Waverley Aged Care Limited Current Status: 29 August 2014


Outcome 1.2: Organisational Management



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Outcome 1.2: Organisational Management


Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner.

Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1)


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

ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5



Attainment and Risk: FA

Evidence:

Waverley House is managed by an experienced manager/owner who has many years of experience in managing aged care facilities. She is supported by a registered nurse who works 20 hours per week from Monday to Friday. The RN provides on call after hours cover for clinical emergencies. During a temporary absence of the owner/manager, the facility is managed by the RN. The manager advised that there is also a memorandum of understanding with another local rest home manager who is available for support.

Waverley House has a current business plan and quality risk management plan. The quality programme is managed by the owner/manager with assistance from the registered nurse. The service has an annual planner/schedule which includes audits, meetings and education.

D15.3d: The manager has maintained at least eight hours of professional development activities annually related to managing a rest home.


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 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3)


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

ARC A4.1; D1.1; D1.2; D5.4; D10.1; D17.7a; D17.7b; D17.7e; D19.1b; D19.2; D19.3a.i-v; D19.4; D19.5 ARHSS A4.1; D1.1; D1.2; D5.4; D10.1; D16.6; D17.10a; D17.10b; D17.10e; D19.1b; D19.2; D19.3a-iv; D19.4; D19.5



Attainment and Risk: PA Moderate

Evidence:

Waverley House has a business plan and quality risk management plan. Progress with the quality plan is monitored through the monthly staff/quality meetings. Quality data is discussed at these meetings. Minutes from staff /quality meetings are available for staff to read.

Discussions with the RN and three caregivers confirm their involvement in the quality programme. Resident satisfaction survey is completed in 2014 and survey results show satisfaction with services provided. Food services survey is also completed in 2014 which shows satisfaction with meal services.

There is an internal audit schedule completed for 2013 and includes (but is not limited to): cleaning, laundry, food service, admission procedures, infection control, care plans, complaints, medication management, personal privacy and safety, continence, cultural safety and spiritual beliefs, wound management, staff training and informed consent. However, 2014 internal audit schedule has not been implemented. An improvement is required.

Three caregivers interviewed confirm that they are informed of new care plan interventions, short term care planning, incident accidents via handovers and meetings. There is evidence of documented management of non-compliance issues.

Waverley House has a health and safety management system and security, and safety policies and procedures are in place to ensure a safe environment is provided. Emergency plans ensure appropriate response in an emergency.

There are infection control programme and corresponding policies. There are restraint minimisation policy, and health and safety policies and procedures that are implemented.

The annual staff training programme is implemented. Records of staff attendance are maintained.

Waverley House collects information on resident incidents and accidents as well as staff incidents/accidents. Accident/incident forms are commenced by caregivers and given to the RN who completes the follow up including resident assessment, treatment and referral if required. All incident/accident forms are seen by the manager who completes any additional follow up as required.

An improvement is required around review of policy and procedures.

D10.1 Death/Tangihanga policy and procedure that outlines immediate action to be taken upon a consumer’s death and that all necessary certifications and documentation is completed in a timely manner.

D17.10e: There are procedures to guide staff in managing clinical and non-clinical emergencies.

D19.3 There are implemented risk management, and health and safety policies and procedures in place including accident and hazard management.

D19.2g Falls prevention strategies such as falls risk assessment, walking aids, use of appropriate footwear, increased supervision and monitoring and sensor mats if required.



Criterion 1.2.3.1 (HDS(C)S.2008:1.2.3.1)

The organisation has a quality and risk management system which is understood and implemented 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.)
Criterion 1.2.3.3 (HDS(C)S.2008:1.2.3.3)

The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.

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 1.2.3.4 (HDS(C)S.2008:1.2.3.4)

There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.

Attainment and Risk: PA Moderate

Evidence:

Waverley House has policies and procedures that are implemented. Since the previous audit, the secure gated facility policy has been reviewed. The manager stated that the support is obtained from the local DHB in review of this policy.



Finding:

Policy review dates are ranging from 2010-2012 and there is no process implemented to ensure that policies are regularly reviewed. This remains an improvement required from the certification audit.



Corrective Action:

Ensure that polices are reviewed and updated at regular intervals.



Timeframe (days): 180 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.3.5 (HDS(C)S.2008:1.2.3.5)

Key components of service delivery shall be explicitly linked to the quality management system.

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 1.2.3.6 (HDS(C)S.2008:1.2.3.6)

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

Attainment and Risk: PA Moderate

Evidence:

Resident satisfaction survey and the food satisfaction surveys are completed in 2014.



Finding:

There is an internal audit schedule for 2014 and internal audits have not been completed at all. A consumer survey was conducted in 2014 and 14 residents were responded. However, a survey evaluation has not been conducted for follow up and identification of corrective actions. This remains a required improvement from the previous auditor. Survey results are also not communicated to the residents or families.



Corrective Action:

Ensure that the internal audit schedule is implemented, results are evaluated. Survey results are communicated to participants.



Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)
Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7)

A process to measure achievement against the quality and risk management plan is implemented.

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 1.2.3.8 (HDS(C)S.2008:1.2.3.8)

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

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 1.2.3.9 (HDS(C)S.2008:1.2.3.9)

Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include:
(a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk;
(b) A process that addresses/treats the risks associated with service provision is developed and implemented.

