Bernadette Life Care Limited Current Status: The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Partial Provisional Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified. General overview This partial provisional audit was undertaken to establish the level of preparedness of Bernadette Life Care to provide an additional 27 beds which will be available for hospital level care. This reconfiguration of this already certified service will increase the total numbers of available beds to 113. The new building is two levels with 14 rooms upstairs and 13 downstairs. The proposed date of opening this service is mid-November 2014. The upstairs level of the service is completed and work is currently being completed on the lower floor level. Equipment and resources are readily available and are being installed on a daily basis and as per the quality improvement action plan.
Transcript
Bernadette Life Care Limited
Current Status:
The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Partial Provisional Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified.
General overview
This partial provisional audit was undertaken to establish the level of preparedness of Bernadette Life Care to provide an additional 27 beds which will be available for hospital level care. This reconfiguration of this already certified service will increase the total numbers of available beds to 113. The new building is two levels with 14 rooms upstairs and 13 downstairs. The proposed date of opening this service is mid-November 2014. The upstairs level of the service is completed and work is currently being completed on the lower floor level. Equipment and resources are readily available and are being installed on a daily basis and as per the quality improvement action plan.
HealthCERT Aged Residential Care Audit Report (version 4.2)
Introduction
This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under the Health and Disability Services (Safety) Act 2001 for submission to the Ministry of Health.
The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).
It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.
Audit Report
Legal entity name: Bernadette Life Care Limited
Certificate name: Bernadette Life Care Limited
Designated Auditing Agency: The DAA Group Limited
Types of audit: Partial Provisional Audit
Premises audited: Bernadette Lifecare
Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)
Dates of audit: Start date: 9 October 2014 End date: 9 October 2014
Proposed changes to current services (if any):
27 additional Hospital beds – New hospital wing
Total beds occupied across all premises included in the audit on the first day of the audit: 68
Audit Team
Lead Auditor XXXXXX Hours on site
8 Hours off site
8
Other Auditors Total hours on site
Total hours off site
Technical Experts Total hours on site
Total hours off site
Consumer Auditors Total hours on site
Total hours off site
Peer Reviewer XXXXX Hours 2
Sample Totals
Total audit hours on site 8 Total audit hours off site 10 Total audit hours 18
Number of residents interviewed Number of staff interviewed Number of managers interviewed 4
Number of residents’ records reviewed
Number of staff records reviewed Total number of managers (headcount)
6
Number of medication records reviewed
Total number of staff (headcount) 71 Number of relatives interviewed
Number of residents’ records reviewed using tracer methodology
Number of GPs interviewed
Declaration
I, XXXXXX, Director of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf
of The DAA Group Limited, an auditing agency designated under section 32 of the Act.
I confirm that:
a) I am a delegated authority of The DAA Group Limited Yes
b) The DAA Group Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes
c) The DAA Group Limited has developed the audit summary in this audit report in consultation with the provider Yes
d) this audit report has been approved by the lead auditor named above Yes
e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes
f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable
g) The DAA Group Limited has provided all the information that is relevant to the audit Yes
h) The DAA Group Limited has finished editing the document. Yes
Dated Thursday, 30 October 2014
Executive Summary of Audit
General Overview
This partial provisional audit was undertaken to establish the level of preparedness of Bernadette Life Care to provide an additional 27 beds which will be available for hospital level care. This reconfiguration of this already certified service will increase the total numbers of available beds to 113. The 27 beds have been built onto the existing facility. The new building is two levels with 14 rooms upstairs and 13 downstairs. The proposed date of opening this service is mid-November 2014. The upstairs level of the service is completed and work is currently being completed on the lower floor level. Equipment and resources are readily available and are being installed on a daily basis and as per the quality improvement action plan. There are two areas of improvement in relation to legislative requirements not yet being available.
Outcome 1.1: Consumer Rights
Not applicable to this audit.
Outcome 1.2: Organisational Management
Bernadette Life Care Limited is the governing body responsible for the service provided at Bernadette Lifecare. Planning documents include a business plan, mission statement, vision and values. Systems are developed and well implemented for monitoring the services provided. Quality meetings are held monthly.
The facility nurse manager is very experienced, has worked in aged care and has recognised post graduate qualifications. The nurse manager is well supported by an assistant nurse manager and eight registered nurses are employed currently.
