HealthCERT Service Provider Audit Report (version 0.9)

Introduction

This report records the results of an audit against the Ngā Paerewa Health and Disability Services Standard (NZS8134:2021) of a health and disability service provider. The audit has been conducted by an auditing agency designated under 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 0.4 of the Ngā Paerewa Health and Disability Services Standard (NZS8134:2021).

It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.

Audit Report

Legal entity name:	Click or to enter text.
Certificate name:	Click or tap here to enter text.

Designated Auditing Agency:	Click or tap here to enter text.

Types of audit:	Click or tap here to enter text.
Premises audited:	Click or tap here to enter text.
Services audited:	Click or tap here to enter text.
Dates of audit:	Start date:	Choose a date	End date:	Choose a date

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:	0

Audit Team

Lead Auditor	Click here to enter text	Hours on site	0	Hours off site	0
Other Auditors	Click here to enter text	Total hours on site	0	Total hours off site	0
Technical Experts	Click here to enter text	Total hours on site	0	Total hours off site	0
Consumer Auditors	Click here to enter text	Total hours on site	0	Total hours off site	0
Peer Reviewer	Click here to enter text	Hours	0

Sample Totals

Total audit hours on site	0	Total audit hours off site	0	Total audit hours	0

Number of residents/patients interviewed	0	Number of staff interviewed	0	Number of managers interviewed	0
Number of residents’/patients’ records reviewed	0	Number of staff records reviewed	0	Total number of managers (headcount)	0
Number of medication records reviewed	0	Total number of staff (headcount)	0	Number of relatives interviewed	0
Number of residents’/patients’ records reviewed using tracer methodology	0	Number of GPs interviewed (Residential Disability providers only)	0

Declaration

I, Enter full name of agent or employee of the company, Enter occupation of person making declaration of Enter town/city or person making declaration hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of the Designated Auditing Agency named on page one of this report (the DAA), an auditing agency designated under section 32 of the Act.

I confirm that:

a)	I am a delegated authority of the DAA	Choose an item
b)	the DAA has in place effective arrangements to avoid or manage any conflicts of interest that may arise	Choose an item
c)	the DAA has developed the audit summary in this audit report in consultation with the provider	Choose an item
d)	this audit report has been approved by the lead auditor named above	Choose an item
e)	the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook	Choose an item
f)	if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider	Choose an item
g)	the DAA has provided all the information that is relevant to the audit	Choose an item
h)	the DAA has finished editing the document.	Choose an item

Dated Choose a date

Executive Summary of Audit

General Overview

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Section 1 Our rights

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Section 2 Workforce and Structure

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Section 3 Pathways to wellbeing

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Section 4 Person-centred and safe environment

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Section 5 Infection prevention and antimicrobial stewardship

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Section 6 Restraint and seclusion

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Summary of Attainment

CI	FA	PA Negligible	PA Low	PA Moderate	PA High	PA Critical
Subsection	0	0	0	0	0	0	0
Criteria	0	0	0	0	0	0	0

UA Negligible	UA Low	UA Moderate	UA High	UA Critical	Not Applicable	Pending	Not Audited
Subsection	0	0	0	0	0	0	0	0
Criteria	0	0	0	0	0	0	0	2

Corrective Action Requests (CAR) Report

Code	Name	Description	Attainment	Finding	Corrective Action	Timeframe (Days)

Continuous Improvement (CI) Report

Code	Name	Description	Attainment	Finding

NZS 8134:2021: Ngā Paerewa Health and disability services standard

Section 1: Our rights

People receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of people’s rights, facilitates informed choice, minimises harm, and upholds cultural and individual values and beliefs.

Subsection 1.1: Pae ora healthy futures (HDSS.2021:1.1)

Te Tiriti: Māori flourish and thrive in an environment that enables good health and wellbeing.
As service providers: We work collaboratively to embrace, support, and encourage a Māori worldview of health and provide high-quality, equitable, and effective services for Māori framed by Te Tiriti o Waitangi.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.1.1 (HDSS.2021:1.1.1)

My service provider shall embed and enact Te Tiriti o Waitangi within all its work, recognising Māori, and supporting Māori in their aspirations, whatever they are (that is, recognising mana motuhake).

