sampled through resident records and collated infection reports. Information sampled confirms that the surveillance programme is appropriate for the size and complexity of the services provided.


Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating

Continuous Improvement

(CI)

Fully Attained(FA)

Partially Attained

Negligible Risk(PA Negligible)

Partially Attained Low

Risk(PA Low)

Partially Attained

Moderate Risk(PA Moderate)

Partially Attained High

Risk(PA High)

Partially Attained Critical

Risk(PA Critical)

Standards 0 6 0 2 13 1 0

Criteria 0 25 0 4 18 1 0

Attainment Rating

Unattained Negligible Risk(UA Negligible)

Unattained Low Risk

(UA Low)

Unattained Moderate Risk(UA Moderate)

Unattained High Risk

(UA High)

Unattained Critical Risk(UA Critical)

Standards 0 0 0 0 0

Criteria 0 0 0 0 0


Attainment against the Health and Disability Services StandardsThe following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome

Attainment Rating

Audit Evidence

Standard 1.1.10: Informed Consent

Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent.

PA Moderate

The previous certification audit identified that not all residents had advanced directives and/or resuscitation orders completed and signed appropriately, this finding remains open.

Staff interviews confirm, where appropriate, residents and their family are provided with information to assist them to make informed choices and give informed consent (refer to 1.1.9.1). The residents' files evidenced signed informed consent forms.

Standard 1.1.13: Complaints Management

The right of the consumer to make a complaint is

PA Moderate

The Ministry inspection identified the complaints processes required improvement and this remains open following this surveillance audit. The facilities manager is responsible for complaints at Granger House and Richard Seddon Hospital. The complaints register and associated documents were reviewed for 2015 and 2016 and the findings evidence this process requires improvement.

The facilities manager advised there had been no complaint investigations by the Ministry of Health, district health board (DHB), Accident Compensation Corporation (ACC), police, coroner and Health and Disability commissioner

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

http://www.health.govt.nz/your-health/services-and-support/health-care-services/services-older-people/rest-home-certification-and-audits


understood, respected, and upheld.

since the Ministry inspection in September 2015.

Residents and their family are advised on entry to the facility of the complaints process via the Health & Disability Commissioners Code of Rights pamphlet. The admission agreement does not record the details of the facility’s complaint policy and procedure and the information sheet in the information pack does not include this information (refer to 1.1.9.1).

The complaints policy, procedure, flow chart and forms do not align with Right 10 of the Code. The complaint / compliment forms are located at entrance to the facility.

Standard 1.1.8: Good Practice

Consumers receive services of an appropriate standard.

PA Moderate

The Ministry inspection identified areas requiring improvement around skin management policy to align to current best practice and practices sighted that were not considered to meet best practice. There was evidence of staff communication around the practices identified at the inspection and these have now ceased. The skin management policy has been reviewed to meet best practice, however there are other policies that require review to align with best practice. This improvement remains open in relation to: policy review; staff education; adverse events; pressure injuries; assessment, care planning and review and first aid.

Standard 1.1.9: Communication

Service providers communicate effectively with consumers and provide an environment conducive to effective communication.

PA Moderate

There is an open disclosure policy. There is inconsistent evidence on the accident/incident forms of communication with family following adverse events.

Residents interviewed confirm they are aware of the staff that are responsible for their care. Staff advised there were no residents at the facility who required interpreter services. Access to an interpreter service is available, if required, via the district health board (DHB).

There are two admission agreements used at the facility. The new admission agreement does not fully align with the ARC contract. Prospective residents and their family are provided with an information pack about the service. The information pack does not include all relevant information about the services at Granger House and Richard Seddon Hospital.

Standard 1.2.1: Governance

The governing body of the organisation ensures services are planned, coordinated,

FA Improvement identified at certification and Ministry inspection relating to the appointment of a permanent facility manager and clinical manager for this facility has been met. There were three managers in short succession at the facility during 2015, until the current facilities manager was appointed. The current manager’s appointment is for one year. The facilities manager is a registered nurse with experience in aged care management. The clinical manager was appointed in December 2015. The clinical manager is a registered nurse with three years’ experience in aged care. Both managers have current practising certificates. An organisational structure for Kiwiannia Care Limited indicates one overall manager for both sites (Granger House and Richard Seddon Hospital and Kowhai Manor) and


and appropriate to the needs of consumers.

a clinical manager at each of the two sites.

Kiwiannia Care Limited is the governing body and is responsible for the services provided at Granger House and Richard Seddon Hospital. A business plan (2015 -2016) was sighted and includes objectives for the service. The facilities manager provides the executive director with minutes of the monthly quality meetings. The executive director was interviewed during this audit and confirmed receiving monthly meeting minutes for the services at Granger House and Richard Seddon Hospital.

The service’s mission statement and philosophy is in an understandable form and is available to residents and their family / representative or other services involved in referring residents to the service.

Granger House and Richard Seddon Hospital provides rest home and hospital level care for up to 69 residents. On the day of the surveillance audit there were 61 residents residing at the facility, 26 rest home and 35 hospital residents. There was one resident under the chronic medical long term contract, two residents under the age of 65 years and one resident receiving respite care. There are 11 dual purpose beds.

Standard 1.2.3: Quality And Risk Management Systems

The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles.

PA Moderate

The previous certification audit and the Ministry inspection identified areas requiring improvements relating to: the quality and risk management system; analysis and evaluation of the quality improvement data; and development and implementation of corrective action plans. All these areas requiring improvement remain open following this surveillance audit. Additional to the above findings, the Ministry inspection identified that policies and procedures require review to meet current best practice, and this remains an improvement following this surveillance audit.

