SURVEILLANCE AUDIT SCOPE (AGED CARE FOR SPOT UNANNOUNCED AUDIT) MODULE
Service name:_____________________________________________
Date completed:_________________________________
INTRODUCTION: As part of HDANZ’s onTrack programme, the following questionnaire is intended to provide you with a self-assessment review of your
service, in relation to key areas of service delivery for your business planning and quality/risk system. Note that this question sub-set is intended as a
guide only and reflects the relevant sector standards and possible good practices. The self-assessment allows you to identify areas that are working well
(Yes) and areas that may need further preparation for your quality system and service delivery (No). There is an action plan template at the end of the
question set. For any “No” responses you can copy and paste that into the action plan and monitor its completion.
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Self-assessment questions
Yes
No
Comments
Aged Care for Spot Unannounced Audit
1.1
Do all residents and family receive information about your service prior to entry?
1.2
Does each subsidised resident (admitted post July 2002) have a signed admission agreement signed on the day of admission
that contains: 1. Information about charges relating to any services or items that are not covered under this Contract (Refer
D14.1), 2. A list of items and charges not covered by this agreement (including how on charging will occur), 3. The extent of the
Provider's liability for damage or loss of the subsidised resident's personal belongings including clothing, 4. A provision to the
effect that the subsidised resident authorises the DHB to contact the subsidised resident's family or nominated representative if
the Provider's authorisation is withdrawn or varied, 5. The procedure that a subsidised resident must follow if he or she wishes to
make a complaint about the provider or services received, and 6. A description of transport policies, procedures and costs,
Information relating to the subsidised resident's rights in respect of the room where that subsidised resident will live including
when that subsidised resident is temporarily absent from the facility.
1.3
Is there an Open Disclosure policy or is Open Disclosure included in other policies such as Complaints/Incidents and Accident
policy that includes open disclosure principles?
1.4
Are resident's family members notified (with consent) as soon as possible if the resident's condition changes significantly (such
as for incidents or changes to care plans)?
1.5
Do resident files include records of communication with family? (there is documented evidence that the resident has consented
to family and information to be shared with them)?
1.6
Do incident forms reviewed reflect that families were notified (where relevant)?
1.7
Is there a complaints register that is up to date?
1.8
Does the complaints register include verbal and written complaints?
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1.9
Does the complaints register include actions that have been taken, dates of actions, outcome and resolution?
1.10
Is there a current business/risk management plan?
1.11
Is there a Manager's job description that includes key responsibilities?
1.12
Has the Manager maintained at least 8 hours of professional development annually?
1.13
Do records demonstrate that residents and/or family have been involved in all stages of service delivery including assessment,
care planning and evaluation?
1.14
Are consumer/resident meetings held that also obtain feedback on services?
1.15
Do you have an implemented Continence Management Policies/procedures and continence assessment tool (note this should be
evident in care plans)?
1.16
Do you have an implemented Management of Challenging/Disruptive Behaviour policy and Management of Behaviour
assessment process or tool (note this should be evident in relevant care plans)?
1.17
Do you have an implemented Pain Management policy and procedure (note this should be evident in relevant care plans) and
pain assessment process/tool?
1.18
Do you have an implemented Personal Grooming & Hygiene policy (note this should be evident in care plans)?
1.19
Have you implemented a Skin Integrity Management policy, Wound Care policy, Wound Care assessment tool, Wound Care
procedures, and Wound Management plan (note this should be evident in relevant care plans)?
1.20
Do your wound care assessment tools link to the Wound Management plan and is the care plan updated to reflect current wound
management?
1.21
Do you have an implemented Health education and disease prevention policy (note this may be included in the infection control
manual)?
1.22
Do you have an implemented transportation of subsidised residents policy and procedure (including costs, resident & staff
safety)?
1.23
Do you have an implemented Death/Tangihanga policy and procedure that outlines immediate action to be taken upon a
consumer's death?
1.24
Do relevant policies have clearly stated procedures to enable staff to implement or follow processes?