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.1.2 (HDSS.2021:1.1.2)

My service provider shall ensure my services are operating in ways that are culturally safe.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.1.3 (HDSS.2021:1.1.3)

My service provider shall actively recruit and retain a Māori health workforce across all organisational roles.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.1.4 (HDSS.2021:1.1.4)

To facilitate equity approaches, my service provider shall be Māori centred.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.1.5 (HDSS.2021:1.1.5)

My service provider shall work in partnership with iwi and Māori organisations within and beyond the health sector to allow for better service integration, planning, and support for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.2: Ola manuia of Pacific peoples in Aotearoa (HDSS.2021:1.2)

The people: Pacific peoples in Aotearoa are entitled to live and enjoy good health and wellbeing.
Te Tiriti: Pacific peoples acknowledge the mana whenua of Aotearoa as tuakana and commit to supporting them to achieve tino rangatiratanga.
As service providers: We provide comprehensive and equitable health and disability services underpinned by Pacific worldviews and developed in collaboration with Pacific peoples for improved health outcomes.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.2.1 (HDSS.2021:1.2.1)

My service provider shall ensure cultural safety for Pacific peoples and that their worldviews, cultural, and spiritual beliefs are embraced.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.2 (HDSS.2021:1.2.2)

My service provider shall focus on achieving equity and efficient provision of health and disability services for Pacific peoples.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.3 (HDSS.2021:1.2.3)

My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.4 (HDSS.2021:1.2.4)

My service provider shall actively recruit, train, and retain a holistic Pacific health and wellbeing workforce that is responsive to the Pacific population’s health and disability needs. This will include Pacific peoples in leadership and training roles.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.2.5 (HDSS.2021:1.2.5)

My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.3: My rights during service delivery (HDSS.2021:1.3)

The People: My rights have meaningful effect through the actions and behaviours of others.
Te Tiriti:Service providers recognise Māori mana motuhake (self-determination).
As service providers: We provide services and support to people in a way that upholds their rights and complies with legal requirements.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.3.1 (HDSS.2021:1.3.1)

My service provider shall know and understand my rights and ensure that I am informed of my rights.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.3.2 (HDSS.2021:1.3.2)

My services shall be provided in a manner that complies with my rights.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.3.3 (HDSS.2021:1.3.3)

My service providers shall provide opportunities for discussion and clarification about my rights.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.3.4 (HDSS.2021:1.3.4)

My service provider shall facilitate support for me in accordance with my wishes, including independent advocacy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.3.5 (HDSS.2021:1.3.5)

My service provider shall recognise Māori mana motuhake.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.4: I am treated with respect (HDSS.2021:1.4)

The People: I can be who I am when I am treated with dignity and respect.
Te Tiriti: Service providers commit to Māori mana motuhake.
As service providers: We provide services and support to people in a way that is inclusive and respects their identity and their experiences.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.4.1 (HDSS.2021:1.4.1)

I shall be asked, and shall have opportunities to share, what is important to me.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.4.2 (HDSS.2021:1.4.2)

My service provider shall be responsive to my identity, which could include my values and beliefs, culture, religion, disabilities, gender, sexual orientation, relationship status, and other social identities or characteristics.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.4.3 (HDSS.2021:1.4.3)

My services shall be provided in a manner that respects my dignity, privacy, confidentiality, and preferred level of interdependence.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.4.4 (HDSS.2021:1.4.4)

Te reo Māori and tikanga Māori shall be actively promoted throughout organisations and incorporated through all their activities.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.4.5 (HDSS.2021:1.4.5)

Services shall ensure health care and support workers receive Te Tiriti o Waitangi training and that this is reflected in day-to-day service delivery.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.4.6 (HDSS.2021:1.4.6)

Service providers shall respond to tāngata whaikaha needs and enable their participation in te ao Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.5: I am protected from abuse (HDSS.2021:1.5)