The facilities manager advised that there is a new quality and risk improvement plan, sighted. The new quality and risk management plan is starting to be implemented, however is not yet fully embedded. A business plan was also reviewed, as was the facility’s philosophy, objectives and a mission statement. Aspects of the quality framework have been centralised to the Granger Home and Richard Seddon Hospital.

There is an internal audit programme in place and completed internal audits for 2015 were reviewed. These evidence corrective action plans are not consistently documented and completed. There is a new quality improvement planner for 2016 and this records audits and checklists. Included in the quality planner are checklists such as: fridge / freezer temperature monitoring; and monthly signage checks. The internal audits on the new quality planner are to be implemented. The clinical audits include: resident questionnaire; resident meetings; medication administration audit; medication management audit; nursing chart audit; hygiene and grooming audit ; restraint policy and staff appraisals. The clinical audits require to be strengthened and include relevant internal audits relating to care services.

The majority of the meeting minutes in 2015, were not available for review. The 2015 meeting minutes that were reviewed evidence corrective actions are not always followed up and there is inconsistent information of the analysis of quality improvement data. Some meeting minutes, such as quality and staff meeting in October 2015 evidence the corrective actions raised were signed off, the day the meeting was held. New meeting structure has been


implemented in 2016. There is a monthly quality meeting that includes: risk management; quality; health and safety; infection control; and audit outcomes. The minutes of these meetings for January and February 2016 were reviewed and evidence discussions around all services provided at Granger House and Richard Seddon Hospital, however more comprehensive information around incident trends, mitigation strategies, and internal audit outcomes are required. Staff meetings are held monthly following the quality meetings and meeting minutes are available for review by staff who are unable to attend.

Quality of life questionnaire relating to the activities programme has been completed, however this is not dated and collation and analysis of the data has not been completed. There is no evidence the results have been communicated to residents and staff. Resident and family satisfaction questionnaires were not available for review on audit days.

Not all policies were able to be sighted at the facility on audit days. Some policies and procedures require review to align with current best practice, as previously identified at the Ministry inspection. There is a systems in place for reviewing and updating the policies and procedures. Policies are currently reviewed every three years and due for review in 2017.

There was a hazard reporting system in place, as well as hazard registers, however these required to be updated. This is a new area requiring improvement identified at this surveillance audit.

Standard 1.2.4: Adverse Event Reporting

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.

PA Moderate

The previous certification audit and the Ministry inspection identified areas requiring improvement around adverse event reporting. The required improvement from the certification audit around essential notification reporting remains open. The Ministry inspection identified the adverse event forms require full documentation and review and this also remains open.

The review of accident / incident forms evidenced: they are not always completed; family were not always notified of the incident (refer to 1.1.9.1); neurological observation were not always completed for unwitnessed falls and the forms were not signed off in timely manner. The accident / incident forms are signed off by the registered nurse (RN) and the forms are reviewed by the facilities manager (FM) at the end of the month.

Standard 1.2.7: Human Resource

PA The previous certification audit identified areas requiring improvement around the ongoing education at the facility and this finding remains open. Ministry inspection identified areas requiring improvement around performance


Management

Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.

Moderate reviews, RN training and staff scope of practice. The improvement required around the staff working within their scope of practice has been met. The remaining requirements remain open.

Aspects of the quality framework have been centralised to the Granger Home and Richard Seddon Hospital and human resource management is included in this centralisation. All staff files (Granger and Kowhai) are held on site at Granger House.

The skills and knowledge required for each position is documented in job descriptions, however these were not sighted in all staff files reviewed. There is no signed job description for the clinical manager and the facilities manager. Copies of annual practising certificates were reviewed for all staff that required them to practice and were current.

The facilities manager is responsible for the in-service education programme. The planned in-service education programme for January and February 2016 did not occur due to speaker cancellations. The education planners for 2015, individual staff attendance records and attendance records for each education session were reviewed and provide evidence that on-going education is required to be provided in core education topics such as: open disclosure; complaints management; adverse event reporting; care planning. The education programme could be strengthened, including education for the registered nurse workforce. Not all staff have current first aid and there are number of shifts on the duty rosters that do not have a staff member with current first aid certificates (refer to 1.2.8.1).

Staff are supported to complete the New Zealand Qualifications Authority approved aged care education modules and these have commenced in December 2015.

An appraisal schedule has not been adhered to and there is evidence number of staff have not had staff appraisals since 2014.

An orientation/induction programme is available and all new staff are required to complete this before they begin to provide care to residents. Care staff interviewed confirmed they have completed an orientation, however orientation has not been completed for the facilities manager and the clinical manager.

Standard 1.2.8: Service Provider Availability

Consumers receive timely, appropriate, and safe service from suitably qualified/skilled

PA Moderate

The Ministry inspection identified areas requiring improvement around the on call arrangements, which are now met. The requirements around completion of rosters in a coordinated way has also been met. The backfilling of staff absences is occurring and this part of the inspection finding has also been met. There are new areas requiring improvement around review of the skill mix policy and for staff to have current first aid.

There is a policy around staff skill mix, however this requires more detail in order to provide safe service delivery. Registered nurse (RN) cover is provided 24 hours a day seven days a week. Night staffing consists of one registered nurse and three care givers. The facilities manager and the clinical manager are available on call, if required and this is communicated to staff on the staff roster. Observations during this audit confirm adequate staff


and/or experienced service providers.

cover is provided. A number of staff have been recently employed and some of these were being orientated on audit days. Residents and family interviewed reported staff provide them with adequate care.

