Audit reports are available for rest homes. This page explains what information is in an audit report, and how to understand it.
An audit report is written when a rest home is audited for certification under the Health and Disability Services (Safety) Act 2001 to provide rest home (aged residential care) services.
The audit reports can help you understand how well a rest home is performing – both the positive aspects and the areas where the rest home should improve.
About the audits
When audits are performed
Audits are required for certification under the Act. Rest homes are certified for set periods of time, usually between one and four years. The level of standard attainment determines how long a rest home is certified for before requiring another audit. The rest home will need to be audited for recertification before the end of that period.
At least one unannounced spot audit is performed around the middle of a rest home’s certification period. This is to check that progress has been made on areas for improvement identified in the earlier certification audit and that standards have been maintained.
Rest homes are also audited when they change ownership or add a new service (eg, adding hospital-level care).
Standards used in the audits
Rest homes are audited against particular standards and audit criteria to make sure they are safe and appropriate for residents. The standards focus on the outcomes that residents experience when services are of good quality. Overall, there are 50 standards and 101 criteria within the standards that can be used for audits of rest homes.
See the Health and Disability Services Standards for more information.
Auditing process
Rest home audits are undertaken by auditing agencies designated by the Ministry (referred to as DAAs or designated auditing agencies). Each audit report is completed by the auditors, reviewed by the rest home and then provided to the Ministry of Health and the rest home's contracted district health board (DHB) for review. The Ministry decides the period of certification, taking into account feedback from the DHB.
Contracts with DHBs
Rest homes also hold service contracts with their DHBs through a national contract called the Age-Related Residential Care (ARRC) Services Agreement. This is to make sure there is a national level of health care services provided throughout the country. These services are referred to in the audit reports as ARRC requirements. You can find out what services are covered at Age-Related Residential Care Service Agreement.
DHBs are also responsible for monitoring the actions identified as needing improvement at an audit and ensuring that these are completed within the required time frame.
Content of the audit reports
An audit report provides information and evidence about how well, or not well, a rest home is meeting the requirements of the standards.
Although all the audit reports have the same format, they do vary in length according to:
- the number of standards audited (spot audits don’t audit as many standards as full certification audits)
- the amount of evidence recorded by the DAA
- the number of corrective actions and/or continuous improvement ratings.
Collecting and analysing the information
Auditors collect information on how well a rest home is meeting the standards in different ways, including:
- observing the rest home in action
- interviewing rest home staff, residents and family members
- looking at documentation of systems, policies, procedures, records.
This information is analysed to decide whether or not the evidence meets the requirement of the individual standard or criterion. The results are reported under six key outcomes:
- 1.1 Consumer Rights
- 1.2 Organisation Management
- 1.3 Continuum of Service Delivery
- 1.4 Safe and Appropriate Environment
- 2 Restraint Minimisation and Safe Practice
- 3 Infection Prevention and Control.
Each outcome has several standards, and each standard has criteria. For example, Outcome 1.3: Continuum of Service Delivery has 12 standards and each standard has a number of criteria.
Attainment levels and risk ratings
You can tell how well the requirements of a standard or criteria have been achieved by the ratings of ‘attainment’ and level of risk.
| Abbreviation | Full word/s | Achievement of standard or criteria |
|---|---|---|
| CI | Continued improvement | Achievement beyond the full attainment |
| FA | Fully attained | Full attainment and meets the requirements |
| PA | Partial attainment | Partial attainment and improvement required |
| UA | Unattained | Not met |
| NA | Not applicable | Standard or criterion not audited as it does not apply |
Risk ratings
A risk rating is given to standards or criteria identified as partially attained (PA) or unattained (UA). These standards or criteria are rated according to the assessed potential risk for consumers – negligible, low, moderate, high or critical risk.
A partial attainment rating does not indicate a failure. Most rest home audits have some standards and criteria assessed as partial attainment. Partial attainment indicates the areas that require improvement. The audits are an opportunity to identify the areas where the rest home should improve and what action is required for improvement.
Corrective actions
Where criteria are partially attained or unattained and an improvement is required, the audit report states the action required and a time frame for correcting the issue/s. This action is called a corrective action request (CAR).
Here is an example from within an audit report.
| Criterion with desired outcome | Attainment Rating | Audit Evidence | Audit Finding | Corrective action required and timeframe for completion (days) |
|---|---|---|---|---|
| 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. |
PA Low | The service has policies and procedures for ensuring all medicine related recording and documentation is: a) legible, b) signed and dated and c) able to meet acceptable good practice standards. Twelve medication charts were reviewed. | One medication chart was not legible due to repeated faxing. One medication chart did not include all medications the resident required and the staff were administering one medication from a discharge summary – this was corrected on the day of audit. | All medication charts are to be legible and include all required medications 30 days |
Navigating the audit report
Front section
The front section of the report provides detail about:
- the rest home audited
- the type of audit
- the kinds of services the rest home is certified to provide
- the number of beds occupied on the day of audit.
Executive Summary of Audit
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 often included that highlight the provider’s attainment against the standards in each of the outcome areas.
Summary of Attainment
This table summarises the number of standards and criteria audited and the ratings they were awarded.
Attainment against the Health and Disability Services Standards
This 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.
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. This table contains the criterion where corrective actions have been recorded.
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. This table contains the criterion where the provider has been rated as having made corrective actions have been recorded.