1.25
Are your policies and procedures typed, dated, approved, indexed and formatted into relevant manual(s) (hard copy or
electronic)?
1.26
Are policy and procedure manuals easily accessible by staff and do they reflect current good practice?
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1.27
Is there evidence of policy and procedure review?
1.28
Do you have a system for informing staff of any update/changes to policy and procedures?
1.29
Is there a Document Control policy that describes the management and review of policies/procedures?
1.30
Are there adequate clinical policies and procedures related to care provided?
1.31
Have the following been entered into the quality management system: 1. Incidents and accidents reported in resident files, 2.
Infections reported/recorded have been entered into infection control monitoring/surveillance system, 3. Complaints (documented
in progress notes/communication records or complaints form), 4. Satisfaction surveys, 5. Internal audits, 6. Hazards identified
through incidents, accidents, inspection or maintenance have been transferred to the hazard register, and 7. Restraint
interventions (if any)?
1.32
Are the results of data gathering communicated to staff and others such as the board of governance (e.g. results of internal
audits, incidents and accidents, complaints, satisfaction surveys, infections)?
1.33
Is internal monitoring information collected and used to identify improvement actions and have these been signed off when
completed?
1.34
Are there regular staff and quality/management meetings that monitor the quality/risk system?
1.35
Is there a quality plan that includes specific goals (long and short) that the performance of the service is measured against?
1.36
Do management and staff participate in the service quality and risk management system and does the service enable consumer
participation wherever appropriate?
1.37
Is an action plan developed in response to data analysis and other internal monitoring such as internal audits, etc?
1.38
Do the action plans include the changes that need to be made, who by, within what timeframes and how these will be monitored
and further verified that the actions have been successful?
1.39
Is there a risk plan that identifies risks to the service and how these can be eliminated, isolated or minimised (note: this is more
than a hazard analysis)?
1.40
Is there implementation of actions required to address actual and potential risks e.g. records of security checks, fire drills,
education of staff?
1.41
Are health and safety procedures in place and overseen by a designated health and safety officer?
1.42
Are incidents and accidents analysed and on the basis of this analysis are actions taken to limit future occurrences of incidents
or accidents?
1.43
Do individual incident forms include appropriate clinical assessment and follow up post incident and does the incident form
identify opportunities for improvement?
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1.44
For care staff who have not completed education related to the care of older people at the time of their appointment, do they
complete training within six months of appointment that addresses (and this is documented)?
1. The ageing process, 2. Practical care skills, 3. Cultural awareness, 4. Communication, 5. Observation and reporting, 6.
Promotion of independence, and 7. Understanding resident's rights.
1.45
Is at least eight hours of staff development or in-service education provided annually?
1.46
Does your training include a system to ensure that staff who miss a scheduled session receive the training and this is
documented?
1.47
Is the content and attendance at staff training/professional development activities?
1.48
Are competencies completed for caregivers and registered nurses?
1.49
If your service is a rest home do you meet the following staffing (tick yes, if you are not a rest home): 1. Ten or fewer subsidised
residents, a care staff member must be on duty at all times, 2. Up to and including 30 subsidised residents, a care staff member
and an on-call care staff member must be on duty at all times, 3. More than 30 residents, at least two care staff members must
be on duty at all times, 4. More than 60 residents, at least three care staff members must be on duty at all times, 5. Where the
layout of the facility, health and personal care needs of residents or the need for supervision determines additional staff are
required, extra staff will be on duty for that period as recommended by the Registered Nurse or Manager, 6. At least one
Registered Nurse shall be employed.
1.50
If your service is a geriatric hospital do you meet the following staffing (tick yes, if you are not a geriatric hospital): 1. One
Registered Nurse shall be on duty at all times. 2. Distribution of staffing is in accordance to resident's needs as determined by a
Registered Nurse. 3. A minimum of 2 care staff must be on duty at all times. 4. The layout of the facility is taken into
consideration in determining staffing numbers and distribution.