Standard 1.2.9: Consumer Information Management Systems

Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required.

PA Low The previous certification audit and Ministry inspection identified that not all resident clinical records evidenced consistent dating and signing by staff. Progress notes entries are legible, dated and signed by the relevant caregiver or registered nurse making the entry. Assessments and care plans reviewed did not evidence that all documents were signed and dated. The previous finding remains open.

Standard 1.3.12: Medicine Management

Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

PA Moderate

The MOH inspection conducted in September 2015 identified that medication management did not adhere to best practice or legislation. This finding remains open. The service uses four weekly blister dose medication packs for all residents at Granger House. There is a signed agreement with the supplying pharmacy. The blister packs are checked and reconciled against medication charts upon arrival to the facility and signed off when the check has been completed.

There are two medication trolleys in the hospital and one in the rest home . All medications are stored securely when trolleys are not in use however, not all trolleys are able to be locked. Medications requiring refrigeration are stored appropriately. The two medication fridge temperatures are monitored and results recorded. Controlled drugs are appropriately stored, managed and disposed of. This aspect of the previous MOH inspection finding has been addressed.

The service has a self-medication policy and procedure. There are no residents currently self-medicating.

The lunch time medication round was observed; staff are signing off as the dose is administered. Staff education in medicine management was provided in October 2015. Not all staff who administer medications have a current medication competency. Twenty four medication charts were sampled. All charts have photo identification. Allergies were not documented on all charts and three monthly reviews were not evident for all charts reviewed. Medication reconciliation has been completed on admission by a registered nurse. There are aspects of medication management which do not align with best practice.


Standard 1.3.13: Nutrition, Safe Food, And Fluid Management

A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.

FA All meals for Granger House residents are prepared and cooked on site. The service has recently reviewed the provision of food services for both Granger House and Kowhai Manor. As of next week the kitchen at Granger House is going to provide the meal service for both facilities. Both cooks have completed the appropriate safe food handling certificates. Meals are served directly from the kitchen to the rest home dining room residents. The hospital residents are served from a bain Marie and residents in the Greenwood wing of the rest home receive a tray meal service. Food covers were noted and the lunch time meal was observed in both areas. There were sufficient staff on hand to assist residents with their meals and drinks. Food temperatures, fridge, chiller, and freezer temperatures are monitored and recorded.

Kitchen services audits were completed. The service provides special equipment as required. On the day of audit the kitchen pantry evidenced extra food stores - enough for three days if required in an emergency.

There is a four weekly rotating summer and winter menu that was last approved by a registered dietitian in 2015. Registered nurses inform the kitchen regarding resident’s dietary requirements which include likes and dislikes, modified diets and preferences. These dietary profiles are reviewed and the cook advised that the kitchen is informed in a timely manner of any changes or new residents. The clinical nurse manager interviewed described the process for management of residents with unexplained weight loss or gain, including referral to a dietician and speech language therapist, as required. Documents reviewed showed monthly monitoring of individual resident's weight. Chair scales are available. Care plans include dietary requirements, however, nutritional assessments have not been fully completed (refer to 1.3.4.2).

Residents and families interviewed were satisfied with the food service provided, and report that individual preferences are well catered and adequate food and fluids are provided.

Standard 1.3.4: Assessment

Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner.

PA Moderate

The MOH inspection conducted in September 2015 identified that the GP initial assessment was not always completed within two working days (refer to 1.3.3.3) and that pain assessments have not been completed when pain was reported. This finding remains open. Granger House has not yet commenced the use of the interRAI assessment tool. Two registered nurses (including the clinical manager) are trained and competent in the use of the interRAI tool however, no resident files reviewed evidenced that the tool has been utilised. A suite of paper based risk assessments are available and have been completed for continence and pressure risk for eight of eight resident files reviewed. A registered nurse comprehensive assessment form has been used in some of the resident files reviewed. Review of risk assessments were not completed at least six monthly or as required (refer to 1.3.3.3). An initial assessment had not been completed for all residents.

Standard 1.3.5: Planning

PA Moderate

The MOH inspection conducted in September 2015 identified that long term care plans did not accurately reflect resident needs. This finding remains open. Residents' care plans are developed by registered nurses. The


Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery.

interRAI assessment tool has not been used in the development of the care plans (refer to 1.3.4.2). Initial care plans were completed for all resident files sampled. Not all long term care plans reviewed recorded all resident care requirements. Short term care plans have not been recorded for all short term needs (refer to 1.3.8.2). Resident’s previous health history and medical risk management plans were included in the care plans. Residents’ files are integrated. Progress notes have been written at least daily by caregivers and registered nurses. Documentation was maintained in the paper-based files. Staff communicate during each shift handover. Residents and family members interviewed were happy with the care provided.

Standard 1.3.6: Service Delivery/Interventions

Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes.

PA High The care being provided for rest home and hospital care residents was not fully consistent with the needs of the residents as evidenced through documentation review and observation. Residents who required registered nurse review following health concerns did have this recorded in progress notes as having been done. Relatives were notified of changes in a resident's condition with exception (refer to 1.1.9.1). The registered nurses initiate a GP consultation for any changes in resident health status. Caregivers document any changes in care/condition of residents in the progress notes. All residents and family/whanau interviewed reported satisfaction with the care and service delivery.

Wound assessments, wound management plans and wound progress reports were not fully completed for the residents with wounds and pressure injuries.