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 1.2.4: Adverse Event Reporting (HDS(C)S.2008:1.2.4)


All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner.

ARC D19.3a.vi.; D19.3b; D19.3c ARHSS D19.3a.vi.; D19.3b; D19.3c



Attainment and Risk: FA

Evidence:

Incident/accidents are documented. Reporting of incidents/accidents occur, and are monitored. This was evident in the sample group of 10 incident forms and five residents’ files. Incidence and accident information was also recorded in progress notes. Incident analysis is performed monthly by the RN. Service short falls are managed with staffing rosters and the availability of on call staff (the RN and the manager).

Ten incident reports for June and July 2014 were reviewed and include six falls with minor or non-injury, one medication error and three skin tears. Family notification documented in either the incident form or family notification sheet. Following a medication error, staff notified the RN and they followed the RN’s instructions.

The RN, the manager or caregivers contacts the family. Three caregivers and two families interviewed confirmed that families are contacted if there are any problems.

D19.3d . Discussions with the manager, and the RN confirm that there is an awareness of the requirement to notify relevant authorities in relation to essential notifications.

Criterion 1.2.4.2 (HDS(C)S.2008:1.2.4.2)

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

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 1.2.4.3 (HDS(C)S.2008:1.2.4.3)

The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.

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.

ARC D17.6; D17.7; D17.8; E4.5d; E4.5e; E4.5f; E4.5g; E4.5h ARHSS D17.7, D17.9, D17.10, D17.11



Attainment and Risk: PA Moderate

Evidence:

Waverley House has a process for validating the qualifications of registered health professionals. The current practicing certificate for the RN is kept in her file.

There is an orientation programme in place and three caregivers interviewed could describe the orientation training. Completed orientation records are evident in the staff files.

There is a documented education plan. Training completed includes (but is not limited to), privacy, skin care, fire training, hazard and emergency management, diabetes, continence management, respiratory diseases, elder abuse, restraint minimisation and enablers, complaints management, infection control, wound management, challenging behaviour and dementia,- walking in another’s shoes- and mental health of older person.

Interview with the manager and the RN confirmed that Waverley House had developed links with the local DHB to ensure that staff employed have access to training and support that is not available within the service.

An improvement required around staff performance appraisals.


The local DHB has requested further information relating to following areas:
1- Caregivers training hours- 2014 training plan is implemented. Caregivers training records are also kept and exceed eight hours a year.
2- RN training records- Training records of the RN is sighted. In 2014, following trainings are completed: 1) January 2014-steps towards positive wellbeing in dementia, walking in another’s shoes, four hours, 2) April 2014- Assessment- clinical supervision and continuing nursing education, seven hours, 3) May 2014 – wound management workshop- one and half hours, 4) June 2014 –Advanced care planning , infection control, medication related to increased falls risk, subcutaneous fluids. six hours, 5) August 2014 – Wound study day- six hours. Training records also show a series of training that offered by the HBDHB. The RN completed 32.5 hours of training in 2013.
3- Medication competencies- Staff who administer medication complete medication competencies yearly. Six staff files reviewed showed that one staff member had current medication competency dated January 2014. One staff member had completed competency but it was not dated and four staff had medication competency completed in 2012. See CAR.1.3.12.3.

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: PA Moderate

Evidence:

There is a performance appraisal process in place. Caregivers training records are also kept and exceed eight hours a year.



Finding:

Five files (one RN and four caregivers) reviewed showed that there is no performance appraisal completed for the RN and two out of four caregivers.



Corrective Action:

Ensure that the RN and the caregivers have annual performance appraisals.



Timeframe (days): 180 (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.

ARC D17.1; D17.3a; D17.3 b; D17.3c; D17.3e; D17.3f; D17.3g; D17.4a; D17.4c; D17.4d; E4.5 a; E4.5 b; E4.5c ARHSS D17.1; D17.3; D17.4; D17.6; D17.8



Attainment and Risk: FA

Evidence:

The service has a rationale that is sufficiently detailed to ensure that there is appropriate staff to safely meet the needs of consumers. There is a roster that provides minimum staffing cover. The manager and registered nurse provide an after-hours on call service to support staff. (link 1.3.3.3)

Interview with five residents and two relatives confirmed that the residents care needs are met. Staff interviewed stated that they have been very busy but they are able to complete their duties.

The roster is as follows: Occupancy 20 residents.

The manager works 08.00-16.30hrs Monday-Thursday.

The RN works for 20 hours per week Monday to Friday. She is available on call.

Diversional therapist works 10 -16.00 four days a week.

Cook works 8-13.00 and there is a dedicated cleaning and laundry staff.

Waverley House contracts with allied health professionals on an as required basis.

Caregivers - am shift

1x 07.00-15.00hrs 1x 07.00-15.00hrs - The manager stated that the second shift is used to be 09-13.00 and the most recently has been changed to 7.00-15.00 due to increased acuity of residents.

Caregivers -pm shift 1x-15.00-23.00hrs, 1x15.00-21.00hrs.

Caregivers Nocte -1x 23.00-07.00hrs.

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.)




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