NNNM Enterprises Limited - Lester Heights Hospital
CURRENT STATUS: 08-Oct-13
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 & NZS8134.3:2008
on the audit date(s) specified.
GENERAL OVERVIEW
Lester Heights Hospital is certified to provide hospital level care only and is proposing to use
12 of its existing 35 hospital level beds as beds that can accommodate either rest home
level residents or hospital level. The facility has two separate lounge and dining areas to
enable separation between the two groups of resident. The facility manager is a new
appointee and comes to the position having previously managed another aged care facility
within Whangarei.
Lester Heights Hospital
NNNM Enterprises Ltd
Partial provisional audit - Audit Report
Audit Date: 08-Oct-13
Audit Report
To: HealthCERT, Ministry of Health
Provider Name
NNNM Enterprises Ltd
Premise Name
Street Address
Suburb
City
Lester Heights Hospital
93 Fourth Avenue
Woodhill
Whangarei
Proposed changes of current services (e.g. reconfiguration):
This partial provisional audit was to review the level of preparedness of Lester Heights Hospital to provide rest home level services for up 12
residents in 12 of the 35 bedrooms that are certified for hospital level care.
Type of Audit
Partial provisional audit and (if applicable)
Date(s) of Audit
Start Date: 08-Oct-13
Designated Auditing
Agency
Health and Disability Auditing New Zealand Limited
End Date: 08-Oct-13
Audit Team
Audit Team
Lead Auditor
Name
Qualification
XXXXXXX
RN, RM, ADN,
BNurs, MBS,
Lead Health
Auditor Cert
Auditor Hours
on site
Auditor Hours
off site
Auditor Dates on site
6.00
4.00
08-Oct-13
Auditor 1
Auditor 2
Auditor 3
Auditor 4
Auditor 5
Auditor 6
Clinical Expert
Technical Expert
Consumer Auditor
Peer Review
Auditor
XXXXXXX
1.00
Total Audit Hours on site
6.00
Total Audit Hours off site
(system generated)
5.00
Total Audit Hours
Staff Records Reviewed
1 of 1
Client Records Reviewed
(numeric)
0 of 0
Staff Interviewed
0 of 0
Management Interviewed
(numeric)
1 of 1
Relatives Interviewed
(numeric)
0
Consumers Interviewed
0 of 0
Number of Medication
Records Reviewed
0 of 0
GP’s Interviewed
(aged residential care
and residential
disability) (numeric)
0
Number of Client
Records Reviewed
using Tracer
Methodology
11.00
0 of 0
Declaration
I, (full name of agent or employee of the company) XXXXXXX (occupation) Director of (place) Christchurch hereby submit this audit report pursuant to section
36 of the Health and Disability Services (Safety) Act 2001 on behalf ofHealth and Disability Auditing New Zealand Limited, an auditing agency designated
under section 32 of the Act.
I confirm that Health and Disability Auditing New Zealand Limitedhas in place effective arrangements to avoid or manage any conflicts of interest that may
arise.
Dated this 22 day of October 2013
Please check the box below to indicate that you are a DAA delegated authority, and agree to the terms in the Declaration section of this document.
This also indicates that you have finished editing the document and have updated the Summary of Attainment and CAR sections using the instructions at the
bottom of this page.
Click here to indicate that you have provided all the information that is relevant to the audit: 
The audit summary has been developed in consultation with the provider: 
Electronic Sign Off from a DAA delegated authority (click here): 
Services and Capacity
Kinds of services certified
Hospital Care
Premise Name
Lester Heights Hospital
Total
Number
of Beds
Number
of Beds
Occupie
d on Day
of Audit
Number
of Swing
Beds for
Aged
Residential Care
35
18
12







Rest Home
Care
Residential Disability
Care






Executive Summary of Audit
General Overview
Lester Heights Hospital is certified to provide hospital level care only and is proposing to use 12 of its existing 35 hospital level beds as swing beds so that it
can accommodate rest home level residents. The facility has two separate lounge and dining areas to enable separation between the two groups of resident.
The facility manager is a new appointee and comes to the position having previously managed another aged care facility within Whangarei.
1.1 Consumer Rights
Not applicable
1.2 Organisational Management
The facility manager is registered nurse with a current practising certificate. The facility is able to be managed by either a registered nurse or the owner would
appoint her mobile clinical manager to the role if the manager was temporarily absent for any length of time. The facility manager follows good practice with
human resource management and there are recruitment and appointment systems in place which are followed.
1.3 Continuum of Service Delivery
The activities programme will be managed by diversional therapist who commences employment Monday 14 October 2013. She is employed 35 hours a
week. She will be supported by the currently employed activities coordinator who works 25 hours a week. The current activities programme is offered in the
main lounge but will be offered in both lounges. The group programme currently includes physical activities, cognitive activities and social activities. Individual
spiritual needs of residents are met by visiting chaplains. The plan is for the new diversional therapist to develop a new activities programme both individual
and group for the proposed rest home level residents and to revise the existing hospital level programme. The manager believes strongly that residents
benefit from being well stimulated in their environment. Residents are able to go for walks outside either on or off the premises. The facility has external
gardens and a new deck off one of the lounges, which can be used for recreation and relaxation. A mobility vehicle is hired or taxis are used when transport is
needed for trips and appointments if the manager's company car is not available.