The People: I feel safe and protected from abuse.
Te Tiriti: Service providers provide culturally and clinically safe services for Māori, so they feel safe and are protected from abuse.
As service providers: We ensure the people using our services are safe and protected from abuse.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.5.1 (HDSS.2021:1.5.1)

I shall receive services free of discrimination; coercion; harassment; physical, sexual, or other exploitation; abuse; or neglect.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.5.2 (HDSS.2021:1.5.2)

My service provider shall have effective safeguards to protect me from abuse and revictimisation.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.5.3 (HDSS.2021:1.5.3)

My property shall be respected, and my finances protected within the scope of the service being provided.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.5.4 (HDSS.2021:1.5.4)

Health care and support workers shall maintain professional boundaries with me and refrain from acts or behaviours that could negatively impact on my wellbeing.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.5.5 (HDSS.2021:1.5.5)

My service provider shall promote an environment in which it is safe to ask the question ‘how is institutional and systemic racism acting here?’

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.5.6 (HDSS.2021:1.5.6)

My service provider shall prioritise a strengths-based and holistic model ensuring wellbeing outcomes for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.6: Effective communication occurs (HDSS.2021:1.6)

The people: I feel listened to and that what I say is valued, and I feel that all information exchanged contributes to enhancing my wellbeing.
Te Tiriti: Services are easy to access and navigate and give clear and relevant health messages to Māori.
As service providers: We listen and respect the voices of the people who use our services and effectively communicate with them about their choices.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.6.1 (HDSS.2021:1.6.1)

I shall receive information in my preferred format and in a manner that is useful for me.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.6.2 (HDSS.2021:1.6.2)

My service provider shall communicate with other agencies involved in my care.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.6.3 (HDSS.2021:1.6.3)

My service provider shall practise open communication with me.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.6.4 (HDSS.2021:1.6.4)

I shall be provided with the time I need for discussions and decisions to take place.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.6.5 (HDSS.2021:1.6.5)

Appropriate interpreter services shall be provided to me.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.6.6 (HDSS.2021:1.6.6)

My service provider shall make communication and information easy for all people to access; understand; and use, enact, or follow.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.7: I am informed and able to make choices (HDSS.2021:1.7)

The people: I know I will be asked for my views. My choices will be respected when making decisions about my wellbeing. If my choices cannot be upheld, I will be provided with information that supports me to understand why.
Te Tiriti: High-quality services are provided that are easy to access and navigate. Providers give clear and relevant messages so that individuals and whānau can effectively manage their own health,
keep well, and live well.
As service providers: We provide people using our services or their legal representatives with the information necessary to make informed decisions in accordance with their rights and their ability to exercise independence, choice, and control.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.7.1 (HDSS.2021:1.7.1)

I shall have the right to make an informed choice and give informed consent.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.2 (HDSS.2021:1.7.2)

I shall be empowered to actively participate in decision making.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.3 (HDSS.2021:1.7.3)

I shall have a right to supported decision making.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.4 (HDSS.2021:1.7.4)

My whānau shall be included in decision making with my consent and shall be enabled to do so through access to quality information, advice, and resources.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.5 (HDSS.2021:1.7.5)

I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.6 (HDSS.2021:1.7.6)

My legal representative shall only make decisions on my behalf in compliance with the law. If my legal representatives make decisions for me, I still have the right to be included.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.7 (HDSS.2021:1.7.7)

My advance directives (written or oral) shall be followed wherever possible.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.8 (HDSS.2021:1.7.8)

The service providers shall have processes and policies to gain my consent and respect my wishes regarding the storage, return, or disposal of my body parts, tissues, and bodily substances.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.7.9 (HDSS.2021:1.7.9)

Service providers shall follow the appropriate best practice tikanga guidelines in relation to consent.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 1.8: I have the right to complain (HDSS.2021:1.8)

