Oceania Care Company Limited - Green Gables Rest Home & Hospital
Introduction
This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and
Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).
The audit has been conducted by Health Audit (NZ) Limited, an auditing agency designated under section 32 of the Health and
Disability Services (Safety) Act 2001, for submission to the Ministry of Health.
The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General)
Standards (NZS8134.0:2008).
You can view a full copy of the standards on the Ministry of Health’s website by clicking here.
The specifics of this audit included:
Legal entity:
Oceania Care Company Limited
Premises audited:
Green Gables Rest Home & Hospital
Services audited:
Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest
home care (excluding dementia care)
Dates of audit:
Start date: 29 January 2015
End date: 29 January 2015
Proposed changes to current services (if any): None
Total beds occupied across all premises included in the audit on the first day of the audit: 40
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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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
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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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
Green Gables provides hospital and rest home level care for up to 51 residents. Occupancy on the day of audit was 41. The facility
is operated by the Oceania Group Limited.
This unannounced surveillance audit was undertaken to establish compliance with specified parts of the Health and Disability
Services Standards and the District Health Board contract. The audit included a review of the two areas of service where shortfalls
were previously identified, one of these has been addressed. The area still requiring improvement relates to care plans. There was
one additional shortfall relating to medicine management.
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.
Interviews with residents and family confirmed services were provided in a respectful manner and staff members facilitated
informed choice. Residents reported that services were appropriate to their needs. Review of resident files provided evidence that
communication with residents and their family occurred in an open and frank manner and this was documented in the
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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communication and adverse event records.
The Health and Disability Commissioner’s (HDC) Code of Health and Disability Services Consumers' Rights (the Code) information
is displayed throughout the facility and residents confirmed having access to complaint forms. The business and care manager is
responsible for complaints management. All complaints were documented in the complaints register. Residents had the opportunity
to raise issues of concern at resident meetings or directly with staff.
The clinical manager had an open door policy and residents confirmed finding staff easily approachable. Residents and family
confirmed having access to advocates and interpreters, should they ever need the service.
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.
Standards applicable
to this service fully
attained.
The purpose values and scope of the organisation is clearly identified in the information brochures that are made available as part
of the information pack.
The organisation appointed a new business and care manager who will commence working at the facility on 3 February 2015. The
business and care manager from another service was standing in for the new manager in the interim.
Oceania had an electronic quality and risk management system and the managers entered the key quality indicator information into
the programme.
The service provider developed and implemented policies and procedures that were aligned with good practice and legislation.
Quality improvement data was collected, analysed and the results were shared with staff on the Oceania Intranet. The service had
an internal audit schedule to measure quality and risk management performance.
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Date of Audit: 29 January 2015
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The service validated professional qualifications, registration and the scope of practice of service providers. The service had a
documented rationale to ensure a variety of skill mixes to ensure appropriate service delivery. Information was entered into the
information system within required timeframes. Document review confirmed accurate and appropriate records.
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 systems reviewed evidenced resident and/or family input into service delivery. In interviews, residents and family confirmed
their input into care planning, access to a typical range of life experiences and choices and that interventions noted in their care
plans were consistent with meeting their needs.
An area identified as requiring improvement at last certification audit relating to risk assessments and initial care plan timeframes
remain open.
A sampling of residents' clinical files validated the service delivery to the residents. Where progress is different from expected, the
service responded by initiating changes to the care plan or recorded the changes on a short term care plan.
Planned activities were appropriate to the group setting. In interviews, residents and family confirmed satisfaction with the activities
programme. The residents' files sampled evidenced individual activities were provided either within group settings or on a one-onone basis.
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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There was an appropriate medicine management system in place. Staff responsible for medicine management, attended
medication management in-service education and had current medication competencies. On audit days there were no residents
who self-administered medicines at the facility. There is one area requiring improvement around prescribing of as required
medications.
Food, fluid, and nutritional needs of residents were provided in line with recognised nutritional guidelines and additional
requirements/modified needs were being met. There is a central kitchen and on site staff that provided the food service. The
kitchen staff had completed food safety training.
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.
A Building Warrant of Fitness was displayed at the main entrance. Review of documentation, visual observation and interviews with
residents, family and staff provided evidence they had appropriate systems in place to ensure the residents’ physical environment
and facilities were fit for their purpose.