The human resources manager and the nurse manager are in the process of recruiting additional staff required to meet the needs of the proposed increased number of residents. Full orientation is provided and checklists are available and a handbook is completed. Education is comprehensive and is ongoing. All registered staff and contracted health providers have current annual practising certificates.
The nurse manager was able to articulate a rationale for staffing levels and skill mix in order to provide safe service delivery that is based on best practice. Documented rationale is available. The additional hospital service will be staffed 24 hours a day.
Outcome 1.3: Continuum of Service Delivery
Policies and procedures for safe medication management are available and accessible to guide staff. Residents currently receive medicines administered by competent staff. Registered nurses are responsible for medication management, ordering and administering the medications. The three contracted general practitioners ensure the medications are reviewed three monthly or more often if required. There is evidence of the contracted pharmacy input, such as reconciliation of medication records on admission and when medicines are dispensed from the pharmacy. The registered nurses check all medications delivered. The controlled drugs are managed effectively and checks are performed weekly by two
registered nurses or the nurse manager and a registered nurse. The new medication room in the new hospital wing will be on level two. The medication will be kept in the locked trolley which is to be provided by the pharmacist.
The food service is well established and the cook has already planned for the proposed increase in the number of residents. Any additional equipment and resources have already been purchased. The menu plans, reviewed in May 2014 by the dietitian, have taken additional numbers and level of residents (hospital) into consideration. The dry stock food is stored appropriately in the pantry and freezers and fridge temperatures are monitored daily. Resident satisfaction surveys and personal interviews reflect satisfaction with the food provided. The previous area requiring improvement has been addressed.
Outcome 1.4: Safe and Appropriate Environment
There are adequately documented processes for the management of waste, hazardous substances, emergencies and security situations. Emergency equipment and resources are available. All staff are trained in first aid. Bernadette Life Care has planned for civil defence emergencies and is linked into the Tauranga Hospital Bay of Plenty District Health Board emergency plan.
Furniture, fixtures and fittings are chosen and maintained with the needs of the residents in mind. The service is maintained at a comfortable temperature. There is adequate ventilation. The new rooms are spacious and well designed for residents requiring mobility aids or the use of hoists. All of the 27 individual rooms and corridors are carpeted. While some new equipment is already in place, not all essential equipment is available and tested for the additional hospital service area. This has been ordered. The Building Code Compliance has not yet been received from the Bay of Plenty Council. The updated fire evacuation plan has yet to be approved by the New Zealand Fire Service and an evacuation drill completed. These areas need to be addressed prior to occupancy.
The laundry is able to accommodate the additional linen to be laundered. Linen has been purchased in readiness for the new hospital wing. There are designated staff who manage the laundry and cleaning.
Outcome 2: Restraint Minimisation and Safe Practice
Not relevant to this audit.
Outcome 3: Infection Prevention and Control
An infection prevention and control manual is developed and implemented which is appropriate for the size and nature of this aged care residential service. The surveillance programme is appropriate and well documented. The infection prevention and control programme has been developed with clear objectives and signed off by the management in readiness for the additional service being certified.
Summary of Attainment
CI FA PA Negligible PA Low PA Moderate PA High PA Critical
Standards 0 13 0 1 1 0 0
Criteria 0 33 0 1 1 0 0
UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited
Standards 0 0 0 0 0 0 0 35
Criteria 0 0 0 0 0 0 0 66
Corrective Action Requests (CAR) Report
Code Name Description Attainment Finding Corrective Action Timeframe (Days)
HDS(C)S.2008 Standard 1.4.2: Facility Specifications
Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.
PA Low
HDS(C)S.2008 Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation.
PA Low While some equipment is available not all essential equipment, though ordered, is available for this additional hospital service. The certificate of public use (CPU) has not yet been received from the BOP Council.
To provide evidence that all equipment has been electrically tested and/or calibrated and that the updated building certificate of public use documentation is available prior to occupancy and displayed appropriately.
Prior to occupancy
HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems
Consumers receive an appropriate and timely response during emergency and security situations.
PA Moderate
HDS(C)S.2008 Criterion 1.4.7.3 Where required by legislation there is an approved evacuation plan.
PA Moderate There is no documented evidence that the fire evacuation scheme has been approved by New Zealand Fire Service (NZFS)
To provide evidence of the approved fire evacuation scheme for the facility inclusive of the new hospital extension and that a fire drill has been
Prior to occupancy
Code Name Description Attainment Finding Corrective Action Timeframe (Days)
Tauranga. arranged prior to occupancy.
Continuous Improvement (CI) Report
Code Name Description Attainment Finding
NZS 8134.1:2008: Health and Disability Services (Core) Standards
Outcome 1.2: Organisational Management
Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.
Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1) The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers.
Bernadette Life Care is a privately owned business. The organisational systems manual, reviewed in February 2014, clearly identifies the philosophy of the organisation and the aim to provide quality health and life care to older people and to strive for excellence. The clear objectives set for 2014-2015 include the extension of the twenty seven bed hospital and this is documented in the business plan reviewed. The service is striving for opening in November 2014. Business and marketing is to commence mid-October. Pamphlets and a website have been developed in readiness.
The quality improvement action plan reviewed was specifically for the new building and additional services to be provided. It is being implemented, and when actioned and closed out, this is recorded. The facility is being set up section by section and this is being achieved as sighted on the tour of the new facility. The management team has not changed since the last audit except for the manager taking more of a role in decision making. The CEO is continuing in this role and has contributed to this organisation for approximately fifteen years.
The nurse manager works closely with the management team and is very experienced in aged care nursing. The nurse manager has completed post graduate studies and has a certificate in Health Science (Advanced Nursing). The nurse manager has been in this role for seven years. The assistant nurse manager has been at this service since the service commenced.
Resident satisfaction surveys are completed annually and these evidence current resident satisfaction with the services provided.
Criterion 1.2.1.1 (HDS(C)S.2008:1.2.1.1) The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3) The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.2.2: Service Management (HDS(C)S.2008:1.2.2) The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers.
ARC D3.1; D19.1a; E3.3a ARHSS D3.1; D4.1a; D19.1a
Attainment and Risk: FA
Evidence:
The CEO and the nurse manager are responsible for the day to day management of Bernadette Life Care rest home and hospital services. The manager has been responsible for the new addition and following this through as per the business plan and quality improvement plans.
During the temporary absence of the nurse manager the role is undertaken by the assistant nurse manager who is very experienced and has worked at this facility since it commenced. The assistant nurse manager is also the facility restraint co-ordinator. The assistant nurse manager has a current annual practising certificate which is available and sighted.
Criterion 1.2.2.1 (HDS(C)S.2008:1.2.2.1) During a temporary absence a suitably qualified and/or experienced person performs the manager's role.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.2.7: Human Resource Management (HDS(C)S.2008:1.2.7) Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation.
The Human Resource Manual was reviewed in February 2014. Policy states that the service supports and facilitates orientation, training and education that is appropriate to the needs of the organisation and maintains records of staff employment and education provided. Job descriptions are available for all staff employed specifying responsibilities/obligations/key tasks to perform, performance objective measures and who they report to for the different positions.
All staff receive full orientation and a comprehensive orientation handbook is completed by staff. A checklist is completed for each new staff member and retained in their individual records. Education records reviewed evidences all education undertaken by each staff member. This is kept in the individual staff files. The education programme is available for the year. Attendance is recorded for all staff education attended.
The validation of professional qualifications and scopes of practice for all service providers is maintained by the nurse manager and completed annually. There are eight registered nurses plus the two nurse managers, the three contracted GPs, the contracted dietitian, the pharmacist, podiatrist and physiotherapist details on record.
The nurse manager has calculated staffing to meet the needs of the hospital level residents in the new hospital wing. No additional care staff will be required until there is fourteen new residents admitted to the service. The nurse manager is interviewing for one further registered nurse based on the current Ministry of Health standards criterion. Employment packs are in readiness.
The nurse manager discussed the staffing structure and rationale developed currently and how the new hospital service will impact on staffing. The nurse manager explained that the current cleaning staff will increase their hours to twenty eight hours a week to enable the new hospital to be adequately covered and no new staff will be required. The care staff will be responsible for cleaning of the lounges in the evening and night duty. The care staff checklists have been modified to include additional responsibilities for the laundry and cleaning. Caregivers hours are to be increased to meet agreement obligations and more added, if required as occupancy increases.
Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2) Professional qualifications are validated, including evidence of registration and scope of practice for service providers.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3) The appointment of appropriate service providers to safely meet the needs of consumers.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4) New service providers receive an orientation/induction programme that covers the essential components of the service provided.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.7.5 (HDS(C)S.2008:1.2.7.5) A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.2.8: Service Provider Availability (HDS(C)S.2008:1.2.8) Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers.
There is a clear process at organisational level to determine safe staffing levels for this facility presently and keeping in mind the development of the hospital extension. This policy relates to staffing levels and skill mix. There are some casual staff available to cover staff replacements as required. The rosters are completed by the human resources manager in consultation with the nurse manager. The rosters reviewed cover the total facility. The nurse manager explained the cover required due to the layout of this facility.
The service provider has adequate registered nurses and caregivers to cover the increased numbers. Staff employed are wishing to increase existing hours which will be adjusted accordingly as occupancy increases after the first fourteen residents are admitted (as per the (sighted) action plan developed and implemented). This will be based on occupancy after the official opening of the new hospital wing. The staff will be allocated to both the upstairs and downstairs areas of the new wing.
The current activities person will be able to cover the increased numbers but they are currently advertising for a part time, qualified diversional therapist to maximise the activities programme offered. This will also provide back up for the full time diversional therapist.
Criterion 1.2.8.1 (HDS(C)S.2008:1.2.8.1) There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Outcome 1.3: Continuum of Service Delivery
Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent
with current legislation.
Standard 1.3.12: Medicine Management (HDS(C)S.2008:1.3.12) Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.
Currently there is a separate medication room in the rest home and one in the existing hospital. There is a medication room designated on level two for when the occupancy increases. All medication rooms are locked and the medication room in the new wing is also noted to be locked. A new medication trolley is being provided by the contracted pharmacy. The current trolleys are seen to be locked when not in use and the manager reports this system will be the same in the new wing.
This service specialises in aged care medication systems. The robotic medication system is used and this will be utilised in the additional hospital service as well. The controlled drugs are managed effectively and the controlled drugs will be managed from the same centralised medication room as is the current practice.
There is clear evidence that medication reconciliation does occur when residents are admitted and six monthly audits are performed by the pharmacist six monthly. Medication records are available for new residents when the service is officially able to admit.
The policies and procedures sighted comply with legislation and guidelines. Only registered nurses will administer medications to the hospital level residents when admitted to this new hospital extension. All registered nurses have completed annual medication competencies.
There is a policy for residents to self-administer medications which is followed. Authorisation has to be gained from the general practitioner and competencies met. For the new hospital the bedside cabinet has a locked drawer and if in use the resident has a key and the nurse manager also has a key.
The contracted general practitioners (three GPs) will be responsible for reviewing the medication records three monthly and this is completed for the current residents at Bernadette Life Care.
The medication fridge is monitored by staff and temperatures sighted are within recommended guidelines.
Criterion 1.3.12.1 (HDS(C)S.2008:1.3.12.1) 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.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each stage they manage.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.5 (HDS(C)S.2008:1.3.12.5) The facilitation of safe self-administration of medicines by consumers where appropriate.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.12.6 (HDS(C)S.2008:1.3.12.6) Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.3.13: Nutrition, Safe Food, And Fluid Management (HDS(C)S.2008:1.3.13) A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.
There are food service policies which contain detailed information about nutrition and menu planning, safe food handling and storage of food. There is a four week rotating menu plan which has been approved (28 May 2014) as suitable for aged care residents. The menu review/audit is based on the dietitian New Zealand audit tool for residents living in long term care. The clinical manager explained how the registered nurses complete a nutritional profile for each resident on admission and this information is shared with the kitchen staff to ensure all needs, wants, dislikes and special diets are catered for. The care staff manage the additional food supplements for the residents (eg, Fortisip).
Processes are in place for residents evidencing weight loss or who are malnourished or at risk of malnutrition. Interventions will be clearly documented on the individual care plans developed as implemented currently.
The cook is prepared for the additional 27 hospital level residents (full capacity) and has adequate equipment and resources for providing for the increase in residents. Additional food will be ordered as numbers increase. Additional plates and equipment for resident use has been purchased. Currently there is one heated trolley for transporting the food from the kitchen to the present hospital wing. An additional heated trolley has been ordered for when an additional five residents are admitted.
All dry food stocks are now in plastic containers with secure lids and labelled appropriately. This is an area of required improvement from the previous audit which has been followed up and has been adequately addressed.
Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1) Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2) Consumers who have additional or modified nutritional requirements or special diets have these needs met.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.3.13.5 (HDS(C)S.2008:1.3.13.5) All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Outcome 1.4: Safe and Appropriate Environment
Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures physical privacy is maintained, has adequate space and
amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.
Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1) Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery.
ARC D19.3c.v; ARHSS D19.3c.v
Attainment and Risk: FA
Evidence:
The waste management policy is included in the cleaning, laundry and infection control manuals. The policies and procedures provide clear processes and guidelines about all types of waste inclusive of hazardous waste and the correct disposal methods. Material data sheets are available and are evident in the sluice rooms and in the separate laundry facility. Appropriate protective equipment and clothing (PPE) is available in the new hospital wing. Paper hand towel dispensers and flowing soap is installed in each individual resident`s room above the hand basins installed.
The CEO discussed the waste disposal system and removal processes undertaken by the local contracted services. Rubbish will be collected twice a week.
New cleaning schedules have been developed and implemented. More equipment has been purchased for the new build, such as rubbish bins, sharps containers for the nurses’ station and foot operated bins for the new sluice room. The cleaners` rooms on each floor have key pad access. Cleaning trolleys are stored appropriately when not in use.
The stock in the outbreak management kit has been increased (per resident by 23%) as noted in the suggestions from the `What we learnt - Aged Care Provider learnings on responding to the February earthquake in Canterbury Eldernet /Canterbury DHB`.
Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1) Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.1.6 (HDS(C)S.2008:1.4.1.6) Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.2: Facility Specifications (HDS(C)S.2008:1.4.2) Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.
The 27 new rooms are appropriate and accessible. On visual inspection the new wing environment is conducive to aged residential care. The additional rooms are purpose built, large and adequate for residents using hoists or walking aides. There are two standing and two sling hoists available. There are plans to purchase another hoist for the facility as resident occupancy increases. All 27 rooms have a nurse call bell system and an emergency bell is available in each individual ensuite bathroom. The rooms are welcoming, modern and well decorated. The corridor is the same width on the upper and lower floors. Handrails are evident in the ensuite bathrooms by the shower and toilets in each individual room.
The new hospital extension will have more external improvements when fully completed. This will include an additional courtyard, garden development and another shade area. This newly developed area will join onto an existing internal communal area which will be used for special functions. There will be more parking provided for visitors to the facility, some extended fencing and an external gate. A kitchen server upstairs is now established and a heated bain-marie is already utilised.
There are two areas of required improvement in relation to meeting building and equipment legislation.
Criterion 1.4.2.1 (HDS(C)S.2008:1.4.2.1) All buildings, plant, and equipment comply with legislation.
Attainment and Risk: PA Low
Evidence:
All equipment and resources except for the new equipment purchased for the new building has been electrically tested and/or calibrated. The electrician is booked on the 16 October 2014 to test and tag all new equipment. A new oxygen concentrator has been purchased to arrive on the 14 October 2014 and two oxygen regulators are on order. The calibration checklist was reviewed. The existing building has a current building warrant of fitness (WOF) sighted near the entrance to this facility and the expiry date is 22 April 2015. The building certificate of public use (CPU) and the fire evacuation have been extended to cover this new additional service, but management have not received the appropriate documentation required.
One new safe external area within the new building has been established. Seating and shade is available.
Finding:
While some equipment is available not all essential equipment, though ordered, is available for this additional hospital service. The certificate of public use (CPU) has not yet been received from the BOP Council.
Corrective Action:
To provide evidence that all equipment has been electrically tested and/or calibrated and that the updated building certificate of public use documentation is available prior to occupancy and displayed appropriately.
Timeframe (days): Prior to occupancy (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.2.4 (HDS(C)S.2008:1.4.2.4) The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.2.6 (HDS(C)S.2008:1.4.2.6) Consumers are provided with safe and accessible external areas that meet their needs.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.3: Toilet, Shower, And Bathing Facilities (HDS(C)S.2008:1.4.3) Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements.
ARC E3.3d ARHSS D15.3c
Attainment and Risk: FA
Evidence:
The 27 individual rooms have ensuite bathrooms inclusive of a shower, hand basin and toilet. A mirror and shelf are situated above each hand basin. Privacy can be maintained at all times. The bathrooms have been already added to the cleaning schedule and health and safety checklist for this service. The CEO is responsible for the temperature monitoring. Monthly checks are maintained and records are available in the maintenance log sighted. The CEO explained that tempering valves have been provided for all new bathrooms.
Surfaces including floor and walls in all service areas are easily able to be cleaned.
Separate facilities are available for staff and visitors.
Criterion 1.4.3.1 (HDS(C)S.2008:1.4.3.1) There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.4: Personal Space/Bed Areas (HDS(C)S.2008:1.4.4) Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting.
ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii
Attainment and Risk: FA
Evidence:
All 27 rooms are for single occupancy. All rooms have adequate space to provide safe manoeuvrability with or without walking frames. Hand rails are mounted on the wall beside the shower and the toilet. There is ample room for hoists and ‘fallout chairs’ if required by a resident. All rooms have hand washing facilities separate from the bathroom. The wardrobe cupboard in each room provides storage for clothes and summer and winter ‘bed throws’ if required.
Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1) Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.5: Communal Areas For Entertainment, Recreation, And Dining (HDS(C)S.2008:1.4.5) Consumers are provided with safe, adequate, age appropriate, and accessible areas to meet their relaxation, activity, and dining needs.
ARC E3.4b ARHSS D15.3d
Attainment and Risk: FA
Evidence:
Residents will be provided with safe, adequate, age appropriate and accessible lounges and dining areas. There is a dining room on both levels with adequate access and wide corridors. Each room has a comfortable chair and a dining table. The chairs are available and are being placed in the individual rooms presently. All areas observed are furnished to meet resident safety and comfort needs. The lounges can be utilised for the activities programme to be implemented in the hospital wing.
Criterion 1.4.5.1 (HDS(C)S.2008:1.4.5.1) Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.6: Cleaning And Laundry Services (HDS(C)S.2008:1.4.6) Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.
There is a separate manual of laundry and cleaning policies which detail the tasks and standards for safe and hygienic practice. The manuals have been reviewed in May 2014. Policies and procedures for the safe storage and use of chemicals are available. Cleaning materials are stored in secure areas. The cleaners` cupboards sighted have key pad access only. Cleaning task lists for all areas of service delivery are developed and implemented. Chemicals are supplied by a contracted company and safety data sheets on all products used is available. These are wall mounted and posters were sighted. All chemicals sighted are labelled correctly and clearly. Training is provided for staff.
Staff employed in the laundry and cleaning will cover this new hospital wing. All laundry is managed on a daily basis on site. There are adequate washing machines and clothes dryers available. Two sluice rooms are available. The CEO and general manager state at interview that processes are implemented for monitoring the effectiveness of the materials used for cleaning and laundry services. New linen bags and stands are available for the new hospital wing and linen trollies will be used during the day on level one and level two. Additional linen and bedding has already been purchased. A large linen cupboard is available in the new hospital wing.
Criterion 1.4.6.2 (HDS(C)S.2008:1.4.6.2) The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.6.3 (HDS(C)S.2008:1.4.6.3) Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.7: Essential, Emergency, And Security Systems (HDS(C)S.2008:1.4.7) Consumers receive an appropriate and timely response during emergency and security situations.
ARC D15.3e; D19.6 ARHSS D15.3i; D19.6
Attainment and Risk: PA Moderate
Evidence:
The service has an emergency plan in place that covers this new building. The CEO is responsible for ensuring the asset register is kept up to date so that available resources can be quickly determined - the plan links with the Bay of Plenty District Health Board. Buildings are maintained inclusive of the new building so that provision of lighting and heating is not compromised except in certain circumstances beyond the control of the organisation. Employees are fully trained about their roles in an emergency situation. The approval letter for the updated fire evacuation scheme is not available (1.4.7.3).
Flip charts for all emergency situations are in each of the two nurses` stations. An emergency trolley has been set up for the new hospital extension.
The CEO interviewed is the health and safety officer. All staff have completed and have current first aid certificates. The certificates are validated for two years.
There is a nurse call system for the new hospital. Each of the 27 rooms and bathrooms have a system in place. Display boards are evident on both floors and a light is visible when a call bell is activated. When activated the call is automatically sent to a pager which will be held by one staff member each shift. The call bells are included in the internal auditing system and will continue to be checked prior to occupancy and annually. The call bell is audible throughout the new facility.
Inspection of emergency equipment and lighting, fire alarms and sprinklers will be carried out on a regular basis to meet legislative requirements. A trial evacuation is planned for 30th October 2014.
The CEO explained that a new separate water tank has been ordered which will contain 4000 litres of water which will far exceed the current requirements which the service already meets. Water hydrants in two boundary streets to the facility would be accessed in case of a fire emergency at the rest home and hospital. The bore can be run through a filter on tanks in the event of an emergency.
The building is wired up in preparedness for a generator to be plugged in for an emergency. There is gas in the kitchen and a barbecue is available. Emergency food is available for at least three days if required.
The staff who will cover this extended area of service will ensure the two floors are secure. Security cameras have been installed in the hallways. The exit door is wired to the nurse call system. There is a bell at the entrance to the facility for after-hours visitors.
Criterion 1.4.7.1 (HDS(C)S.2008:1.4.7.1) Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.7.3 (HDS(C)S.2008:1.4.7.3) Where required by legislation there is an approved evacuation plan.
Attainment and Risk: PA Moderate
Evidence:
The CEO advises that a fire consultant has submitted the draft fire evacuation scheme to the New Zealand Fire Service (NZFS) for approval. A trial evacuation has been booked for 30th October, prior to occupancy.
Finding:
There is no documented evidence that the fire evacuation scheme has been approved by New Zealand Fire Service (NZFS) Tauranga.
Corrective Action:
To provide evidence of the approved fire evacuation scheme for the facility inclusive of the new hospital extension and that a fire drill has been arranged prior to occupancy.
Timeframe (days): Prior to occupancy (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.7.4 (HDS(C)S.2008:1.4.7.4) Alternative energy and utility sources are available in the event of the main supplies failing.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.7.5 (HDS(C)S.2008:1.4.7.5) An appropriate 'call system' is available to summon assistance when required.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.7.6 (HDS(C)S.2008:1.4.7.6) The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Standard 1.4.8: Natural Light, Ventilation, And Heating (HDS(C)S.2008:1.4.8) Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature.
ARC D15.2f ARHSS D15.2g
Attainment and Risk: FA
Evidence:
All of the 27 new residents’ rooms have at least one opening window for ventilation and natural light. The facility is ventilated effectively and is maintained at a comfortable temperature. The twenty seven rooms are heated individually with underfloor heating. A separate dial control is located in each room. Hallways have a control system in place. The net curtaining and curtains are made but are not installed at the time of the audit (this is to be done when all fixtures and fittings are installed in each room). Privacy will be maintained.
Criterion 1.4.8.1 (HDS(C)S.2008:1.4.8.1) Areas used by consumers and service providers are ventilated and heated appropriately.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.4.8.2 (HDS(C)S.2008:1.4.8.2) All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards
Standard 3.1: Infection control management (HDS(IPC)S.2008:3.1) There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service.
ARC D5.4e ARHSS D5.4e
Attainment and Risk: FA
Evidence:
The infection control manual contains policies that meet the requirements of the standards. A registered nurse is the designated infection control co-ordinator. The nurse manager oversees the programme to ensure it is implemented. The current infection control programme for the overall rest home and hospital services is more than adequate to meet the requirements for the additional 27 hospital level beds being added to Bernadette Lifecare.
The infection control co-ordinator monitors infections, uses standardised definitions to identify infections, surveillance, changes in behaviours, monitoring of organisms related to antibiotic use and the monthly surveillance record. Infection control is a standing agenda item in the risk meeting and staff meetings. The surveillance results are communicated to staff, management and where applicable, to the BOP DHB and public health departments. There have been no infection outbreaks since the last audit. The contents of the outbreak kit has been increased pending the additional number of residents to be admitted.
Processes for the prevention of exposing providers, residents and visitors from infections is in place. Additional antibacterial gel dispensers will be strategically placed around the new building for easy access for staff and visitors to the new facility. Staff during the audit were observed to demonstrate good infection prevention and control techniques and awareness of standard precautions, such as hand washing.
Criterion 3.1.1 (HDS(IPC)S.2008:3.1.1) The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 3.1.3 (HDS(IPC)S.2008:3.1.3) The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 3.1.9 (HDS(IPC)S.2008:3.1.9) Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.
Attainment and Risk: FA
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 3.5.7 (HDS(IPC)S.2008:3.5.7) Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.
Attainment and Risk: Not Audited
Evidence:
Finding:
Corrective Action:
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