The medicine management system in use is based on the robotic system for administering packaged tablets. Other medicines are administered from
dispensed containers. The facility uses medication charts that are issued with the medicines when supplied by the pharmacy. These charts are signed by the
general practitioner and used by staff to guide the administration of medicines. Policies and procedures are in use to guide practice. There is a contract in
place with a local pharmacy for the dispensing of medicines to residents and one general practitioner provides services to all permanent residents. There is a
secure medication room and a safe for the storage of controlled drugs located in the locked medication room. There is a medication competency test in use
which is consistent with the guidelines. All medicines are administered by registered nurses only who will also administer medicines to the proposed rest home
level residents.
All food is prepared on site by two cooks. The main cook who is employed Monday to Friday, is primarily responsible for all aspects of food procurement and
food delivery in consultation with the facility manager. There is a rotating four weekly menu approved by a dietitian in use. The menu is a Radius Care
approved menu and the owners are in the process of developing their own menu to implement for summer. A range of dietary needs are able to be met. A
registered nurse completes each resident's nutritional profile on admission and these are kept in the kitchen. Any changes are communicated to the cooks.
Food safety information and a kitchen manual is available to guide staff. Residents likes and dislikes are known. Residents requiring extra support to eat and
drink are assisted. The service has a well equipped kitchen with delivery, storage, baking and food preparation, serving and dishwashing areas. There are gas
hobs and electric oven for cooking. A barbeque is available for summer barbeques. There is a process in use to check food in both the fridge and freezers to
ensure it is fit for consumption. Fridge/freezer temperatures are monitored. Food in the chiller is covered and dated. The kitchen is clean and all food is
stored off the floor. Cleaning schedules are in place. All chemicals are locked away. One cook has completed HSI (Hospitality service industry) units in April
2013 and the other cook who has been employed less than two months and works in the weekends is booked to attend training.
1.4 Safe and Appropriate Environment
There is a process in place for the management of hazardous waste. The building warrant of fitness expires on 1 December 2013. The proposed rest home
beds, which are currently certified as hospital level beds, are covered by the existing building warrant of fitness. The NZ Fire Service approved the evacuation
scheme on 21 July 2001. Fire equipment checks are conducted by an external fire safety contractor. All residents have access to their own bedrooms, which
include hand basins and built in wardrobes. Bedrooms floors are not fully carpeted although some have carpet squares on the vinyl flooring. Some bedrooms
are large enough to accommodate married couples. There are no bedrooms with ensuites. All residents use communal toilets and showers. Communal toilets
and showers are spacious enough to be able to use mobility aids. There are privacy slide signs on the toilet/shower doors. Hand sanitizer gel is provided
throughout the facility and is available in each bedroom. There are separate visitors and staff toilets. There are toilets by communal areas. Tempering values
are installed on taps to ensure hot water temperatures can be maintained at a safe temperature. Rest home residents will have a separate lounge and dining
room that will seat all 12 residents. There is space for residents to talk privately to their visitors. Hospital residents will have access to the main lounge and
dining room. There is an external wooden deck off the small (proposed rest home) lounge which enables residents to have a 180 degree view of Whangarei
city. There are a number of grassed external areas. The facility manager has engaged a landscaper to develop possibilities for external improvements and a
plan has been proposed on 4 October 2013 which has options for consideration. Cleaning staff hours will be increased as soon as occupancy increases. All
laundry is done on site in a laundry which is located downstairs on a level lower than the residential care level. The laundry is staffed exclusively by Radius
Care staff under contract. There is sufficient capacity in the existing laundry to accommodate the proposed change as the laundry is capable of servicing 35
hospital level residents. Currently the laundry is servicing two other aged care facilities and has spare capacity. Chemicals are stored in a locked room in the
laundry when not in use. The building is divided in four wings and each wing has access to a sluice room for the disposal of soiled waste. Staff use laundry
chutes which are connected to the downstairs laundry area. Appropriate protective clothing is available for staff use. Fire training, emergency evacuation and
education on security are included as part of staff orientation and on-going training. Emergency equipment is available. Civil defence boxes are available.
Emergency water supplies are stored onsite. Additional stocks of food is carried for emergency management. First aid training has been provided for staff and
there is at least one staff member on duty at all times with a first aid certificate. There are call bells in all areas. There is good natural lighting in both the
common areas and bedrooms. Bedrooms are ventilated by the use of external opening windows and doors. The heating system is a mix of electric eco
heaters, electric heaters and heat pumps which also act as air conditioners. The temperature of the building is monitored by staff. General living areas are
appropriately heated..
2
Restraint Minimisation and Safe Practice
Not applicable
3.
Infection Prevention and Control
There is an infection prevention and control programme in place that is clearly defined, documented and reviewed annually. The programme is developed in
consultation with relevant key stakeholders and approved and overseen by the facility manager. The role of the infection prevention and control coordinator is
assigned to a registered nurse who has a separate job description for this role and attends external training. Policies and procedures are in place. External
advice and support is available as needed from the GP, staff at Whangarei Base hospital, the laboratory and Bug Control . Staff receive ongoing training on
infection prevention and control.