The people: I feel it is easy to make a complaint. When I complain I am taken seriously and receive a timely response.
Te Tiriti: Māori and whānau are at the centre of the health and disability system, as active partners in improving the system and their care and support.
As service providers: We have a fair, transparent, and equitable system in place to easily receive and resolve or escalate complaints in a manner that leads to quality improvement.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.8.1 (HDSS.2021:1.8.1)

My right to make a complaint shall be understood, respected, and upheld by my service provider.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.8.2 (HDSS.2021:1.8.2)

I shall be informed about and have easy access to a fair and responsive complaints process that is sensitive to, and respects, my values and beliefs.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.8.3 (HDSS.2021:1.8.3)

My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 1.8.4 (HDSS.2021:1.8.4)

I am informed of the findings of my complaint.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.8.5 (HDSS.2021:1.8.5)

The Code of Health and Disability Services Consumers’ Rights and the complaints process shall work equitably for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 1.9: Health and wellbeing of children born as a result of, and people accessing, reproductive technology services (HDSS.2021:1.9)

The people: I understand my options and what they mean for the health and wellbeing of our whānau. I feel the information is given in a compassionate manner.
Te Tiriti: Māori and tamariki\ experience equitable outcomes from reproductive technology services.
As service providers: We ensure that the health and wellbeing of the offspring born as a result of reproductive technology services and of people accessing these technologies is the guiding principle of our service delivery.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.9.1 (HDSS.2021:1.9.1)

Service provision shall be designed to mitigate the risks of assisted reproductive technology treatment.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.9.2 (HDSS.2021:1.9.2)

Service providers shall submit information to agencies appointed by the Ministry of Health.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.9.3 (HDSS.2021:1.9.3)

Service providers shall ensure that people are aware of their rights and obligations under the Human Assisted Reproductive Technology Act 2004.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.9.4 (HDSS.2021:1.9.4)

People shall be informed of available treatment options.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 1.10: Requirements of donation and surrogacy (HDSS.2021:1.10)

The people: We are aware of the rights and responsibilities of everyone involved in donation and surrogacy, and the interests of unborn children are protected.
Te Tiriti: The provision of reproductive technologies protects the interests and health of Māori donors, intending parents, surrogates, and offspring.
As service providers: We ensure the provision of reproductive technologies protects the interests and health of donors, intending parents, surrogates, and offspring.

Attainment and Risk: Not Audited

Evidence:

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Criterion 1.10.1 (HDSS.2021:1.10.1)

Service providers shall encourage and support people to inform offspring of their genetic and gestational origins and shall store information to enable access.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.10.2 (HDSS.2021:1.10.2)

Donors shall be made aware of their rights and responsibilities and shall be encouraged to exercise them.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 1.10.3 (HDSS.2021:1.10.3)

Gametes, embryos, or reproductive tissue shall be screened and safe for donation.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.10.4 (HDSS.2021:1.10.4)

Service providers shall have a policy that limits the number of families created from an individual donor.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 1.10.5 (HDSS.2021:1.10.5)

Service providers shall ensure that people participating in donation or surrogacy receive counselling from a person who is eligible to be an Australian and New Zealand Infertility Counsellors Association (ANZICA) approved counsellor.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Section 2: Workforce and structure

People receive quality services through effective governance and a supported workforce.

Subsection 2.1: Governance (HDSS.2021:2.1)

The people: I trust the people governing the service to have the knowledge, integrity, and ability to empower the communities they serve.
Te Tiriti: Honouring Te Tiriti, Māori participate in governance in partnership, experiencing meaningful inclusion on all governance bodies and having substantive input into organisational operational policies.
As service providers: Our governance body is accountable for delivering a highquality service that is responsive, inclusive, and sensitive to the cultural diversity of communities we serve.

Attainment and Risk: Not Audited

Evidence:

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Criterion 2.1.1 (HDSS.2021:2.1.1)

Governance bodies shall ensure compliance with legislative, contractual, and regulatory requirements with demonstrated commitment to international conventions ratified by the New Zealand government.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.2 (HDSS.2021:2.1.2)

Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.3 (HDSS.2021:2.1.3)

Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.4 (HDSS.2021:2.1.4)

Governance bodies shall evidence leadership and commitment to the quality and risk management system.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.5 (HDSS.2021:2.1.5)

Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.6 (HDSS.2021:2.1.6)

Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for tāngata whaikaha people with disabilities.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.7 (HDSS.2021:2.1.7)

Governance bodies shall ensure service providers identify and work to address barriers to equitable service delivery.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.8 (HDSS.2021:2.1.8)

Governance bodies shall support people receiving services and whānau to participate in the planning, implementation, monitoring, and evaluation of service delivery.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.9 (HDSS.2021:2.1.9)

Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.10 (HDSS.2021:2.1.10)

Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.1.11 (HDSS.2021:2.1.11)

There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 2.2: Quality and risk (HDSS.2021:2.2)

The people: I trust there are systems in place that keep me safe, are responsive, and are focused on improving my experience and outcomes of care.
Te Tiriti: Service providers allocate appropriate resources to specifically address continuous quality improvement with a focus on achieving Māori health equity.
As service providers: We have effective and organisation-wide governance systems in place relating to continuous quality improvement that take a risk-based approach, and these systems meet the needs of people using the services and our health care and support workers.

Attainment and Risk: Not Audited

Evidence:

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Criterion 2.2.1 (HDSS.2021:2.2.1)

Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.2 (HDSS.2021:2.2.2)

Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.3 (HDSS.2021:2.2.3)

Service providers shall evaluate progress against quality outcomes.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.4 (HDSS.2021:2.2.4)

Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.5 (HDSS.2021:2.2.5)

Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.6 (HDSS.2021:2.2.6)

Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.7 (HDSS.2021:2.2.7)

Service providers shall ensure their health care and support workers can deliver highquality health care for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.2.8 (HDSS.2021:2.2.8)

Service providers shall improve health equity through critical analysis of organisational practices.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 2.3: Service management (HDSS.2021:2.3)

The people: Skilled, caring health care and support workers listen to me, provide personalised care, and treat me as a whole person.
Te Tiriti: The delivery of high-quality health care that is culturally responsive to the needs and aspirations of Māori is achieved through the use of health equity and quality improvement tools.
As service providers: We ensure our day-to-day operation is managed to deliver effective person-centred and whānau-centred services.

Attainment and Risk: Not Audited

Evidence:

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Criterion 2.3.1 (HDSS.2021:2.3.1)

Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.2 (HDSS.2021:2.3.2)

Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.3 (HDSS.2021:2.3.3)

Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.4 (HDSS.2021:2.3.4)

Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.5 (HDSS.2021:2.3.5)

Service providers shall assist with training and support for people and service providers to maximise people and whānau receiving services participation in the service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.6 (HDSS.2021:2.3.6)

Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 2.3.7 (HDSS.2021:2.3.7)

Service providers shall invest in the development of organisational and health care and support worker health equity expertise.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.8 (HDSS.2021:2.3.8)

Support systems promote health care and support worker wellbeing and a positive work environment.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 2.3.9 (HDSS.2021:2.3.9)

Service providers demonstrates people with lived experience of the service participate in the planning, implementation, monitoring, and evaluation of service delivery.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.10 (HDSS.2021:2.3.10)

Service providers ensure people with lived experience of the service who are involved in the planning, implementation, and evaluation of services have a clear terms of reference or position description.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.11 (HDSS.2021:2.3.11)

Service providers have policies and procedures related to people with lived experience participating in service delivery. These are used to maximise their involvement and ensure their collective feedback is sought.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.12 (HDSS.2021:2.3.12)

Service providers demonstrate whānau and community participate, where relevant, in the planning, implementation, monitoring, and evaluation of service delivery.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.13 (HDSS.2021:2.3.13)

Service providers shall ensure whānau who participate in an advisory capacity have clear terms of reference or position description.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.3.14 (HDSS.2021:2.3.14)

Service providers shall have policies and procedures relating to whānau participation. These are used to maximise whānau involvement in the service and ensures their collective feedback is sought.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 2.4: Health care and support workers (HDSS.2021:2.4)

The people: People providing my support have knowledge, skills, values, and attitudes that align with my needs. A diverse mix of people in adequate numbers meet my needs.
Te Tiriti: Service providers actively recruit and retain a Māori health workforce and invest in building and maintaining their capacity and capability to deliver health care that meets the needs of Māori.
As service providers: We have sufficient health care and support workers who are skilled and qualified to provide clinically and culturally safe, respectful, quality care and services.

Attainment and Risk: Not Audited

Evidence:

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Criterion 2.4.1 (HDSS.2021:2.4.1)

Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.2 (HDSS.2021:2.4.2)

Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.3 (HDSS.2021:2.4.3)

Professional qualifications shall be validated prior to employment, including evidence of registration and scope of practice for health care and support workers.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.4 (HDSS.2021:2.4.4)

Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.5 (HDSS.2021:2.4.5)

Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.6 (HDSS.2021:2.4.6)

Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.4.7 (HDSS.2021:2.4.7)

Health care and support workers shall have the opportunity to be involved in a debrief and discussion, and receive support following incidents to ensure wellbeing.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 2.5: Information (HDSS.2021:2.5)

The people: Service providers manage my information sensitively and in accordance with my wishes.
Te Tiriti: Service providers collect, store, and use quality ethnicity data in order to achieve Māori health equity.
As service provider: We ensure the collection, storage, and use of personal and health information of people using our services is accurate, sufficient, secure, accessible, and confidential.

Attainment and Risk: Not Audited

Evidence:

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Criterion 2.5.1 (HDSS.2021:2.5.1)

Service providers shall maintain quality records that comply with the relevant legislation, health information standards, and professional guidelines, including in terms of privacy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.5.2 (HDSS.2021:2.5.2)

Service providers shall maintain an information management system that:
(a) Ensures the captured data is collected and stored through a centralised system to reduce multiple copies or versions, inconsistencies, and duplication;
(b) Makes the information manageable;
(c) Ensures the information is accessible for all those who need it;
(d) Complies with relevant legislation;
(e) Integrates an individual’s health and support records.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 2.5.3 (HDSS.2021:2.5.3)

Service providers responsible for National Health Index registration of people receiving services shall meet the recording requirements specified by the Ministry of Health.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Section 3: Pathways to wellbeing

People participate in the development of their pathway to wellbeing, and receive timely assessment, followed by services that are planned, coordinated, and delivered in a manner that is tailored to their needs.

Subsection 3.1: Entry and declining entry (HDSS.2021:3.1)

The people: Service providers clearly communicate access, timeframes, and costs of accessing services, so that I can choose the most appropriate service provider to meet my needs.
Te Tiriti: Service providers work proactively to eliminate inequities between Māori and non-Māori by ensuring fair access to quality care.
As service providers: When people enter our service, we adopt a person-centred and whānau-centred approach to their care. We focus on their needs and goals and encourage input from whānau. Where we are unable to meet these needs, adequate information about the reasons for this decision is documented and communicated to the person and whānau.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.1.1 (HDSS.2021:3.1.1)

During the initial engagement prior to service entry, service providers shall ensure:
(a) There is accurate information about the service available in a variety of accessible formats;
(b) There are documented entry criteria that are clearly communicated to people, whānau, and, where appropriate, local communities and referral agencies.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.1.2 (HDSS.2021:3.1.2)

There shall be clearly documented processes for determining a person’s entry into a service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.1.3 (HDSS.2021:3.1.3)

The entry process shall:
(a) Respect the rights and identity of the person entering services;
(b) Allow for ongoing consultation with whānau;
(c) Where entry to the service is delayed, ensure the person receives timely updates.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.1.4 (HDSS.2021:3.1.4)

There shall be clear processes for communicating the decisions for declining entry to a service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.1.5 (HDSS.2021:3.1.5)

Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.1.6 (HDSS.2021:3.1.6)

Prior to a Māori individual and whānau entry, service providers shall:
(a) Develop meaningful partnerships with Māori communities and organisations to benefit Māori individuals and whānau;
(b) Work with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.2: My pathway to wellbeing (HDSS.2021:3.2)

The people: I work together with my service providers so they know what matters to me, and we can decide what best supports my wellbeing.
Te Tiriti: Service providers work in partnership with Māori and whānau, and support their aspirations, mana motuhake, and whānau rangatiratanga.
As service providers: We work in partnership with people and whānau to support wellbeing.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.2.1 (HDSS.2021:3.2.1)

Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.2 (HDSS.2021:3.2.2)

Care or support plans shall be developed within service providers’ model of care.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.3 (HDSS.2021:3.2.3)

Fundamental to the development of a care or support plan shall be that:
(a) Informed choice is an underpinning principle;
(b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan;
(c) Comprehensive assessment includes consideration of people’s lived experience;
(d) Cultural needs, values, and beliefs are considered;
(e) Cultural assessments are completed by culturally competent workers and are accessible in all settings and circumstances. This includes traditional healing practitioners as well as rākau rongoā, mirimiri, and karakia;
(f) Strengths, goals, and aspirations are described and align with people’s values and beliefs. The support required to achieve these is clearly documented and communicated;
(g) Early warning signs and risks that may adversely affect a person’s wellbeing are recorded, with a focus on prevention or escalation for appropriate intervention;
(h) People’s care or support plan identifies wider service integration as required.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.4 (HDSS.2021:3.2.4)

In implementing care or support plans, service providers shall demonstrate:
(a) Active involvement with the person receiving services and whānau;
(b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective;
(c) That the person receives services that remove stigma and promote acceptance and inclusion;
(d) That needs and risk assessments are an ongoing process and that any changes are documented.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.5 (HDSS.2021:3.2.5)

Planned review of a person’s care or support plan shall:
(a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers;
(b) Include the use of a range of outcome measurements;
(c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations;
(d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review process, and ensure changes are implemented;
(e) Ensure that, where progress is different from expected, the service provider in collaboration with the person receiving services and whānau responds by initiating changes to the care or support plan.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.6 (HDSS.2021:3.2.6)

Service providers shall:
(a) Together with tāngata whaikaha, develop policies and procedures that ensure tāngata whaikaha and whānau participate in service development;
(b) Deliver services that give tāngata whaikaha choice and control over their supports;
(c) Remove barriers that prevent tāngata whaikaha and whānau from independently accessing information.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.2.7 (HDSS.2021:3.2.7)

Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.3: Individualised activities (HDSS.2021:3.3)

The people: I participate in what matters to me in a way that I like.
Te Tiriti: Service providers support Māori community initiatives and activities that promote whanaungatanga.
As service providers: We support the people using our services to maintain and develop their interests and participate in meaningful community and social activities, planned and unplanned, which are suitable for their age and stage and are satisfying to them.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.3.1 (HDSS.2021:3.3.1)

Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.3.2 (HDSS.2021:3.3.2)

People receiving services shall be supported to access their communities of choice where possible.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.3.3 (HDSS.2021:3.3.3)

Service providers shall encourage their workforce to support community initiatives that meet the health needs and aspirations of Māori and whānau.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.3.4 (HDSS.2021:3.3.4)

Service providers shall facilitate opportunities for Māori to participate in te ao Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.4: My medication (HDSS.2021:3.4)

The people: I receive my medication and blood products in a safe and timely manner.
Te Tiriti: Service providers shall support and advocate for Māori to access appropriate medication and blood products.
As service providers: We ensure people receive their medication and blood products in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.4.1 (HDSS.2021:3.4.1)

A medication management system shall be implemented appropriate to the scope of the service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.2 (HDSS.2021:3.4.2)

The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.3 (HDSS.2021:3.4.3)

Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.4 (HDSS.2021:3.4.4)

A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.5 (HDSS.2021:3.4.5)

Based on prescriber instructions, service providers shall provide ongoing support for people’s understanding of their medication.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.6 (HDSS.2021:3.4.6)