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.
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
Standards applicable
to this service fully
attained.
Page 6 of 19
The restraint policy, procedures and definitions of restraint and enabler were congruent with the restraint minimisation and safe
practice standard. There were two residents using restraint and one resident using an enabler on the audit day. Staff education in
restraint, de-escalation and challenging behaviour had been provided.
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.
In interviews, staff confirmed they were familiar with infection control measures at the facility.
The infection control surveillance data was sampled through resident records, clinical indicators and collated infection control
reports. The information sampled confirmed that the surveillance programme was appropriate for the size and complexity of the
services provided.
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Date of Audit: 29 January 2015
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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
14
0
1
1
0
0
Criteria
0
40
0
1
1
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
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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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
FA
The business and care manager is responsible for complaint management. The
service uses the Oceania intranet system to access the quality and risk management
processes for complaints reporting. The service had a current complaints register
with seven complaints documented for 2014. All complaints were signed off and
resolved. All complaints are recorded and managed including verbal complaints.
The right of the consumer to make a complaint is
understood, respected, and upheld.
The business and care manager and the regional operations manager confirmed that
there were no complaint investigations by the Ministry of Health, the Health and
Disability Commissioner, Police, the Coroner, Accident Compensation Corporation
(ACC) or the Nelson Marlborough District Health Board.
The service had appropriate complaints policies and procedures which were
compliant with Right 10 of the Code. Interviews with residents and their families
confirmed that the service discussed the Code with them at admission and they had
access to information brochures and pamphlets.
Visual inspection of the service provided evidence that the complaint process was
displayed and that individual that wanted to complaint could do so anonymously.
Care staff confirmed during interviews that they are informed of the key quality
indicators, including complaints. This information is communicated to staff via staff
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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meetings, meeting minutes and notice boards.
Standard 1.1.9: Communication
FA
Service providers communicate effectively with
consumers and provide an environment conducive to
effective communication.
Residents and family interviews confirmed communication with staff. The acting
business and care manager from another facility, (BCM) advised access to interpreter
services were available if required. Interpreter services were accessible through the
Nelson Marlborough District Health Board interpreter services.
Staff members were easily identified by their name badges and uniforms. Residents
confirmed that staff members introduced themselves upon entering the resident's
room; this was also observed during the on-site audit.
Visual inspection of the facility provided evidence the Code of Health and Disability
Services Consumers' Rights (the Code) information was readily available and
displayed. This information included the complaints process and access to complaint
forms.
Standard 1.2.1: Governance
FA
The purpose, values and scope of the organisation were clearly identified and
displayed throughout the facility. The interim business and care manager (BCM) who
is also a registered nurse (RN) previously worked as the facility manager at Green
Gables. The facility’s previous business and care manager resigned in December
2014 and the newly appointed BCM will be starting on the 3 February 20115. The
new business and care manager does not have a clinical back ground, but has
extensive management experience including being the area manager for a large
service provider.
FA
The service has an electronic quality and risk management system. Managers
entered information relating to quality indicators into the programme. This included
complaints management; however the service kept a hard copy of the complaints
register which evidenced the investigation processes of all complaints. All complaints
recorded during 2014 were closed out.
The governing body of the organisation ensures
services are planned, coordinated, and appropriate to
the needs of consumers.
Standard 1.2.3: Quality And Risk Management
Systems
The organisation has an established, documented,
and maintained quality and risk management system
that reflects continuous quality improvement
principles.
Oceania Care Company Limited - Green Gables Rest Home & Hospital
The BCM reports on the following quality and risk indicators: falls, restraint,
infections, wounds, incidents accidents, training, health and safety internal audits and
satisfaction surveys for staff members and residents, confirmed during interview with
the BCM. The BCM’s completed an additional monthly facility status report on
Date of Audit: 29 January 2015
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financial, health and safety, clinical and operational matters.
The service developed and implemented policies and procedures that were aligned
with current best practice and legislation. Policy review was an on-going process to
ensure up to date guidelines and information, confirmed at the interview with the
BCM. The service was notified by Oceania support office via email when policies
were reviewed and older policies were removed. Each facility archived their obsolete
policies.
The quality improvement data was collected, analysed and results were distributed to
staff to ensure staff members are informed of quality outcomes through meeting
minutes and notice boards, sighted the meeting minutes of January 2014.