Summary of Attainment
1.1 Consumer Rights
Attainment
CI
FA
PA
UA
NA
of
Standard 1.1.1
Consumer rights during service delivery
Not Applicable
0
0
0
0
0
1
Standard 1.1.2
Consumer rights during service delivery
Not Applicable
0
0
0
0
0
4
Standard 1.1.3
Independence, personal privacy, dignity and respect
Not Applicable
0
0
0
0
0
7
Standard 1.1.4
Recognition of Māori values and beliefs
Not Applicable
0
0
0
0
0
7
Standard 1.1.6
Recognition and respect of the individual’s culture, values, and beliefs
Not Applicable
0
0
0
0
0
2
Standard 1.1.7
Discrimination
Not Applicable
0
0
0
0
0
5
Standard 1.1.8
Good practice
Not Applicable
0
0
0
0
0
1
Standard 1.1.9
Communication
Not Applicable
0
0
0
0
0
4
Standard 1.1.10
Informed consent
Not Applicable
0
0
0
0
0
9
Standard 1.1.11
Advocacy and support
Not Applicable
0
0
0
0
0
3
Standard 1.1.12
Links with family/whānau and other community resources
Not Applicable
0
0
0
0
0
2
Standard 1.1.13
Complaints management
Not Applicable
0
0
0
0
0
3
Consumer Rights Standards (of 12): N/A:12
UA Neg: 0
Criteria (of 48):
CI:0
FA:0
CI:0
UA Low: 0
PA:0
FA: 0
UA Mod: 0
UA:0
PA Neg: 0
UA High: 0
PA Low: 0
UA Crit: 0
NA: 0
PA Mod: 0
PA High: 0 PA Crit: 0
1.2 Organisational Management
Attainment
CI
FA
PA
UA
NA
of
Standard 1.2.1
Governance
FA
0
2
0
0
0
3
Standard 1.2.2
Service Management
FA
0
1
0
0
0
2
Standard 1.2.3
Quality and Risk Management Systems
Not Applicable
0
0
0
0
0
9
Standard 1.2.4
Adverse event reporting
Not Applicable
0
0
0
0
0
4
Standard 1.2.7
Human resource management
FA
0
4
0
0
0
5
Standard 1.2.8
Service provider availability
FA
0
1
0
0
0
1
Standard 1.2.9
Consumer information management systems
Not Applicable
0
0
0
0
0
10
Organisational Management Standards (of 7):
Criteria (of 34):
CI:0
FA:8
N/A:3
PA Crit: 0
PA:0
CI:0
UA Neg: 0
UA:0
FA: 4
UA Low: 0
PA Neg: 0
UA Mod: 0
NA: 0
PA Low: 0
UA High: 0
PA Mod: 0
UA Crit: 0
PA High: 0
1.3 Continuum of Service Delivery
Attainment
CI
FA
PA
UA
NA
of
Standard 1.3.1
Entry to services
Not Applicable
0
0
0
0
0
5
Standard 1.3.2
Declining referral/entry to services
Not Applicable
0
0
0
0
0
2
Standard 1.3.3
Service provision requirements
Not Applicable
0
0
0
0
0
6
Standard 1.3.4
Assessment
Not Applicable
0
0
0
0
0
5
Standard 1.3.5
Planning
Not Applicable
0
0
0
0
0
5
Standard 1.3.6
Service delivery / interventions
Not Applicable
0
0
0
0
0
5
Standard 1.3.7
Planned activities
FA
0
1
0
0
0
3
Standard 1.3.8
Evaluation
Not Applicable
0
0
0
0
0
4
Standard 1.3.9
Referral to other health and disability services (internal and external)
Not Applicable
0
0
0
0
0
2
Standard 1.3.10
Transition, exit, discharge, or transfer
Not Applicable
0
0
0
0
0
2
Standard 1.3.12
Medicine management
FA
0
4
0
0
0
7
Standard 1.3.13
Nutrition, safe food, and fluid management
FA
0
3
0
0
0
5
Continuum of Service Delivery Standards (of 12):
Criteria (of 51):
CI:0
FA:8
N/A:9
PA Crit: 0
PA:0
CI:0
UA Neg: 0
UA:0
FA: 3
UA Low: 0
PA Neg: 0
UA Mod: 0
NA: 0
PA Low: 0
UA High: 0
PA Mod: 0
UA Crit: 0
PA High: 0
1.4 Safe and Appropriate Environment
Attainment
CI
FA
PA
UA
NA
of
Standard 1.4.1
Management of waste and hazardous substances
FA
0
2
0
0
0
6
Standard 1.4.2
Facility specifications
FA
0
3
0
0
0
7
Standard 1.4.3
Toilet, shower, and bathing facilities
FA
0
1
0
0
0
5
Standard 1.4.4
Personal space/bed areas
FA
0
1
0
0
0
2
Standard 1.4.5
Communal areas for entertainment, recreation, and dining
FA
0
1
0
0
0
3
Standard 1.4.6
Cleaning and laundry services
FA
0
2
0
0
0
3
Standard 1.4.7
Essential, emergency, and security systems
FA
0
5
0
0
0
7
Standard 1.4.8
Natural light, ventilation, and heating
FA
0
2
0
0
0
3
Safe and Appropriate Environment Standards (of 8): N/A:0
PA Crit: 0
Criteria (of 36):
CI:0
FA:17
PA:0
CI:0
UA Neg: 0
UA:0
FA: 8
UA Low: 0
PA Neg: 0
UA Mod: 0
NA: 0
PA Low: 0
UA High: 0
PA Mod: 0
UA Crit: 0
PA High: 0
2
Restraint Minimisation and Safe Practice
Attainment
CI
FA
PA
UA
NA
of
Standard 2.1.1
Restraint minimisation
Not Applicable
0
0
0
0
0
6
Standard 2.2.1
Restraint approval and processes
Not Applicable
0
0
0
0
0
3
Standard 2.2.2
Assessment