1.51
Does your roster reflect staff consistent with the documented staffing levels policy?
1.52
Does a registered nurse complete an assessment of the resident and develop the individual care/support plans?
1.53
Is the registered nurse involved in re-assessment when the residents condition changes?
1.54
Are residents/consumers and or their family/whānau involved in care/support planning?
1.55
Are these time frames included in policy and implemented? 1. Initial nursing assessment completed within 24 hrs, 2. Initial care
plan completed within 48 hrs, 3. Long term care plan developed within 3 weeks, 4. Resident examined by a medical practitioner
within two working days of admission (unless a medical summary is provided on admission), 5. Resident examined not less than
once a month and as clinically indicated except where the general practitioner has determined (and documented) the resident is
stable and suitable for review not less than once every three months?
1.56
Do records demonstrate that residents and/or family have been involved in all stages of service delivery including assessment,
care/support planning and evaluation??
1.57
Does the care plan address the following: 1. Current abilities of resident, 2. Level of independence, 3. Identified needs, 4.
Personal preferences, 5. Individual habits and idiosyncrasies 6? Personal care needs, 7. Healthcare needs, 8. Rehabilitation
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needs, 9. Maintenance of function, 10. Care of the dying?
1.58
Are resident/consumer goals or outcomes identified using an assessment process?
1.59
Have interRAI assessments been implemented by competent/trained registered nurses?
1.60
Are assessments reviewed 6 monthly or more frequently if change in health status?
1.61
Do care/support plans describe goals or outcomes and the required support required?
1.62
Are short term needs with planned interventions documented?
1.63
Are care/support plans up to date?
1.64
Are wound assessments, management plans and on-going evaluations completed for all identified wounds?
1.65
Are evaluations and progress towards meeting desired goals documented by a registered nurse at least 6 monthly?
1.66
Are care/support plans changed when progress toward outcomes (or goals) is less than expected?
1.67
Is there a programme of activities that is meaningful to residents/consumers and within their potential capabilities?
1.68
Does the activities programme include group and individual activities and involve the wider community?
1.69
Do planned activities reflect ordinary patterns of life and include the involvement of family/whānau?
1.70
Does a skilled person undertake assessment, implementation and evaluation of social, diversional and motivational recreational
programmes for each resident?
1.71
Does the service have policies and procedures that are based on recognised good practice for the management of medicine
administration?
1.72
Is there individual activity plans that are reviewed six monthly as part of the care plan review?
1.73
Do service policies and procedures identify medicine management responsibilities of staff?
1.74
Are staff that administer medicine trained and are records of their competency in the role completed?
1.75
Are allergies or sensitivities recorded in medication charts and resident files?
1.76
Are there procedures in place for the self-administration of medicines, and are they adhered to?
1.77
Are medicines for self-administration safely stored?
1.78
Are internal audits of the medicine administration system completed?
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1.79
Is there an agreement in place with the pharmacy?
1.80
(If relevant) where there is controlled drug medicine use, is there: 1. A controlled drug register, 2. Does regular checking
(including weekly register checks) occur, 3. Is there secure safe storage, and 4. Do signing charts align with controlled drug
register?
1.81
Does the GP review medication at least 3 monthly?
1.82
Is there clear processes in place for medication reconciliation? 1. On admission a copy of the medication chart or script
accompanies the resident, and 2. Medication packs are checked against the medication chart on arrival from the pharmacy.
1.83
Does the charting of all “as required’ medication include a documented reason for given?
1.84
Are standing orders utilised and if so, does the procedure align with the standing orders guideline 2012?
1.85
Is there dietitian input available as needed for residents that have been assessed as requiring specialist input?
1.86
Are residents weight monitored on a regular basis, and is the care plan reflective of management of weight loss?
1.87
Has the menu been approved by a dietitian at least two yearly?
1.88
Is there a current building warrant of fitness and (where relevant) are other compliances (e.g. for use of gas) met?
1.89
Are fire safety and emergency management procedures in place?
1.90
Are fire drills completed at least 6 monthly?
