Lansdowne Park Village Limited - Lansdowne Park Village

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 and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

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

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

The specifics of this audit included:

Legal entity: Lansdowne Park Village Limited

Premises audited: Lansdowne Park Village

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

Dates of audit: Start date: 14 September 2017 End date: 14 September 2017

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: 62

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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

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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

Lansdowne Park Village rest home and hospital is part of the Arvida aged care residential group. The service provides rest home and hospital level of care for up to 50 residents in the care centre and up to 29 residents at rest home level in the serviced studio apartments. On the day of the audit there were 62 residents. An experienced aged care manager/registered nurse has been in the role two months and is supported by a full-time clinical manager and stable workforce.

This unannounced surveillance audit was conducted against a sub-set of the relevant Health and Disability Standards and the contract with the district health board. The audit process included the review of policies and procedures, the review of residents and staff files, observations, and interviews with residents, management and staff.

The residents interviewed spoke positively about the care and services supports provided at Lansdowne rest home and hospital.

Three of seven previous findings have been addressed relating to care plan documentation, family input into care plan development and documented interventions for safe restraint use.

There continues to be areas of improvement around documentation of quality data, human resources, medicine management and implementation.

This audit identified and area for improvement around interRAI assessments for new admissions.

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Consumer rights

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

Standards applicable to this service fully attained.

Residents and family are informed; including information relating to changes in residents’ health. The village manager and clinical manager have an open-door policy. Complaints processes are implemented and complaints and concerns are managed and documented and learnings from complaints are shared with staff.

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.

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

The quality and risk management programme includes service philosophy, goals and a quality/business planner. Meetings are held to discuss quality and risk management processes. Residents/family meetings are held every four months and residents and families are surveyed annually. Incidents and accidents are reported and followed through. The service has an orientation programme in place that provides new staff with relevant information for safe work practice. An education and training programme is being implemented with a current training plan in place for 2017. A roster provides sufficient and appropriate coverage for the effective delivery of care and support.

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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.

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

The registered nurses are responsible for each stage of service provision. A registered nurse assesses and reviews residents' needs, develops care plans and evaluates goals against goals.

Care plans viewed in resident records demonstrated service integration and were evaluated at least six-monthly. Resident files included medical notes by the contracted GP and visiting allied health professionals.

Medication policies reflect legislative requirements and guidelines. Registered nurses and senior caregivers responsible for administration of medicines complete education and medication competencies. Administration signing sheets corresponded with the prescribed medications.

Two diversional therapists oversee the activity programme for the residents. The programme includes community visitors and outings, entertainment and activities that meet the individual recreational, physical, cultural and cognitive abilities and preferences for rest home and hospital residents.

Residents' food preferences and dietary requirements are identified at admission and all meals and baking is cooked on-site. Special diets and dislikes are accommodated. Food, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines and additional requirements/modified needs were being met.

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Safe and appropriate environment

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.

The building has a current building warrant of fitness.

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.

Standards applicable to this service fully attained.

Lansdowne Park Village has restraint minimisation and safe practice policies and procedures in place. Staff receive training around restraint minimisation and the management of challenging behaviour. On the day of the audit there were three residents with restraints and five residents using an enabler.

Infection prevention and control

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.

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The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control coordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility. There has been one outbreak that was managed well.

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 13 0 3 2 0 0

Criteria 0 39 0 3 2 0 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

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Attainment against the Health and Disability Services Standards

The 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 1.1.13: Complaints Management

The right of the consumer to make a complaint is understood, respected, and upheld.

FA The service has a complaints policy that describes the management of complaints process. There is are complaint forms available. Information about complaints is provided on admission. Interview with residents demonstrated an understanding of the complaints process. There is a complaint register. Verbal and written complaints are documented. Ten complaints have been made since the last audit in August 2016. All complaints reviewed had a documented, investigation, timeframes and corrective actions when and where required and resolutions were in place. Results are fed back to complainants. All staff interviewed were able to describe the process around reporting complaints.