Not Applicable
0
0
0
0
0
2
Standard 2.2.3
Safe restraint use
Not Applicable
0
0
0
0
0
6
Standard 2.2.4
Evaluation
Not Applicable
0
0
0
0
0
3
Standard 2.2.5
Restraint monitoring and quality review
Not Applicable
0
0
0
0
0
1
Restraint Minimisation and Safe Practice Standards (of 6): N/A: 6
High: 0
PA Crit: 0
CI:0
UA Neg: 0
Criteria (of 21):
UA:0
CI:0
FA:0
PA:0
FA: 0
UA Low: 0
NA: 0
PA Neg: 0
UA Mod: 0
PA Low: 0
UA High: 0
PA Mod: 0
UA Crit: 0
PA
3
Infection Prevention and Control
Attainment
CI
FA
PA
UA
NA
of
Standard 3.1
Infection control management
FA
0
3
0
0
0
9
Standard 3.2
Implementing the infection control programme
Not Applicable
0
0
0
0
0
4
Standard 3.3
Policies and procedures
Not Applicable
0
0
0
0
0
3
Standard 3.4
Education
Not Applicable
0
0
0
0
0
5
Standard 3.5
Surveillance
Not Applicable
0
0
0
0
0
8
Infection Prevention and Control Standards (of 5): N/A: 4
PA Crit: 0
Criteria (of 29):
CI:0
FA:3
Total Standards (of 50)
Neg: 0
N/A: 34
UA Low: 0
Total Criteria (of 219)
CI: 0
PA:0
CI: 0
UA Mod: 0
FA: 36
CI:0
UA Neg: 0
UA:0
FA: 16
UA High: 0
PA: 0
FA: 1
UA Low: 0
UA: 0
PA Neg: 0
UA Crit: 0
N/A: 0
PA Neg: 0
UA Mod: 0
PA Low: 0
UA High: 0
PA Mod: 0
UA Crit: 0
PA High: 0
NA: 0
PA Low: 0
PA Mod: 0
PA High: 0
PA Crit: 0
UA
Corrective Action Requests (CAR) Report
Provider Name:
Type of Audit:
NNNM Enterprises Ltd
Partial provisional audit
Date(s) of Audit Report:
DAA:
Lead Auditor:
Start Date:08-Oct-13
End Date: 08-Oct-13
Health and Disability Auditing New Zealand Limited
XXXXXXX
Continuous Improvement (CI) Report
Provider Name:
Type of Audit:
NNNM Enterprises Ltd
Partial provisional audit
Date(s) of Audit Report:
DAA:
Lead Auditor:
Start Date:08-Oct-13
End Date: 08-Oct-13
Health and Disability Auditing New Zealand Limited
XXXXXXX
1. 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
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The facility is owned by NNNM Enterprises Limited who purchased the facility in mid-2013. The major shareholder is Madhu Mudaliar who since 2008 has
owned and operated other aged care facilities in New Zealand. The business is currently operating under its transition plan (sighted). Staff are following
existing policies and procedures that were in place under the previous ownership. An external contractor is currently working with the business to review and
replace its quality documentation and to train staff so that the new policies can be implemented in practice.
The manager is a recent appointment who has been in the position since 9 September 2013. Prior to this appointment she was employed in the same role in
another aged care facility in Whangarei. She is in the process of orientating to the position and is being supported by the owner and a team of registered
nurses. The manager is a registered nurse with a current practising certificate. She has a background in aged care management, and a background in mental
health and in caring for people with acquired brain injuries. She is a suitably qualified and experienced person who has the authority, accountability and
responsibility for the services (job description sighted). She has maintained the minimum requirements for professional development activities related to
managing a hospital (sighted).
Criterion 1.2.1.1
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.
Audit Evidence
Finding Statement
Corrective Action Required:
Attainment: FA
Risk level for PA/UA:
Timeframe:
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.2.2 Service Management
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
During the manager's temporary absence the facility would be managed by either a registered nurse with a current practising certificate, who has background is nursing
education and has been employed at the facility since 28 December 2012 or the owner would appoint her mobile clinical manager to the role depending on how long the
manager was likely to be absent.
Criterion 1.2.2.1
During a temporary absence a suitably qualified and/or experienced person performs the manager's role.