The service had an internal audit schedule for measuring the quality and risk
management performance within the facility, sighted the 2014 internal audit
programme. The internal audit records included the area of the audit, method,
procedure to be followed, references, frequency of audits, analysis of the findings and
the audit outcomes. Requirements for improvement were identified; corrective
actioned implemented and closed out. The service identified and documented actual
and potential risks with steps to manage the risks.
Standard 1.2.4: Adverse Event Reporting
FA
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.
The acting business and care manager (BCM) understood the process relating to
essential notification including the importance of contacting the correct authorities
when required during outbreaks and adverse events.
Staff members were documenting adverse, unplanned and untoward events on an
electronic register. The registered nurse (RN) reported completing assessments of
residents after incidents and accidents. Assessments include neurological
observations after a resident sustained a head injury or when falls were unobserved.
Adverse events were collated and graphs of incidents and accidents were generated
monthly as part of their electronic system. Each month incidents and accidents were
summarised as part of the monthly key quality reporting process, verified records for
March to June 2014. The service documented incidents / accidents in order to identify
requirements for improvements. They used this system to safely manage risks in their
facility.
Staff members, residents and their families confirmed incidents and accidents that
may have occurred with the residents were discussed in an open and frank manner.
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Date of Audit: 29 January 2015
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Standard 1.2.7: Human Resource Management
FA
Human resource management processes are
conducted in accordance with good employment
practice and meet the requirements of legislation.
The clinical manager was responsible for implementation of the in-service education
programme with oversight from the business and care manager (BCM). Education
for staff is provided via training days as part of the internal education and training
programme and the Oceania national training planner. Staff education plans, staff
competency register and staff education records were maintained and were reviewed
for 2013 and 2014.
The skills and knowledge required for each position within the service was
documented in job descriptions. Accountabilities, responsibilities and authority were
reviewed in staff files along with employment agreements, police vetting, completed
orientations and induction records, reference checks and performance appraisals.
Competency and professional registration with regulatory bodies were up to date for
all the registered nurses, the physiotherapist, the pharmacists, the podiatrist and
general practitioners (GPs).
Interviews with staff members confirmed they completed orientation and induction at
commencement of their employment. Care staff confirmed their attendance at ongoing in-service education and had annual performance appraisals completed.
Standard 1.2.8: Service Provider Availability
FA
There was a documented rationale (‘Staffing Skill mix’) for determining staffing levels
and skill mixes in order to provide safe service delivery that was based on best
practice.
The minimum number of staff was provided during the night shift. The business and
care manager (BCM), the clinical manager and other registered nurses shared the
after-hours on call and the on call registered nurse was clearly indicated on the
roster. Care staff interviewed reported they had adequate staff available and that they
were able to get through the work allocated to them. Residents and family members
interviewed reported there was enough staff on duty to provide them with adequate
care. Visual observations during this audit confirmed adequate staff cover was
provided.
PA Low
In interview, the clinical manager / registered nurse reported that prescribed
medications were delivered to the facility and checked on entry, evidence was
sighted. The medication area in the facility, including controlled drug storage
Consumers receive timely, appropriate, and safe
service from suitably qualified/skilled and/or
experienced service providers.
Standard 1.3.12: Medicine Management
Consumers receive medicines in a safe and timely
manner that complies with current legislative
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Date of Audit: 29 January 2015
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requirements and safe practice guidelines.
evidenced an appropriate and secure medicine dispensing system, free from heat,
moisture and light, with medicines stored in original dispensed packs. The controlled
drug register was maintained and evidenced weekly checks and six monthly physical
stock takes. The medication fridge temperatures were conducted and recorded.
All staff authorised to administer medicines had current competencies. The
medication rounds were observed and evidenced the staff members were
knowledgeable about the medicine administered and signed off, as the dose was
administered. Administration records were maintained, as were specimen signatures.
Staff education in medicine management was conducted in August and November
2014.
Medicine charts sampled evidenced residents' photo identification, allergies recorded,
medicine charts were legible, three monthly medicine reviews were conducted and
discontinued medicines were dated and signed by the GPs. There were no residents
self-administering medicines at the facility. There is a policy on self-administration of
medication by competent residents, sighted.