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Standard 1.1.9: Communication

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

FA Six residents interviewed (three rest home and three hospital) stated they were welcomed on entry and given time and explanation about the services and procedures. No family members visited on the day of audit.

Policies and procedures relating to accident/incidents, complaints and open disclosure policy, alert staff to their responsibility to notify family/next of kin of any accident/incident that occurs. Twelve incident/accidents forms reviewed for August 2017 had documented evidence of family notification or noted if family did not wish to be informed. Interpreter services are available as required.

Standard 1.2.1: Governance

The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.

FA Lansdowne Park Village is owned and operated by the Arvida Group. The service provides care for up to 79 residents with 50 dual-purpose beds in the main care centre and up to 29 studio apartments certified to provide rest home level care. On the day of the audit, there were 62 residents. There were 19 residents at rest home level and 27 residents at hospital level care. There were no residents under medical services. There were 16 rest home residents in the 29 studio apartments. All residents were under the aged residential related care (ARRC) agreement.

There is a village manager and village support services manager (wife and husband), who have both been in their roles for two months. The village manager/registered nurse has responsibility for the operational/HR management and the village support services manager has responsibility of building and maintenance requirements. A full time clinical manager supports the village manager. The clinical manager has been in the position for one year and has over 20 years aged care experience as an RN and facility manager.

The village manager reports to the general manager operations on a variety of operational issues and provides a monthly report. Arvida has an overall business/strategic plan. The organisation has a philosophy of care, which includes a mission statement. Lansdowne Park Village has a business plan for 2017 and a quality and risk management programme. The business plan identifies the future provision of hospital and medical services.

The village manager and clinical manager have completed in excess of eight hours of professional development in the past 12 months.

Standard 1.2.3: Quality And Risk Management Systems

The organisation has an established, documented, and maintained quality and

PA Moderate

There is a business/strategic plan that includes quality goals and risk management plans for Lansdowne Park Village. Interviews with staff confirmed that there is discussion about quality data at various staff meetings, however, meetings have not occurred as per meeting schedule and there is no documented evidence of discussion of trends and analysis in the minutes sighted. The previous finding around quality data remains. The village manager advised that she is responsible for providing oversight of the quality programme on-site, which is also monitored at organisational level. The quality and risk management programme is designed to monitor contractual and standards compliance. The site-specific service's policies are being transitioned over to the

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risk management system that reflects continuous quality improvement principles.

Arvida Group polices, which will be reviewed at least every 2 years across the group. Head office sends new/updated policies.

Data is collected in relation to a variety of quality activities and an internal audit schedule has been completed. Areas of non-compliance identified through quality activities are actioned for improvement. The service has a health and safety management system that is regularly reviewed. Restraint and enabler use is reported within the quality and clinical staff meetings. Falls prevention strategies are in place that includes the analysis of falls incidents and the identification of interventions on a case-by-case basis to minimise future falls.

The internal audit programme continues to be implemented and all issues identified had corrective action plans and resolutions. All staff interviewed could describe the quality programme corrective action process. There is an annual staff training programme that is implemented and based around policies and procedures and records of staff attendances maintained. An infection control programme is implemented and all infections are documented monthly. Residents/relatives are surveyed to gather feedback on the service provided and the outcomes are communicated to residents, staff and families. The 2017 resident relative survey overall result shows satisfaction with services provided. Resident/family meetings occur every four months and resident and families interviewed confirmed this.

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.

FA There is an accidents and incidents reporting policy. An RN conducts clinical follow-up of residents and the clinical manager investigates accidents and near misses to identify corrective/preventative actions. Twelve incident forms reviewed demonstrated that appropriate clinical follow-up and investigation occurred following incidents. Neurological observation forms were completed for any unwitnessed falls. Discussions with the village manager confirmed that there is an awareness of the requirement to notify relevant authorities in relation to essential notifications. Five section 31 incident notification forms (sighted) have been completed since the last audit. Three notifications were for fractures, one in October 2016 and two in January 2017, one for a pressure injury and one for a norovirus outbreak in June 2017.