Audit Evidence
Finding Statement
Attainment: FA
Risk level for PA/UA:
Corrective Action Required:
Timeframe:
STANDARD 1.2.7 Human Resource Management
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The owner took possession of the site on the 30 August 2013. Since then she has appointed the facility manager. The employment of other staff who were previously
employed by Radius Care has been continued. Staff have a collective agreement under NZNO for the whole site and have the choice of joining the collective agreement or
having an individual employment agreement. The facility manager is in the process of recruiting more staff and is advertising, shortlisting, reference and NZ Police checking,
checking employment eligibility (eg, Visa / work permit status) and has employed one casual health care assistant (HCA) who is in the process of orientation. Lester Heights
Hospital is currently occupied at 50 per cent capacity (ie, 18 residents) in its hospital level bedrooms and during the morning and afternoon shifts employs 1 registered nurse
(RN) and three healthcare assistants (HCAs) and overnight the facility is staffed by 1 RN and 1 HCA. The intention is to increase the number of health care assistants as
occupancy increases. The facility also uses a nursing bureau to cover casual absences if needed. Orientation of HCAs previously included completion of ACE training. The
latest employee who is a HCA has received five days of orientation under the supervision of the RN on duty. The owner is moving to Careerforce training for new staff.
Caregivers who have not achieved a level two qualification prior to commencement of employment will be expected to start this training as soon as they have completed their
orientation with the intention that they complete this training within six months. The 2013 training programme includes key aspects of the health and disability standards with
mandatory training topics (sighted).
Criterion 1.2.7.2
Professional qualifications are validated, including evidence of registration and scope of practice for service providers.
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
Attainment: FA
Risk level for PA/UA:
Criterion 1.2.7.3
The appointment of appropriate service providers to safely meet the needs of consumers.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.2.7.4
provided.
New service providers receive an orientation/induction programme that covers the essential components of the service
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.2.7.5
to consumers.
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services
Audit Evidence
Finding Statement
Corrective Action Required:
Attainment: FA
Risk level for PA/UA:
Timeframe:
STANDARD 1.2.8 Service Provider Availability
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
There is a skill mix policy is in operation for the facility, which is a Radius Care policy on acuity and clinical staffing ratios. The organisation is in the process of
developing its own policies. As part of the sale arrangements, and as stated in the transition plan between 29 July 2013 and 2 October 2013, an agreement
was made to utilise existing Radius Care policies for the transition between the companies with a plan to replace all policies over time. It is expected that the
process may take six months from the change of ownership. A private consultant has been contracted to develop the policies, associated procedures and
forms for the current owners, which align with their other aged care facility and a programme of education of the staff will take place as new policies and their
associated procedures and forms are implemented. There is a social roster in place for the hospital level services. The proposed roster for the rest home
beds will be based on a 1:9 ratio depending on resident acuity and occupancy. There will always be an RN onsite 24 hours a day, seven days a week to meet
the hospital resident's needs. The beds will be staffed by one HCA when the first room is occupied with a subsidised rest home level resident. That person will
be supported by the RNs who will be covering the whole site and the facility manager.
In addition to the nursing team of RNs and HCAs, the facility employs: a registered diversional therapist (who commences 14 October 2013) and will be
employed 35 hours a week Monday to Friday; a activities coordinator (existing employee) who works 25 hours a week Monday to Friday; one maintenance
person who is employed 32 hours a week, four days a week; two cooks (1 fulltime from Monday to Friday and 1 weekend cook employed from 6.30 am to 2
pm each day); three kitchen hands who cover a roster over the week (the kitchen hands work 9.30 to 1.30pm daily and 4.pm to 6.30 pm daily and the cooks
prepare the breakfast, lunch and tea); two cleaners (1 Monday to Friday and 1 weekend hours are 8 am to 2pm daily).
The laundry is done by Radius who under the terms of sale employs all laundry staff and provides full laundry services to the facility. This arrangement exists
until Radius builds other laundry facilities for its two aged care facilities that operate in Whangarei.
The on-call roster is covered by the facility manager.
Criterion 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.
Audit Evidence
Finding Statement
Attainment: FA
Risk level for PA/UA:
Corrective Action Required:
Timeframe:
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 1.3.7 Planned Activities
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.
ARC D16.5c.iii; D16.5d ARHSS D16.5g.iii; D16.5g.iv; D16.5h
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The activities programme will be managed by diversional therapist (DT) who commences employment Monday 14 October 2013. She is employed 35 hours a week. The DT
will be supported by the Manager and the current activities co-ordinator will be supported by the qualified DT who is employed 35 hours per week. Training will be provided to
the current activities co-ordinator for her to achieve a DT qualification. The current activities programme is offered in the main lounge. The group programme currently
includes physical (eg bowls, chair aerobics, yoga, Tai Chi), cognitive (eg, quizzes, group readings, bingo, puzzles, board games), social (eg, outings such as trips to cafes,
events around town and visiting guests (eg, schools, singers). Spiritual needs are met by visiting chaplains when available. Residents have their own visiting chaplains. The
new DT will develop a new activities programme both individual and group for the rest home level residents and will revise the existing hospital level programme. Both group
programmes will include a range of activities covering physical, cognitive, social, and spiritual needs of residents. All residents will have an individual plan. Residents are able
to go for walks outside either on or off the premises. The facility has external gardens and an outside deck which can be used for recreation and relaxation. Staff hire a vehicle
and or taxis when transport is needed for trips or appointments and the facility manager's car is unavailable.
Criterion 1.3.7.1
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are
meaningful to the consumer.
Audit Evidence
Finding Statement
Attainment: FA
Risk level for PA/UA:
Corrective Action Required:
Timeframe:
STANDARD 1.3.12 Medicine Management
Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.