The MOH inspection conducted in September 2015 identified that appropriate equipment and supplies were not fully available for the residents’ clinical needs. Equipment reviewed on the days of audit included sufficient supplies. There were adequate dressing and incontinence supplies sighted on the day of audit in storage facilities in both the rest home and the hospital areas. Supplies of linen, sensor mats, sling and standing hoists and chair scales were available. Checking and calibration of equipment has been conducted. The service has addressed this aspect of the MOH inspection finding. Pressure relieving devices are now available and the facility manager advised that new equipment has been purchased. Pressure relieving devices were not in place for all residents with assessed risk. Improvements remain in relation to this aspect of the previous MOH inspection finding.

Standard 1.3.7: Planned Activities

Where specified as part of the service delivery plan for a consumer, activity

PA Low There is an activities coordinator who works for thirty hours per week over four days and provides activities to rest home and hospital residents. The coordinator is supported by volunteers and care staff. Activities time is divided between the rest home and hospital area. The activities staff member interviewed reported that they modified the programme related to the response and interests received from residents. Resident's capability and cognitive abilities were considered in planning the activities program. The activities programme covers residents’ physical, social, recreational and emotional needs.


requirements are appropriate to their needs, age, culture, and the setting of the service.

Granger House has access to a van for outings. Not all residents files reviewed evidenced that activities assessments and activities care plans have been completed. Residents and families interviewed confirmed that the programme included interests of individuals and points of interest in the community.

Standard 1.3.8: Evaluation

Consumers' service delivery plans are evaluated in a comprehensive and timely manner.

PA Moderate

Six monthly care plan reviews have not all been consistently conducted or within the timeframes required (refer to 1.3.3.3). The service has a care plan review form which aligns with each aspect of the long term care plan. Multi-disciplinary team meetings are held. None of the eight resident files reviewed had a care plan review completed after 1 January 2016 therefore, the interRAI assessment has not been required as part of the evaluation process. The GPs examine residents monthly or if the resident is stable then at least three monthly. Three monthly medication reviews were not consistently evident in medication charts reviewed (refer to 1.3.12.1). Where progress was different from expected, the service responded by initiating changes to the long term care plan. Short term care plans had not been used for all identified short term care issues. The residents and family/whanau interviewed reported satisfaction with the care provided at the service.

Standard 1.4.2: Facility Specifications

Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

FA Service provider's documentation and visual inspection evidences a current building warrant of fitness that expires 01 July 2016. There have been no alteration to the buildings since the last certification audit.

Standard 3.5: Surveillance

Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection

FA The type of surveillance undertaken is appropriate to the size and complexity of this service. Standardised definitions are used for the identification and classification of infection events.

Infection control surveillance data was sampled through resident records, staff interviews and collated infection control reports. Infection control data is communicated to staff at facility meetings, sighted in the monthly risk and quality meetings that commenced in January 2016. Infection logs are maintained for infection events, sighted.

In interviews, staff reported they are made aware of any infections of individual residents by way of feedback from the RN's, verbal handovers, short term care plans and progress notes (refer to 1.3.8.2).


control programme.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA There are restraint minimisation and safe practice policies applicable to the service. The policy includes enabler and restraint procedures, assessment guidelines, timeframes, monitoring, observation, evaluation and review. Guidelines of the use of restraints policy ensures that enablers are voluntary, the least restrictive option and allows residents to maintain their independence. There are currently four hospital residents using restraint and seven hospital residents with enablers. Four files reviewed evidence that restraint and enablers are managed in the same way with assessments, consents, care planning and review documentation completed. Monitoring is completed and documented.

Standard 2.2.3: Safe Restraint Use

Services use restraint safely

FA The Ministry inspection conducted in September 2015 identified that restraint practice did not align with the standard. Advised by the management that the Greenwood wing of the rest home is no longer locked. The wing was not observed to be locked at any time during the audit. Two restraint and two enabler files were reviewed. All files evidence that assessments have been completed, consent forms are completed appropriately by either the resident (enablers) or the family and the general practitioner (restraint). Care planning includes alternatives and risks associated with restraint. Restraint and enabler monitoring forms have been routinely completed for the sample of files reviewed. A restraint and enabler register is maintained by the clinical nurse manager (restraint coordinator). The service has addressed and monitored this previous finding.


Specific results for criterion where corrective actions are requiredWhere a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded.

Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights.

If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit.

Criterion with desired outcome

Attainment Rating

Audit Evidence Audit Finding Corrective action required and timeframe for completion (days)

Criterion 1.1.10.7

Advance directives that are made available to service providers are acted on where valid.

PA Moderate

In interviews, residents confirmed their choices and decisions were acted on. The residents' files evidenced signed informed consent forms. Two of eight files sampled evidenced the not for resuscitation (NFR) orders were not valid.

Advance directives were not correctly documented for two of eight residents’ files.

Provide evidence of valid not for resuscitation orders

60 days

Criterion 1.1.13.3

An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.

PA Moderate

The Ministry inspection in September 2015 identified the complaints process as requiring improvement and this remains open.

The complaint policy, procedure, flow chart and complaint forms sighted do not comply with Right 10 of the Code.

The complaints register is maintained and includes records of some verbal and written complaints. The complaints register evidences: not all complaints are recorded; the complaints are

i) The complaint policy, procedure, flowchart and the complaint form do not comply with Right 10 of the Code.

ii) The complaints

Provide evidence:

i) The complaint policy, procedure, flow charts and form comply with Right 10 of the


not consistently notified in writing to the complainant within five working days of receipt of the complaint; there is inconsistency of the complainant being informed of independent advocacy service; the actions of the provider regarding the investigation of a complaint are inconsistently documented; and the satisfaction of the complainant is not always recorded.