Standard 1.2.7: Human Resource Management

Human resource management processes are conducted in accordance with good

PA Low There are human resource management policies in place. This includes that the recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications, experience and veracity. A copy of practising certificates is kept. Six staff files were reviewed (one clinical manager, two registered nurses (RN), two caregivers and one kitchen manager) and there is evidence that reference checks were completed before employment was offered. However, not all annual staff performance appraisals were evident in the staff files reviewed. Completed orientation is on file and staff described the orientation

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employment practice and meet the requirements of legislation.

programme.

The service has an orientation programme in place that provides new staff with relevant information for safe work practice. The in-service education programme for 2016 (since the previous audit) has been completed and the plan for 2017 is being implemented. Education/training has been provided on the mandatory education/training topics and records are per the scheduled calendar. This aspect of the previous audit finding has been addressed. The village manager, clinical manager and RNs are able to attend external training, including sessions provided by the local DHB. Discussions with the caregivers and the RNs confirmed that ongoing training is encouraged and supported by the service. There are 20 RNs and 10 have completed interRAI training, including the clinical manager.

Standard 1.2.8: Service Provider Availability

Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.

FA Lansdowne Park Village policy includes staff rationale and skill mix. Sufficient staff are rostered on to manage the care requirements of the residents. The service has a total of 86 staff in various roles. Staffing rosters were sighted and there is staff on duty to meet the resident needs of different shifts. The village manager and clinical manager work 40 hours per week, Monday to Friday and are available on call after-hours. In addition to the village manager and clinical manager there is at least one RN on at any one time. The RN on each shift is aware that extra staff can be called on for increased resident requirements. Interviews with staff and residents confirm there are sufficient staff to meet the needs of residents.

The service currently has 19 rest home residents and 27 hospital residents in the care home. In the hospital area, there is one RN on the morning and afternoon shifts and one RN on night duty. The hospital RNs are supported by eight caregivers rostered on the morning, six caregivers on the afternoon shift and two caregivers on night duty. In the rest home area, there is one RN on the morning and afternoon shifts. The rest home RNs are supported by two caregivers rostered on the morning and afternoon shifts and one caregiver on night duty. The studio apartments have 16 rest home residents and has a separate roster with two caregivers on the morning and afternoon shifts. The caregiver in the rest home supervises the rest home level care residents in the studio apartments on the night shift. There are dedicated housekeeping and laundry staff.

Standard 1.3.12: Medicine Management

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

PA Low There are policies and procedures in place for safe medicine management that meet legislative requirements. Clinical staff who administer medications (RNs and senior caregivers) have been assessed for medication. Registered nurses have completed syringe driver training. The RN checks all medications (robotic rolls) on delivery against the medication chart on the electronic medication system. Any discrepancies are fed back to the supplying pharmacy. There were three rest home and one hospital resident self-medicating. The RN and GP had assessed the residents as competent to self-medicate. All medications are stored safely. The medication fridges are monitored daily.

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and safe practice guidelines.

Ten medication charts were reviewed on the electronic medication system. Prescribing of regular and ‘as required’ medications met the legislative requirements and the GP had reviewed the medication charts three-monthly. This aspect of the previous audit has been rectified; however, oxygen therapy for one resident had not been charted

The previous finding around prescribing of medications remains.

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 and baking at Lansdowne are prepared and cooked on-site by qualified cooks who are supported by morning and afternoon kitchen assistants. There is a five-weekly menu which had been reviewed by a dietitian. Meals are served from the bain marie in the main kitchen to residents who dine in the main dining room. Meals are plated, covered and delivered by trolley to residents in rooms. Meals are served from the bain marie in the upstairs kitchenette/dining room to rest home residents in the studio apartments. Dietary needs are known, with individual dislikes and allergies accommodated. Dietary requirements are met and include vegetarian, dairy free, pureed/soft, high protein diets and thickened fluids.

Fridge and freezer temperatures are taken and recorded daily. Temperatures for all facility fridges in kitchenettes are taken and recorded. End-cooked food temperatures are recorded. All foods including dry goods were dated. The dishwasher is checked regularly by the chemical supplier. A cleaning schedule is maintained.

Resident meetings and surveys, along with direct input from residents, provide resident feedback on the meals and food services generally. Residents interviewed were satisfied with the food and confirmed alternative food choices were offered for dislikes.

All food services staff have completed training in food safety and hygiene and chemical safety.

Standard 1.3.5: Planning

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

FA Resident care plans reviewed were resident focused and comprehensive. The level of risk as identified in risk assessment tools and the outcome of interRAI assessments (link 1.3.3.3) were documented in the long-term care plans, which included appropriate supports/needs to meet the resident desired goals. Residents interviewed stated they or their relative has been involved in the development of care plans. There is documented evidence of relative/resident input.

Short-term care plans document appropriate interventions to manage short-term changes in health.

Resident care plans demonstrate service integration. There was evidence of allied health care professionals involved in the care of the resident including physiotherapist, podiatrist, dietitian and palliative care team.

The previous finding around documented supports/needs in care plans and resident/relative input into care plan

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development have been addressed.

Standard 1.3.6: Service Delivery/Interventions

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

PA Moderate

When a resident's condition alters, the registered nurse initiates a review and if required, GP or nurse specialist consultation. There is evidence that family members were notified of any changes to their relative’s health as sighted on the family/EPOA communication page.

Adequate dressing supplies were sighted in the treatment room. Wound management policies and procedures are in place. Wound assessments and treatment plans were in place for 11 wounds including two chronic wounds. Evaluations/change of dressings had not occurred at the documented frequency for all wounds. There were no pressure injuries on the day of audit.

Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified.

There are a number of monitoring forms and charts available for use including (but not limited to); weight, vital signs, neurological observations, blood glucose, pain, behaviours and challenging behaviour. Interventions had not been implemented for one hospital resident with weight loss.

The previous finding around implementation remains.

Standard 1.3.7: Planned Activities

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.

FA The service employs two qualified diversional therapists (DT) who develop and implement the integrated activity programme Monday to Friday 9.30am to 4.30pm. There are two DTs on each afternoon which allows for a variety of activities and one-on-one time with residents who are unable to or choose not to join in with group activities. All residents receive a programme including the rest home residents in studio apartments.

Activities provided meet the recreational preferences of rest home and hospital residents. Activities occur in the lounges of each wing or in the large activities room. The activity programme is varied (but not limited to); walks, exercises, news reading, word games, movies, baking, art, cards, Tai Chi, entertainers, weekly mystery drives and outings into the community such as concerts, library and musical events. A volunteer from the village provides a weekly church service. Residents are supported to maintain their community links including card groups and men’s shed.

A diversional therapy assessment and activity plan was in place for resident files reviewed. The activity plan is reviewed at the same time as the care plan.

Residents have the opportunity to provide feedback directly and through surveys and resident meetings.

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Standard 1.3.8: Evaluation

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

FA All initial care plans reviewed were evaluated by the RN and resident/relative within three weeks of admission. Long-term care plans have been evaluated and reviewed at least six-monthly and as indicated. Progress notes document evaluation of care including the effectiveness of analgesia. Pain management plans are evaluated as part of the six monthly care plan review or earlier as required.

The six-monthly multidisciplinary team reviews include the GP, care staff and the resident/relative. The GP reviews the residents three-monthly or earlier if required.

Standard 1.4.2: Facility Specifications

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

FA The building has a current building warrant of fitness that expires 20 November 2018.

Standard 3.5: Surveillance

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

FA There is a policy describing surveillance methodology for monitoring of infections. The infection control coordinator (RN) collates information obtained through surveillance to determine infection control activities and education needs in the facility. Individual infection reports and short-term care plans are completed for all infections. Infection control data is available, however, there is no documented evidence of analysis or trends discussed at meetings (link 1.2.3.6). Definitions of infections are in place appropriate to the complexity of service provided. Systems in place are appropriate to the size and complexity of the facility. Arvida organisational benchmarking is yet to be commenced for this facility.

There has been one confirmed outbreak of norovirus in June 2017. Documentation sighted included case logs, outbreak management checklists, Section 31 and public health notification and letter of response from the public health service.