ARC D1.1g; D15.3c; D16.5e.i.2; D18.2; D19.2d ARHSS D1.1g; D15.3g; D16.5i..i.2; D18.2; D19.2d
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The facility uses the robotic system to administer packaged tablets and other medicines are administered from dispensed containers. The facility uses
medication charts that are issued with the medicines when supplied by the pharmacy and these charts are signed by the general practitioner and used by staff
to guide the administration of medicines. There are medication policy and procedures are in use. Staff use the aged care guidelines to guide practice. The
service has a contract with a local pharmacy for the dispensing of medicines to residents and uses a single general practitioner (who works as a part time
anaesthetist for the DHB) to provide services to all permanent residents. There is a secure medication room and a safe for the storage of controlled drugs in
the locked medication room. There is a medication competency test in use which is consistent with the guidelines. Currently all medicines are administered by
RNs and RNs will administer medicines to rest home residents (confirmed in discussion with the facility manager). Residents' allergies and sensitivity status is
noted on their medicines charts their medicine chart. Management of adverse reactions are described in the medication policy.
D16.5.e.i.2; Six of six medication charts reviewed identified that the GP had seen the reviewed the resident 3 monthly and the medication chart was signed. A
previous CAR was identified at the provisional audit whereby instructions for PRN medicines was not documented by the prescribing GP. Since the provisional
audit the GP has reviewed all PRN medicines and documented his instructions. The previous CAR is considered met.
Criterion 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.
Audit Evidence
Finding Statement
Corrective Action Required:
Attainment: FA
Risk level for PA/UA:
Timeframe:
Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.3.12.5 The facilitation of safe self-administration of medicines by consumers where appropriate.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 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.
Audit Evidence
Finding Statement
Attainment: FA
Risk level for PA/UA:
Corrective Action Required:
Timeframe:
STANDARD 1.3.13 Nutrition, Safe Food, And Fluid Management
A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery.
ARC D1.1a; D15.2b; D19.2c; E3.3f ARHSS D1.1a; D15.2b; D15.2f; D19.2c
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The service employs two cooks and three kitchen hands to provide meal services over seven days a week. The main cook who is employed Monday to Friday
is primarily responsible for all aspects of food procurement and food delivery in consultation with the facility manager. Food storage, food preparation and
service delivery from the kitchen is a shared responsibility between both cooks. There is a rotating four weekly menu approved by a dietitian. The menu is a
Radius Care approved menu, which has been approved by their dietitian and the new owners are in the process of developing their own menu and have been
in discussions with a registered dietitian to implement a changed summer menu. A range of dietary needs are able to be met (eg soft/pureed/diabetic/high
calorie diets). There are specialised drinking cups, lip plates and large grip utensil as required. An RN completes each resident’s nutritional profile on
admission with the aid of the resident and family. Copies of residents nutritional profiles are kept in the kitchen and any changes are communicated to the
cooks. There is a food services communication diary. Food safety information and a kitchen manual is available in the kitchen. Resident’s likes and dislikes
are known. Residents requiring extra support to eat and drink are assisted, this was observed during lunch. Food served on the day of audit was hot and well
presented. Hot and cold food temperatures are monitored at each meal. Temperature recordings are within acceptable ranges. The service has a well
equipped kitchen with delivery, storage, baking and food preparation, serving and dishwashing areas. There are gas hobs and electric oven for cooking. A
barbeque is available for summer barbeques. There is a process to checking of food in both the fridge and freezers to ensure it is not past its expiry date.
Fridge/freezer temperatures are checked daily. Foods in the chiller are covered and dated. The kitchen is clean and all food is stored off the floor. Cleaning
schedules and duties lists are in place. All chemicals are locked away.
D19.2: One cook has completed HSI (Hospitality service industry) units in April 2013 and the other cook who has been employed less than two months and
works in the weekend is booked to attend training.
The kitchen will be able to accommodate the needs of both rest home and hospital residents.
Criterion 1.3.13.1 Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the
consumer group.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.3.13.2 Consumers who have additional or modified nutritional requirements or special diets have these needs met.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current
legislation, and guidelines.
Audit Evidence
Attainment: FA
Finding Statement
Corrective Action Required:
Timeframe:
OUTCOME 1.4
SAFE AND APPROPRIATE ENVIRONMENT
Risk level for PA/UA:
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.
These requirements are superseded, when a consumer is in seclusion as provided for by of NZS 8134.2.3.
STANDARD 1.4.1 Management Of Waste And Hazardous Substances
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The service has implemented policies and procedures for the disposal of waste and hazardous material to minimise the risk of harm to residents, visitors and staff. There are
safety data sheets available in service areas where chemicals are stored. All chemicals are correctly labelled and stored safely. Emergency flip charts include instructions for
chemical spills and are displayed throughout the facility. There is an emergency plan to respond to significant waste or hazardous substance management. Waste
management/chemical safety training occurs (last training was 3 April 2013). Sufficient gloves, aprons, and goggles are available for staff. An external company has the
contract for the collection of general and infectious waste. Incontinent products are double bagged before disposal into general waste. There is recycling of cardboard and
plastic containers. There is a pest control programme in place. The maintenance person is an approved handler for pesticides and attends to any ant, spider concerns and
weed spraying. There is protective wear provided such as heavy duty gloves, boots, respirator and masks to carry out the duties.