Interview with a family member who lodged a verbal complaint in 2016 was conducted and confirmed their satisfaction with the outcome. This verbal complaint is entered on the complaint register, however there is no detail of the complaint in associated documentation; no information about the actions taken by the provider regarding the complaint; and no written statement of the complainant satisfaction with the outcome.

register does not consistently record: all complaints; notification of the complaint; independent advocacy service; the actions of the provider regarding the complaint; and satisfaction of the complainant.

Code.

ii) The complaints register maintains an accurate record of complaints received and the complaints process complies with Right 10 of the Code

90 days

Criterion 1.1.8.1

The service provides an environment that encourages good practice, which should include evidence-based practice.

PA Moderate

The Ministry inspection identified, the skin management policy did not align to current best practice. The skin management policy has been reviewed, however there are number of policies, procedures and protocols that require review to align with best practice and staff to understand the new policies, procedures and protocols (refer to 1.2.3.3).

The Ministry inspection sighted practices that are not considered to meet best practice were not observed at this surveillance audit.

The adverse events do not consistently follow policies and procedures, such as conducting neurological observations following unwitnessed falls (refer to 1.2.4.3). Staff in-service education requires to be conducted regularly (refer to 1.2.7.5). Not all staff have current first aid certificates (refer to 1.2.8.1). Clinical documentation does not fully comply with the standards (refer to 1.3.3.3; 1.3.4.2; 1.3.6.1; 1.3.8.2).

The services provided do not always meet good practice.

Ensure residents receive services of an appropriate standard through evidence based practice.

30 days

Criterion 1.1.9.1 PA The accidents / incident forms reviewed did not consistently i) Family Provide


Consumers have a right to full and frank information and open disclosure from service providers.

Moderate record that family members were notified of adverse events occurring.

All residents’ files reviewed evidenced signed admission agreements. Of the eight residents’ files reviewed, four files had previous admission agreements and four files had new admission agreements. The new admission agreement (no date) does not comply with the ARC contract.

Prospective residents and their families are provided with an information pack about the service. The information pack includes pamphlets on the Code; the advocacy service information; and typed information sheets about the service. The service’s information sheets include: mission statement; philosophy; introduction; eligibility; exemptions; services at Granger House and Richard Seddon Hospital and description of the facility’s environment. The information sheets do not cover all areas of the service, such as information about activities, meal service and cultural support.

notification of residents’ adverse events is inconsistently conducted.

ii) The admission agreement does not comply with the ARC contract.

iii) The information pack does not include all required information relating to the service.

evidence;

i) Family are notified of adverse events

ii) The admission agreement complies with the ARC contract

iii) The information pack contains all relevant information about the service.

90 days

Criterion 1.2.3.1

The organisation has a quality and risk management system which is understood and implemented by service providers.

PA Moderate

There is a new quality and risk improvement plan, introduced in 2016. The service demonstrates aspects of the quality management system are in place, however, overall the quality framework requires strengthening to be fully implemented. There are aspects of the quality framework that have been centralised to the Granger Home and Richard Seddon Hospital.

The clinical audits on the new quality planner include: resident questionnaire; resident meetings; medication administration audit; medication management audit; nursing chart audit; hygiene and grooming audit ; restraint policy and staff appraisals. The clinical audits require to be strengthened and include relevant internal audits relating to care services.

The quality and risk management system requires strengthening and to be fully implemented.

Provide evidence that the quality and risk management systems introduced in 2016 are fully embedded.

90 days

Criterion 1.2.3.3 PA The Ministry inspection identified there were instances where policies were not being implemented as prescribed. This has

Not all policies and procedures

Provide evidence all


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.

Moderate been actioned and is now met. The inspection also identified the policies require review to ensure they meet current best practice and this finding this stands (refer to 1.1.8.1). A number of policies were not available on days of audit.

align with current good practice.

policies and procedures are reviewed and align with evidenced –based practice

90 days

Criterion 1.2.3.6

Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.

PA Moderate

Clinical indicators and quality improvement data is recorded on various registers and forms. Some quality improvement data has been graphed.

The 2015 meeting minutes reviewed evidence there is inconsistent information of the analysis of quality improvement data. 2016 meeting minutes evidence discussions around all services provided at Granger House and Richard Seddon Hospital, however more comprehensive information around incident trends, mitigation strategies, and internal audit outcomes are required.

Questionnaire relating to the activities programme has been completed, however collation and analysis of the data has not been completed. There is no evidence the results have been communicated to residents and staff. Resident and family satisfaction questionnaires were not available for review on audit days.

Quality improvement data is not being comprehensively analysed and evaluated to identify trends and communicated to all concerned.

Provide documented evidence that quality improvement data is being comprehensively analysed and evaluated to identify trends and communicated to all concerned.

30 days

Criterion 1.2.3.8

A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.

PA Moderate

Improvements to recording and management of corrective action plans were identified at previous audits (certification and Ministry inspection) and improvements are still required as corrective action plans have not been consistently developed, implemented and monitored to address all of the shortfalls identified.

The internal audit programme evidences corrective action plans are not consistently documented and implemented.

The 2015 meeting minutes that were reviewed evidence

Corrective action plans are not being consistently developed, implemented, monitored and evaluated to address all shortfalls

Provide evidence corrective action plans are being developed, implemented, monitored and evaluated to address any


corrective actions are not always followed up. Some meeting minutes, such as quality and staff meeting in October 2015 evidence the corrective actions raised were signed off, the day the meeting was held.

identified to service delivery; and the person/s responsible for the corrective action plans and the timeframe/s for implementation have not been consistently documented.

shortfalls identified to service delivery; and that the person/s responsible and the timeframe/s for implementation are clearly documented.