The required improvement identified at the last certification audit relating to residents
self- administering medicines was fully attained.
Standard 1.3.13: Nutrition, Safe Food, And Fluid
Management
FA
The service followed a four week seasonal menu that was reviewed by a dietitian.
At interview, the kitchen manager confirmed they were aware of residents’ individual
dietary needs. The residents' dietary requirements were identified, documented and
reviewed on a regular basis and dietary changes communicated to kitchen staff.
There were current copies of the residents' dietary profiles in the kitchen.
A consumer's individual food, fluids and nutritional
needs are met where this service is a component of
service delivery.
The residents' files demonstrated monthly monitoring of individual resident's weight.
At interviews, residents were satisfied with the food service provided, reported their
individual preferences were well catered and adequate food and fluids were provided.
Kitchen staff had food safety training.
The food temperatures were recorded as were the fridge and freezer temperatures,
sighted. All decanted food was dated.
Standard 1.3.6: Service Delivery/Interventions
FA
Oceania Care Company Limited - Green Gables Rest Home & Hospital
The residents’ files evidenced the GP documentation and records were current.
Date of Audit: 29 January 2015
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Consumers receive adequate and appropriate
services in order to meet their assessed needs and
desired outcomes.
There were adequate continence and dressing supplies in accordance with
requirements of the service agreement. In interviews, residents and family confirmed
their and their relatives’ current care and treatments they were receiving met their
needs and their involvement in the care planning process. The family communication
sheets recorded family communications, sighted in all residents' files sampled.
Nursing progress notes and observations charts were maintained. In interviews, care
staff were familiar with the current interventions of the resident they were allocated to
care for.
Standard 1.3.7: Planned Activities
FA
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.
In interview, the diversional therapist (DT) confirmed the activities programme met
the needs of the service group and the service had appropriate equipment.
Residents, family and staff interviews confirmed the activities programme included
input from external agencies and supported ordinary unplanned/spontaneous
activities that included festive occasions and celebrations. Regular exercises and
outings were provided for those residents able to partake, sighted at audit.
The DT and the activities coordinator were responsible for conducting residents’
activities assessments and implementation and evaluation of the activities
programme. The activities care plans were part of the person centred care plans and
conducted by the RNs in consultation with the DT and the activities coordinator. The
residents’ activities attendance records were maintained, sighted. The residents’
meeting minutes were sighted and evidenced residents’ involvement and consultation
of the planned activities programme.
The residents' files demonstrated the individual activities care plans were current and
individualised.
Standard 1.3.8: Evaluation
FA
Consumers' service delivery plans are evaluated in a
comprehensive and timely manner.
In interviews, staff reported that family were notified of any changes in resident's
condition. The communication with family members was recorded in residents' files
sampled. The care plan evaluations were conducted by the RNs with input from the
resident, family, health care assistants, DT, activities coordinator and GPs. In
interviews, residents and family confirmed their participation in care plan evaluations
and this was evidenced in the files reviewed. The multidisciplinary reviews sighted
were current.
When resident’s progress was different than expected, the RN contacted the GP, as
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Date of Audit: 29 January 2015
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required. In interview, the GPs confirmed this. Short term care plans were in some of
the residents’ files sampled, used when required.
Time frames in relation to care planning evaluation were documented. There was
recorded evidence of additional input from professionals, specialist or multidisciplinary sources, if this was required. The residents' files evidenced referral letters
to specialists and other health professional when this was required.
The residents' care plans were up-to-date and reviewed six monthly.
Standard 1.4.2: Facility Specifications
FA
Consumers are provided with an appropriate,
accessible physical environment and facilities that are
fit for their purpose.
A Building Warrant of Fitness was displayed at the main entrance. There was a
secure external area dementia unit for residents. Hospital and rest home residents
had access to external areas that were appropriate to their needs.
There was evidence a preventative maintenance plan was in place and reactive
maintenance has been occurring. Medical equipment checks were conducted by an
external contractor and testing and tagging of electrical equipment occurred. Visual
inspection indicates there was safe storage of medical equipment.
Corridors were wide enough to allow residents to pass each other safely. Safety rails
were secure and appropriately located. Floor surfaces/coverings were appropriate to
the resident group and setting.