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.2 Facility Specifications
Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.
ARC D4.1b; D15.1; D15.2a; D15.2e; D15.3; D20.2; D20.3; D20.4; E3.2; E3.3e; E3.4a; E3.4c; E3.4d ARHSS D4.1c; D15.1; D15.2a; D15.2e; D15.2g; D15.3a;
D15.3b; D15.3c; D15.3e; D15.3f; D15.3g; D15.3h; D15.3i; D20.2; D20.3; D20.4
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The building holds a current warrant of fitness, which expires on 1 December 2013. The proposed rest home beds, which are currently certified as hospital
level beds are covered by the existing building warrant of fitness. A copy of the NZ Fire Service Approval of an evacuation scheme is available on site (dated
21 July 2001). Fire equipment checks are conducted by an external fire safety contractor. The maintenance person has attended an electrical testing course
and carries out checks on essential equipment two yearly. Testing tags were sighted for March 13. There is a maintenance requisition form which is checked
daily and in most cases the issue can be repaired or resolved on the same day. There is a list of preferred contractors for electrical, plumbing, building and
other requirements. A sample of hot water temperatures in resident areas are taken monthly and these are maintained at 43 degrees. All call bells are
checked monthly. The maintenance person has completed health and safety courses. He has a background in landscaped gardening and tends to the
gardens and grounds. The outdoor areas are well maintained with safe paving, outdoor seating and shade sails in the summer. There is an outdoor resident
designated smoking area and the facility manager is exploring options regarding a new smoking area solely for rest home residents. Staff smoke outside off
the staff room. The facility's amenities, fixtures, equipment and furniture are appropriate for hospital care residents. There is sufficient space to allow the
movement of residents around the facility using the mobility aids or lazy boy chairs. The hallways have hand rails appropriately placed. All bedrooms have
vinyl flooring although some have carpet squares. There is non-slip flooring in the showers and toilet areas throughout the facility. The main hallways and
communal living areas are carpeted.
ARC D15.3;The following equipment is available, pressure relieving mattresses, electric beds, shower chairs, two hoists, chair scales, walking frames, over
bed tables, wheelchairs, shower tilting chair, resident transferring aids. Equipment is calibrated by an external contractor.
There is an external wooden deck off the small (proposed rest home) lounge which enables residents to have a 180 degree view of the Whangarei city . There
are a number of grassed external areas. The facility manager has engaged a landscaper to develop possibilities for external improvements and a plan has
been proposed on 4 October 2013 which has options for consideration.
There were three previous CARs which were as follows:
1. A communal shower/toilet area had paint peeling off the wet surface areas posing an infection control risk which has been repaired (sighted).
2. One shower chair was rusting around the wheels causing the equipment to become unsafe to use which has been removed from use.
3. There was an area of carpet that had lifted (from underneath) near the main entrance that was a potential slip, trip or fall hazard which has been repaired
All three CARs are considered met.
Criterion 1.4.2.1
All buildings, plant, and equipment comply with legislation.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 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.
Audit Evidence
Attainment: FA
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.2.6
Consumers are provided with safe and accessible external areas that meet their needs.
Risk level for PA/UA:
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.3 Toilet, Shower, And Bathing Facilities
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
All resident rooms have direct access to a hand basin. There are no bedrooms which have ensuites. All residents use communal toilets and showers. Communal toilets and
showers are spacious enough to be able to use mobility aids (eg shower chair and hoists) if needed. The owners have purchased a shower bed which they are awaiting
delivery. There are privacy slide signs on the toilet/shower doors. Hand sanitizer gel is provided throughout the facility and is available in each bedroom. There is a separate
visitors and staff toilets. There are toilets by communal areas. Tempering values have been installed on taps used by residents to ensure hot water temperatures can be
maintained.
Criterion 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.
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
Attainment: FA
Risk level for PA/UA:
STANDARD 1.4.4 Personal Space/Bed Areas
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
There is adequate space in all bedrooms for residents and staff. Doorways into residents' rooms and communal areas are wide enough for walking frames, wheelchairs,
hoists and ambulance trollies. Some beds have to be dismantled when shifting furniture between bedrooms. All bedrooms are able to personalized. The bedrooms vary in
size. Some bedrooms would be able to accommodate a married couple. The proposed rest home bedrooms are the same size as other bedrooms occupied by hospital level
residents. There are built in wardrobes in each bedroom.
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.5 Communal Areas For Entertainment, Recreation, And Dining
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The rest home residents will have a separate lounge and dining room that will seat all 12 residents. There is space for residents to talk privately to their visitors. The hospital
residents will have access to the main lounge/dining room. The activities programmes can be provided in both lounges. Dining and recreational needs will be able to be
delivered in two separate areas. The areas are welcoming and the décor provides a homely atmosphere. Seating is appropriate and placement allows for group or individual
activities to take place.
Criterion 1.4.5.1
consumers.
Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.6 Cleaning And Laundry Services
Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided.