30 days

Criterion 1.2.3.9

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.

PA Low There is a health and safety manual that includes relevant policies and procedures. There is a hazard reporting system in place, as well as hazard registers for services provided at the facility, however these are not up to date.

Chemical safety data sheets are available. The biomedical equipment has appropriate performance verified stickers in place. Electrical safety stickers are in place.

Hazard registers are not current and require review.

Provide evidence the hazard registers are current

180 days


Criterion 1.2.4.2

The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.

PA Low Previous requirement for improvement from last certification audit relating to HealthCERT not being advised in a timely manner of a request from a Coroner for information following the sudden death of a resident has been met, however this criterion remains open as HealthCERT have not been notified of pressure injuries. There were seven pressure injuries at the facility on audit days. The facilities manager was not aware of six of these pressure injuries (refer to 1.3.6.1).

Essential notification reporting is not consistently conducted.

Provide confirmation that all essential notifications as required by legislation are made to the appropriate authorities in a timely manner.

90 days

Criterion 1.2.4.3

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.

PA Moderate

The required improvements identified at the Ministry inspection around adverse event reporting remain open.

Some aspects of the quality framework have been centralised to Granger Home and Richard Seddon Hospital and this includes the adverse event reporting. The system implemented around adverse event reporting, maintains the original incident forms for Kowhai Manor residents at Granger House and Richard Seddon Hospital (Granger). A photocopy of the incident form for Kowhai events is retained on the resident’s file. Two of nine incident forms reviewed at Granger did not have incident form completed (not including pressure injuries).

Number of incident / accident forms were not signed off by the facilities manager. The system implemented currently is that the accident / incident forms are signed off by the registered nurse (RN) and the forms are reviewed by the facilities manager (FM) at the end of the month. This centralised system of adverse event reporting requires review (refer to 1.2.3.6).

The review of accident / incident forms evidenced: they are not completed fully and family are not always notified of the incident (refer to 1.1.9.1). Data of adverse events for 2015 is not consistently completed monthly (refer to 1.2.3.6).

There was evidence the collation, analysis and trends of

Adverse events are not consistently documented, reported, signed off in timely manner and protocols are not followed.

Provide evidence the adverse event reporting system is reviewed to comply with standard, protocols and guidelines and to identify and manage risks.

30 days


incidents / incidents in 2016 include time and location of the accident, however there is no detailed analysis of individual residents, an area that could be strengthened in order to identify opportunities to manage individual resident risk.

A falls response protocol is used inconsistently and does not link to policy (refer 1.2.3.6 and 1.1.8.1). Unwitnessed falls do not evidence neurological observation are consistently completed and pain assessments are conducted (refer to 1.3.4.2).

Criterion 1.2.7.4

New service providers receive an orientation/induction programme that covers the essential components of the service provided.

PA Moderate

There is an orientation programme in place, however the orientation booklet provides generic orientation and does not focus on specific roles, such as registered nurses; clinical manager and facilities manager. The clinical manager and the facilities manager have no recorded evidence of orientation to their roles. The facilities manager file was not available to be reviewed on audit days.

Review of staff files evidenced four out of the eight files did not have job descriptions.

The orientation programme is not conducted for all new staff, is not role specific and job descriptions are not competed for all staff employed.

Provide evidence the orientation programme is conducted for all new staff, is specific to the role and job descriptions are provided for all staff employed.

90 days

Criterion 1.2.7.5

A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.

PA Moderate

The six out of the eight staff files reviewed evidenced annual performance reviewed were not current.

Individual education records were reviewed on staff files. Some staff are not attending in-service education on a regular basis. In-service education attendance records for each session were reviewed and some of these sessions were poorly attended.

There is no recorded evidence of staff education for 2016. The planned in-service education programme for January and February 2016 did not occur due to speaker cancellations. The education planners for 2015, individual staff attendance records and attendance records for each education session were

i) There is evidence the on-going staff education has not been provided in core education topic; is poorly attended; and does not include specific education for the registered nurse workforce.

i) Provide evidence the on-going staff education is provided in core education topic; is well attended; and include specific education for the registered nurse workforce.


reviewed and provide evidence that on-going education is required to be provided in core education topic such as: open disclosure; complaints management; adverse event reporting; care planning. The education programme could be strengthened, including education for the registered nurse workforce.

ii) Staff performance reviews are not current

ii) Provide evidence the staff performance reviews are current.

90 days

Criterion 1.2.8.1

There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.

PA Moderate

Ministry inspection identified areas requiring improvement around: the on call arrangements; completing of rosters in a coordinated way and the backfilling of staff absences and these have all been met. On call arrangements are communicated to staff on the staff roster. The facilities manager and the clinical manager share the responsibility for on call. The rosters are completed by the facilities manager with some changes to the roster being implemented. New staff have been employed at the service and some were completing their orientation at the facility on audit days.

There are new areas requiring improvement around review of the skill mix policy and for staff to have current first aid. The policy sighted, is not detailed enough to guide the practice of safe service delivery at the facility.

The review of staff files and first aid certificates evidenced not all RNs have current first aid certificates. The roster evidenced five RNs did not have current first aid certificates resulting gaps in first aid cover during the audit on: two morning shifts; three afternoon shifts and five night duty shifts. Interview with the facilities manager confirmed the RNs are attending a first aid course on the week following the audit. The planned first aid course staff attendance was sighted.

i) The skill mix policy sighted is not detailed enough to guide the practice of safe service delivery at the facility.

ii) Not all RNs have current first aid certificates.

Provide evidence;

i) The skill mix policy is detailed enough to guide the practice of safe service delivery at the facility.

ii) All RNs have current first aid certificates

30 days

Criterion 1.2.9.9

All records are legible and the

PA Low Eight residents’ files and twenty four medication charts were reviewed. Progress notes entries evidence the designation, date and time of the person making the entry. Long term care plans

Resident documentation including one

Ensure that all clinical documentation is


name and designation of the service provider is identifiable.

reviewed were dated and signed. Risk assessments and short term care plans were dated and signed in five of eight resident files reviewed.

short term care plan for a rest home resident was not dated and signed off, and risk assessments for three residents were not dated.

dated and signed.

60 days

Criterion 1.3.12.1

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.

PA Moderate

Registered nurses and a senior caregiver administer medications to the residents. Twenty four medicine charts were sampled (twelve rest home and twelve hospital). All 24 charts had residents' photo identification on them. Allergies or nil known allergies were recorded for 21 of 24 charts reviewed. Three monthly medication reviews were completed for 21 of 24 resident medication charts reviewed. Medications are stored appropriately and securely when not in use. Two of three medication trolleys are able to be locked. Medication orders were signed for appropriately on 23 of 24 charts reviewed. As required medication orders documented reasons for administration. Standing orders were in place for fourteen residents. Eight standing orders evidence annual review. Three of twenty four administration signing sheets were fully completed.

i) Allergies or nil known allergies were not recorded in all of the 24 medication charts reviewed;

ii) Three monthly GP reviews had not been consistently conducted for all residents

iii) Administration signing sheets evidence gaps in staff signing

iv) Standing orders have not been reviewed annually for six residents.

v) The GP has group-signed for all medications on one medication

i) Ensure that allergies or nil known allergies are recorded for all residents

ii) Provide evidence that three monthly medication reviews are conducted by the GP

iii) Ensure that staff sign for all medications as given

iv) Provide evidence that standing orders are reviewed annually for all residents.

v) Provide evidence that prescribers are


chart reviewed

vi) One medication trolley is not able to be locked when in use.

signing for each individual medication order

vi) Provide evidence that all medication trolleys are able to be locked.

30 days

Criterion 1.3.12.3

Service providers responsible for medicine management are competent to perform the function for each stage they manage.

PA Moderate

Registered nurses administer medications to residents in the hospital area. In the rest home area, either a registered or enrolled nurse or one senior caregiver administers medications to rest home and hospital residents. The registered nurses have a current medication competency completed.

Not all staff who administer medications have a current annual medication competency completed.

Ensure that all staff who are responsible for medication administration and checking have an annual competency completed.

30 days

Criterion 1.3.3.3

Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.

PA Moderate

Initial assessments were completed in three of eight resident files sampled. Initial care plans were completed on the day of admission for eight of eight residents. Risk assessments where completed, have not been reviewed six monthly for two rest home and one hospital resident. A GP had seen and admitted new residents within two working days in four of eight resident files reviewed. One resident had been admitted from hospital and had appropriate discharge documentation completed.

i)Assessments, care plans or evaluations have been not completed within the required time frames for all resident files reviewed; and ii) four of eight residents were not seen and admitted by a GP

i) Ensure that all assessments, care plans and evaluations are completed within the required timeframes; and ii) ensure that the GP admits new residents within two working days.


within two working days of admission to the facility. 30 days

Criterion 1.3.4.2

The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.

PA Moderate

Initial assessment were completed for four of eight residents reviewed. The clinical nurse manager and one registered nurse have completed interRAI training and have current competency. The interRAI assessment tool has not been utilised for residents admitted after 1 July 2015. Paper based risk assessment tools are available and include pain, falls risk, pressure injury risk, and continence however, nutrition and behaviour risk assessments are not utilised. All eight residents whose files were reviewed had continence, falls risk and pressure injury risk assessment tools completed. Behaviour assessments and pain assessments have not been completed where required. Behaviour management strategies were documented in the care plans reviewed and staff were knowledgeable on the implementation of these strategies.

i) Initial assessments were not completed in four of eight resident files reviewed (three rest home and one hospital);

ii) Pain assessments were not completed for one rest home and one hospital resident;

iii) Nutritional assessments had not been completed for all eight resident files reviewed;

iv) Two rest home residents with challenging behaviours had not had a behaviour assessment completed; and

v) Four residents (out of the eight

i) ensure that initial assessments are completed for all new admissions;

ii) Ensure that pain assessments are completed for all residents with identified chronic and acute pain issues;

iii) Ensure that nutritional assessments are completed for all residents with identified needs;

iv) Complete behaviour assessments for residents with identified challenging behaviours; and

v) Provide evidence that the interRAI assessment tool is completed for


reviewed), who were admitted after 1 July 2015, did not have an interRAI assessment completed.

all new admissions and when resident care plan evaluations are conducted.

30 days

Criterion 1.3.5.2

Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.

PA Moderate

Long term care planning has not been completed within the required time frames for all residents (refer to 1.3.3.). Six of eight care plans reviewed were comprehensive and personalised (refer to 1.3.6.1).

Pressure area cares for one rest home resident with two grade II pressure injuries were not recorded on the long term care plan (refer to rest home tracer 1.3.3.3). One rest home respite resident with a history of falls and a high falls risk did not have this recorded on the respite care plan.