Staff received education in the safe use of medical equipment and there was a
system in place to review staff competency for specific equipment; for example hoists
competency. This had been confirmed during interview with clinical staff and review
of staff education records.
Standard 3.5: Surveillance
FA
Surveillance for infection is carried out in accordance
with agreed objectives, priorities, and methods that
have been specified in the infection control
programme.
The type of surveillance undertaken was appropriate to the size and complexity of
this service. Definitions of infection for surveillance in long term care facilities were
used for the identification and classification of infection events. The infection control
surveillance programme data was entered monthly into the Oceania intranet clinical
indicator programme for further analysis and benchmarking against other Oceania
facilities.
The infection control surveillance data was sampled through resident records, staff
interviews and collated infection control reports. This information confirmed the
surveillance programme was appropriate and fully implemented. The infection control
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Date of Audit: 29 January 2015
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data was communicated to staff at facility’s meetings. Residents’ files evidenced the
residents’ who were diagnosed with an infection had a short term care plan and
review was also conducted of their person centred care plan, if required.
At interviews, staff reported they were made aware of any infections of individual
residents by way of feedback from the RN's, verbal handovers, short term care plans
and progress notes. This was evidenced during attendance at the staff handover and
review of the residents’ files.
At interview, the infection control coordinator confirmed there was an outbreak at the
facility in March 2014. The outbreak data was reported on separately from general
surveillance data collection and forwarded to Oceania head office. The required
authorities were notified of the outbreak.
Standard 2.1.1: Restraint minimisation
FA
Services demonstrate that the use of restraint is
actively minimised.
The definition of restraint and enabler was congruent with the definition in the
Standard. The process of assessment, care planning, monitoring and evaluation of
restraint and enabler use was recorded in policies and procedures. There was
evidence this was followed in residents’ files sampled. There were two residents who
used restraint and one resident who used an enabler at the facility on audit day.
The Oceania national restraint authority group meeting was conducted in February
2014. The meeting minutes included progress in reducing restraint usage nationally
and clinical indicator data that showed reduction in restraint use.
In interviews, staff confirmed that the approval process for enabler use was activated
when a resident voluntarily requested an enabler to assist them to maintain
independence and/or safety.
The restraint coordinator conducted education and training on restraint minimisation
and safe practice in June 2014, confirmed at interview and their education register.
Prevention and/or de-escalation techniques staff education was conducted in
February 2014.
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Date of Audit: 29 January 2015
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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 1.3.12.1
PA Low
As required medications (PRN) were recorded
for individual residents, however the prescribed
PRN medicines did not evidence specific target
symptoms and rationale for using the medicines
in 12 of the 20 medication charts reviewed. At
interview, the clinical manager confirmed that the
PRN medication was administered by the RN in
the hospital and the rest home. The facility had
commenced the use of new medication charts
that included new prescribing requirements for
PRN medicines, including symptoms and
rationale for use. These new medication charts
were sighted to be used for some residents.
As required medications
(PRN) were not correctly
prescribed on 12 of 20
residents’ medication
charts reviewed.
Provide evidence that
required medications
are correctly
prescribed on
residents’ medication
charts.
The rest home tracer methodology of a resident
recently admitted to the facility evidenced the
resident’s initial care plan was not conducted.
Resident’s initial care
plan was not conducted
and some of their risk
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.
Criterion 1.3.3.3
Each stage of service provision
(assessment, planning, provision,
PA
Moderate
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
30 days
Provide evidence
timeframes of
assessments and
Page 17 of 19
evaluation, review, and exit) is
provided within time frames that safely
meet the needs of the consumer.
The long term care plan was completed within
two weeks of admission. In interview, the clinical
manager confirmed the initial care plan was not
conducted and there was no recorded evidence
of care planning for the first two weeks following
admission to the facility. The risk assessments
(RN assessment; pain; cultural and pressure
area risk assessment) were completed two days
post admission to the facility. Reviews of three
additional residents’ files of recently admitted
residents were conducted in respect of initial
care plans and these files evidenced the initial
care plans and risk assessments were
conducted on admission, as per ARC contract.
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
assessments were
conducted two days post
admission.
initial care plans are
conducted as per
ARC contract.
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.
Oceania Care Company Limited - Green Gables Rest Home & Hospital
Date of Audit: 29 January 2015
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