ARC D15.2c; D15.2d; D19.2e ARHSS D15.2c; D15.2d; D19.2e
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
There are cleaning policies and processes in place. Internal and external cleaning audits occur. Corrective actions required are followed through the quality/risk management
and staff meetings. The proposed plan is to increase the hours for the current cleaner when occupancy increases. The cleaner is looking forward to having her hours
increased. There is a cleaning trolley which is well equipped. The cleaner wears correct protective clothing when working. The laundry is located downstairs and is staffed
exclusively by Radius. There is sufficient capacity in the existing laundry to accommodate 35 residents. Currently the laundry is servicing three facilities and has spare
capacity. There is keypad access only for staff. The dirty linen is delivered in colour coded bags and gets sorted on arrival in the laundry. The laundry operates from 7am to
8pm daily. Adequate linen supplies are available. There are large commercial auto feed washing machines and dryers. There is a clean and dirty flow within the laundry. The
laundry has a clothes and linen labelling machine. Chemicals are stored in a locked room within the laundry. All chemicals sighted had correct manufacturer labels. Safety
data sheets are readily available. The building is divided in four wings and each wing has access to a sluice room for the disposal of soiled water or waste. There is
appropriate protective clothing available. Staff use laundry chutes from the wings as the laundry is located in the lower (ie, basement) level.
Criterion 1.4.6.2
The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.6.3
chemicals.
Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.7 Essential, Emergency, And Security Systems
Consumers receive an appropriate and timely response during emergency and security situations.
ARC D15.3e; D19.6 ARHSS D15.3i; D19.6
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
The NZ Fire Service approved the evacuation scheme on 21 July 2001. Fire evacuation practices occur (last evacuation was held on 14 June 2013 and it took
5 minutes to evacuate at 1.30 pm). A contracted service provides checking of all facility equipment including fire equipment. Fire training, emergency
evacuation and security situations are part of orientation of new staff and on-going training. Emergency equipment is available. Civil defence boxes are
available (sighted). The facility manager stated that they have spare blankets and alternative cooking methods if required (viewed). There is sufficient water
stored to ensure for three litres per day for three days per resident. The staffing level provided adequate numbers of staff to facilitate safe care to hospital level
residents. First aid training has been provided for staff and there is at least one staff member on duty at all times with a first aid certificate. There are call bells
in all communal areas, toilets, bathrooms and residents rooms. The proposed rest home bedrooms have call bells and the maintenance person checks these
monthly as well as fire hoses, extinguishers and emergency lights. Visitors and contractors sign in when visiting the facility. There is alarm system set up on
the main door which operates at night. There is a registered nurse on site 24 hours per day, seven days per week.
D19.6: There are emergency management plans in place to ensure health, civil defence and other emergencies are included.
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.7.3
Where required by legislation there is an approved evacuation plan.
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.7.4
Audit Evidence
Alternative energy and utility sources are available in the event of the main supplies failing.
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.7.5
An appropriate 'call system' is available to summon assistance when required.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.7.6
The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
STANDARD 1.4.8 Natural Light, Ventilation, And Heating
Attainment: FA
Risk level for PA/UA:
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
Each bedroom has an external window for natural lighting. There is good natural lighting in the common areas. The bedrooms are ventilated by the use of external opening
windows and doors. The heating system is a mix of electric eco heaters, Electric heaters and heat pumps which also act as air conditioners. The temperature of the building is
monitored by staff. General living areas are appropriately heated.
Criterion 1.4.8.1
Areas used by consumers and service providers are ventilated and heated appropriately.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 1.4.8.2
natural light.
All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
Attainment: FA
Risk level for PA/UA:
3. HEALTH AND DISABILITY SERVICES (INFECTION PREVENTION AND CONTROL) STANDARDS
STANDARD 3.1
Infection control management
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
Evaluation methods used: D  SI  STI  MI  CI  MaI  V  CQ  SQ  STQ  Ma  L 
How is achievement of this standard met or not met?
Attainment: FA
There is an infection prevention and control (IPC) programme in place that is clearly defined and documented and reviewed annually. The infection control programme is
developed in consultation with relevant key stakeholders, taking into account the risk assessment process, monitoring and surveillance data, trends, and relevant strategies.
The facility manager approves and oversees the programme. The role of the IPC coordinator is assigned to an RN and she has a job description for this role and attends
external training. Policies and procedures are in place and sighted. There are clear lines of accountability for IPC leading to the facility manager and owners. The IPC has
received additional training to undertake this role. IPC is discussed at the weekly RNs/Facility manager meetings and at whole of staff meetings which occur monthly or more
frequently if necessary. External advice and support is available as needed from the GP, staff at Whangarei Base hospital, the laboratory and Bug Control. Staff and residents
with infections are prevented as much as possible from passing on infections to other people. There is a clear process for early consultation and feedback with the IPC
significant changes are proposed to staffing, practices, products, equipment, the facility, or the development of new services. Service providers and/or consumers and visitors
suffering from, or exposed to and susceptible to, infectious diseases are prevented from exposing others while infectious if staff are aware of the risk. Staff last received
training from Bug Control on 17 September 2013.
Criterion 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.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 3.1.3
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.
Audit Evidence
Attainment: FA
Risk level for PA/UA:
Finding Statement
Corrective Action Required:
Timeframe:
Criterion 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.
Audit Evidence
Finding Statement
Corrective Action Required:
Timeframe:
Attainment: FA
Risk level for PA/UA: