Waverley Aged Care Limited Current Status: 29 August 2014



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Waverley Aged Care Limited

Current Status: 29 August 2014


The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance 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


Waverley House provides care for up to 20 residents who require rest home care, and there were 20 residents on the day of this audit.

The owner is the manager and she is supported by a registered nurse. Residents and family interviews and consumer satisfaction survey results show satisfaction with services provided.

Two of five shortfalls identified at the previous certification audit have been addressed. Improvements continue to be required around implementation of the quality and the risk management system and timely assessment of residents.

This audit identified two high risk findings around implementation of medication management system and timely documentation of service provisions and obtaining an approval from the local need assessment service coordination team before residents enter to the service, particularly for residents requiring higher level of care.



Further improvements are required by the service around implementation of the quality and risk management system, care plan interventions and evaluations, performance appraisals, and a dietition input to the menu.

Audit Summary as at 29 August 2014


Standards have been assessed and summarised below:

Key


Indicator

Description

Definition




Includes commendable elements above the required levels of performance

All standards applicable to this service fully attained with some standards exceeded




No short falls

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




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

Consumer Rights as at 29 August 2014


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




Standards applicable to this service fully attained.

Organisational Management as at 29 August 2014


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




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

Continuum of Service Delivery as at 29 August 2014


Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.




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

Safe and Appropriate Environment as at 29 August 2014


Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities.




Standards applicable to this service fully attained.

Restraint Minimisation and Safe Practice as at 29 August 2014


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




Standards applicable to this service fully attained.

Infection Prevention and Control as at 29 August 2014


Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme.




Standards applicable to this service fully attained.
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