1.91
Is there is an evacuation scheme approved by the New Zealand Fire Service that meets the requirements of The Fire Service Act
1975?
1.92
Does the restraint policy include definition of enablers and clear assessment processes?
1.93
Is the use of enablers voluntary and does documentation reflect this?
1.94
Is the use of enablers the least restrictive option and consistent with the assessment, consent and care plan?
1.95
Has training been provided for staff around prevention of challenging behaviour and use of de-escalation techniques?
1.96
Does the infection surveillance programme include collection of all infections?
1.97
Is the infection data collected analysed which leads to the development of action plans (where appropriate) to prevent or reduce
infections?
1.98
Do staff meeting minutes include infection control surveillance activities?
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2
Dementia Specific Health Services (If Applicable)
2.1
Is there written information on the service philosophy and practices particular to the dementia service/unit in the information pack
including (but not limited to): a) the need for a safe environment for self and others; b) how behaviours different from other
residents are managed and c) specifically designed and flexible programmes, with emphasis on: 1. Minimising restraint, 2.
Behaviour management, and 3. Complaint policy.
2.2
Is the service designed to provide quiet and low stimulus areas?
2.3
Is there adequate space and areas for maximum freedom of movement and that promote safety for residents/consumers who
tend to wander?
2.4
Is there a safe and secure outside area that is easily accessible for residents/consumers?
2.5
Does a qualified/skilled or experienced staff member complete relevant assessments of people who enter the service?
2.6
Does the assessment tool being utilised, include identifying any behaviour specific to the resident/consumer?
2.7
Does each resident/consumer have an assessment on file that identifies individual diversional, motivational and recreational
requirements?
2.8
Each resident/consumer assessment completed on entry has been completed, with input from any specialist assessment
available, or gained from the resident, their family, or nominated representative?
2.9
All residents/consumers have a care plan on their file that includes; a) Interventions that identify the consumers current abilities,
level of independence, identified needs/deficits, and takes into account the consumers habits, routines, idiosyncrasies, and
specific behavioural management strategies; b) strategies for minimising episodes of challenging behaviours based on an
appropriate assessment process and prevention; c) description of how the consumer behaviour is best managed over a 24 hour
period; d) description of the activities that meet their needs in relation to individual diversional, motivational and recreational
therapy during the twenty four hour period.
These activities will reflect their former routines and activities that are still familiar to the Resident.
2.10
Are residents/consumers provided with appropriate activities, which ensure diversion at appropriate times during the day and in
accordance with the needs identified in their care plan?
2.11
There is a designated person, skilled in assessment, implementation and evaluation of diversional and motivational recreation,
such as a diversional therapist that develops the activities programme?
2.12
Does documentation demonstrate that involvement of family/whānau and support is promoted at all times?
2.13
Do regular care plan evaluations include a documented review of the person's behaviour associated with dementia?
2.14
Is there is at least one care staff member on duty in the unit at all times, and a second staff member is available at the facility (or,
where you only provide Specialist Dementia Services, at the unit) and on-call?
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2.15
Is there a suitably qualified and experienced registered nurse or registered psychiatric nurse involved in development of the care
plan and clinical care?
2.16
Does the staff orientation include; 1. A session on how to implement activities and therapies, 2. Managing challenging behaviour,
and 3. Focusing on the promotion of quality of life.
2.17
Have all Care Givers obtained passes in the following unit standards. i. 23920; ii. 23921; iii. 23922; iv. 23923.
2.18
Have all newly employed care givers commenced study within six months of their appointment and obtained passes in those
standards within 12 months.
2.19
Are there additional snacks available over a 24 hour period and these are accessible?
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ACTION PLAN: SURVEILLANCE AUDIT SCOPE (AGED CARE FOR SPOT UNANNOUNCED AUDIT) MODULE
Ref #
Self-assessment questions
(for “No” responses above)
Improvement action to be taken
Due
date
Person
responsible
Date
completed
(Add additional rows as necessary)
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