Standard 2.1.1: Restraint minimisation

Services demonstrate that the use of restraint is actively minimised.

FA The service has documented systems in place to ensure the use of restraint is actively minimised. There were three residents with restraints (all bedrails) and five residents using an enabler (two chair briefs and three lap belts) during the audit. Staff interviews and staff records evidence guidance has been given on restraint minimisation and safe practice (RMSP), enabler usage and prevention and/or de-escalation techniques. Policies and procedures include definition of restraint and enabler that are congruent with the definition in NZS 8134.0. Staff education on restraint minimisation and management of challenging behaviour has been provided.

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Standard 2.2.3: Safe Restraint Use

Services use restraint safely

FA Procedures around monitoring and observation of restraint use are documented in policy. Approved restraints are documented. Assessments identify the specific interventions or strategies trialled before implementing restraint. Restraint authorisation is in consultation/partnership with the resident and family and the restraint coordinator. The use of restraint is linked to the residents’ care plans. Each episode of restraint is monitored at pre-determined intervals depending on individual risk to that resident. There were documented interventions to manage the risks of restraint for each of the three residents with bedrails used as restraints. The previous finding around documented interventions has been addressed. A restraint register is in place providing an auditable record of restraint use and is completed for all residents requiring restraints and enablers.

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Specific results for criterion where corrective actions are required

Where 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 1.2.3.6

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

PA Moderate

Data is collected in relation to a variety of quality activities and an internal audit schedule has been completed. Areas of non-compliance identified through quality activities are actioned for improvement. The service collates accident/incident and infection control data. However, staff meeting minutes did not evidence the meeting schedule had been followed and the minutes sighted did not document discussion around quality data and accident/incident trend analysis.

1) Staff (three monthly) and quality (monthly) meetings were not completed as per the annual calendar schedule. There has been one staff meeting in July 2017 and one quality meeting in August 2017 documented since the last audit.

2) The minutes of the meetings held did not document evidence of quality data including; incident/accident and infection control trends and

1) Ensure that staff and quality meetings are completed as per the annual calendar schedule.

2) Ensure that quality data including trends and analysis of incident/accident and infection control is documented in meeting

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analysis. minutes.

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 Low There are human resource management policies in place. This includes that the recruitment and staff selection process requires that relevant checks are completed to validate the individual’s qualifications, experience and veracity. Six staff files were reviewed (one clinical manager, two registered nurses (RN), two caregivers and one kitchen manager). However, not all annual staff performance appraisals were evident in the staff files reviewed.

Six staff files were reviewed. Four of six staff files did not have an up-to-date performance appraisal completed.

Ensure that all staff performance appraisals are completed annually.

90 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 Low The service has implemented an electronic medication system. Medication charts reviewed had photo identification and allergy status. All medications prescribed met legislative requirements, however, oxygen therapy had not been prescribed.

There was no oxygen prescribed for one hospital resident on continuous oxygen therapy.

Ensure oxygen therapy is prescribed.

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 Low All resident files reviewed had initial assessments completed on admission. Long-term care plans were completed within 21 days of admission. Routine interRAI assessments had been completed, however, interRAI assessments had not been completed within the required timeframe for two new admissions.

Two hospital admissions did not have an interRAI assessment completed within 21 days of admission.

Ensure the first interRAI assessment is completed within 21 days of admission.

90 days

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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 Moderate

There are a number of monitoring forms in use. The ‘stop and watch’ form records early warning signs and symptoms, which is reviewed by the RN on duty and interventions implemented as required. Short-term care plans are used for resident health changes. There were no interventions implemented for one resident with weight loss. All wounds had wound assessments completed by the RN, however, not all wounds had been evaluated at the documented frequency.

1) There were no interventions implemented for a hospital resident with weight loss.

2) Five of eleven wounds did not have a change of dressing at the documented frequency.

1) Ensure interventions are implemented for weight loss.

2) Ensure wounds have dressing changes as per the documented frequency.

90 days

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Specific results for criterion where a continuous improvement has been recorded

As 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.

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