Ensure that all care plans fully record the interventions and care required for all residents.

30 days

Criterion 1.3.6.1

The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.

PA High Long term care plans and progress notes were reviewed for a sample of eight residents. Progress notes have been written by caregivers and registered nurses at least once a day for rest home residents and on every shift for hospital residents. Exception reporting of falls and incidents was also recorded but not fully documented on incident reports (refer to1.2.4.3). The progress notes reviewed evidenced regular registered nurse input and review of residents care. There were ten wounds recorded for eight hospital residents and ten wounds for six rest

i) Wound assessment documentation has not been completed for 21 of 24 wounds reviewed for both hospital and rest home residents.

i) Ensure that all wounds and pressure injuries are assessed, and that this is recorded in sufficient detail to clearly describe each


home residents.

One of ten hospital resident wounds evidenced a wound assessment completed. Wound dressing records were documented for the 10 wounds but the documentation did not include a comprehensive wound management plan, wound progress and ongoing assessment and evaluation. Four hospital residents have pressure injuries which have not been reported via the incident reporting process (refer to 1.2.4.3). On interview, the facility manager advised that there was one pressure injury in the facility, however, following review of wound folders and on interview with caregivers and registered nurses, there were seven pressure injuries identified. Four pressure injuries were facility acquired and three were acquired elsewhere. The RN stated there was one stage III pressure injury and one unstageable pressure injury (depth unknown) for another resident. The remaining pressure injuries were all stage II. The facility manager stated that the stage III pressure injury was in fact stage II. The audit team did not observe dressing changes to confirm the correct pressure injury stage classification (refer to 1.3.3 PI table).

There were ten residents in the rest home area with wounds (two hospital and eight rest home). Two of ten wounds have had a wound assessment completed. Wound dressing records were documented for the ten wounds however, the documentation did not include a comprehensive wound management plan, wound progress and ongoing assessment and evaluation. One rest home resident has two pressure injuries which have not been reported. Skin tears were included in the wound records with individual plans in place for five residents. Advised by the facility manager that wound documentation has been reviewed and discussed at quality meetings and that revised documentation is now available.

There was insufficient detail recorded on the wound care plans regarding the size, description and type of wounds, and for pressure injuries there was no record of the stage of each pressure injury;

ii) Management was unaware of the number of pressure injuries within the facility;

iii) Wound care plans did not include comprehensive dressing regimes. Registered nurses chose which dressings to apply at each dressing change, which results in a lack of coordination around wound management;

iv) Pressure relieving devices were not being utilised for all residents with

wound;

ii) Ensure that management are informed of all pressure injuries;

iii) Utilise wound documentation fully to ensure that each wound or pressure injury has a comprehensive plan in place to guide staff in the management of each wound;

iv) Ensure that pressure relieving devices are fully utilised for all residents with pressure injuries and those who are at risk of developing pressure injuries;

v) Ensure that each wound or pressure injury is reassessed and evaluated at each dressing time and that this is clearly


identified pressure injuries and for those who were at risk of pressure injuries. The facility manager advised that pressure relieving mattresses have been purchased and are now available for use;

v) Reassessment and evaluation of wounds at wound dressing times was not recorded in sufficient detail to show each wound’s progress; and

vi) Three skin tears for one hospital resident were recorded on one form.

i) Wound assessment documentation has not been completed for 21 of 24 wounds reviewed for both hospital and rest home residents. There was

recorded to identify progress of wounds; and

vi) Ensure that each wound has individual documentation completed

7 days


insufficient detail recorded on the wound care plans regarding the size, description and type of wounds, and for pressure injuries there was no record of the stage of each pressure injury;

ii) Management was unaware of the number of pressure injuries within the facility;

iii) Wound care plans did not include comprehensive dressing regimes. Registered nurses chose which dressings to apply at each dressing change, which results in a lack of coordination around wound management;

iv) Pressure relieving devices were not being utilised for all residents with identified


pressure injuries and for those who were at risk of pressure injuries. The facility manager advised that pressure relieving mattresses have been purchased and are now available for use;

v) Reassessment and evaluation of wounds at wound dressing times was not recorded in sufficient detail to show each wound’s progress; and

vi) Three skin tears for one hospital resident were recorded on one form.

Criterion 1.3.7.1

Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.

PA Low The activities are planned on a month by month basis. The monthly planner is available in large print and is posted in both areas of the facility. The activities coordinator advised that each resident receives a copy of the programme. Volunteers assist with the implementation of the programme and provide music entertainment, Tai Chi, craft and church services. Four of eight resident files reviewed evidenced completed activities assessments and care plans.

Two rest home and two hospital resident files reviewed did not contain completed activities assessments and activities plans

Ensure that all residents have completed activities assessments and care plans.


60 days

Criterion 1.3.8.2

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.

PA Moderate

Short term care plans have been used in six of eight resident files reviewed. Long term care plan evaluations have been conducted for three residents, and four resident care plan evaluations are not yet due. Care plan reviews, where completed, have been signed and dated by the registered nurse, and by the resident and/or a family member. Where long term care plans have been completed, each aspect of the care plan including goals and interventions have been reviewed.

i) One rest home resident long term care plan has not been reviewed – last completed in August 2015; and

ii) short term care plans have not been developed for two residents

i) Ensure that six monthly care plan reviews are conducted; and

ii) Ensure that short term care plans are developed for acute care needs.

30 days


Specific results for criterion where a continuous improvement has been recordedAs well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded.

As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights

If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit.

No data to display

End of the report.