Service providers shall facilitate safe self-administration of medication where appropriate.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.7 (HDSS.2021:3.4.7)

Where standing orders are used, the relevant guidelines shall be consulted to guide practice.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.8 (HDSS.2021:3.4.8)

Over-the-counter medication and supplements shall be considered by the prescriber as part of the person’s medication.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.9 (HDSS.2021:3.4.9)

Service providers shall identify cases in which there are difficulties accessing medication, and support people to access it. Service providers support Māori and whānau to access medication.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.10 (HDSS.2021:3.4.10)

Service providers shall provide appropriate support, advice, and treatment for Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.11 (HDSS.2021:3.4.11)

People shall receive their blood components in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.4.12 (HDSS.2021:3.4.12)

Where applicable, people shall receive their fractionated plasma products in a safe and timely manner that complies with current legislative requirements and safe practice guidelines.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.5: Nutrition to support wellbeing (HDSS.2021:3.5)

The people: Service providers meet my nutritional needs and consider my food preferences.
Te Tiriti: Menu development respects and supports cultural beliefs, values, and protocols around food and access to traditional foods.
As service providers: We ensure people’s nutrition and hydration needs are met to promote and maintain their health and wellbeing.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.5.1 (HDSS.2021:3.5.1)

Menu development that considers food preferences, dietary needs, intolerances, allergies, and cultural preferences shall be undertaken in consultation with people receiving services.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.2 (HDSS.2021:3.5.2)

People and whānau shall have the opportunity to be involved in preparation of food as appropriate to the service.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.3 (HDSS.2021:3.5.3)

Service providers shall ensure people’s dining experience and environment is safe and pleasurable, maintains dignity and is appropriate to meet their needs and cultural preferences.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.4 (HDSS.2021:3.5.4)

The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.5 (HDSS.2021:3.5.5)

An approved food control plan shall be available as required.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.6 (HDSS.2021:3.5.6)

All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal shall comply with current legislation and guidelines.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.5.7 (HDSS.2021:3.5.7)

Service providers adopt a holistic approach to menu development that ensures nutritional value, respecting and supporting cultural beliefs, values, and protocols around food. Māori and whānau shall have menu options culturally specific to te ao Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.6: Transition, transfer, and discharge (HDSS.2021:3.6)

The people: I work together with my service provider so they know what matters to me, and we can decide what best supports my wellbeing when I leave the service.
Te Tiriti: Service providers advocate for Māori to ensure they and whānau receive the necessary support during their transition, transfer, and discharge.
As service providers: We ensure the people using our service experience consistency and continuity when leaving our services. We work alongside each person and whānau to provide and coordinate a supported transition of care or support.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.6.1 (HDSS.2021:3.6.1)

Service providers shall implement a process to support a safe, timely, seamless transition, transfer, or discharge.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.6.2 (HDSS.2021:3.6.2)

Service providers shall discuss and document reasons for transition, transfer, or discharge with the person and their whānau including any expressed concerns.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.6.3 (HDSS.2021:3.6.3)

People and whānau shall be advised of their options to access other health and disability services and social support or kaupapa Māori agencies where indicated or requested.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.6.4 (HDSS.2021:3.6.4)

A documented transition, transfer, or discharge plan, including current needs and risk mitigation, shall be developed in collaboration with the person and whānau and the accepting service provider.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.6.5 (HDSS.2021:3.6.5)

Service providers shall ensure people obtain the support they need, and that this is documented in the transition, transfer, or discharge plan.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.7: Electroconvulsive therapy (HDSS.2021:3.7)

The people: I can choose to have electroconvulsive therapy if it is appropriate, after receiving all the information on the benefits, risks, and known side effects.
Te Tiriti: Service providers deliver care for Māori with recognition of and respect for their cultural and or ethical beliefs.
As service providers: We ensure electroconvulsive therapy is safe and effective for the people using our service.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.7.1 (HDSS.2021:3.7.1)

Electroconvulsive therapy (ECT) shall be provided according to legislation and current national guidelines.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.7.2 (HDSS.2021:3.7.2)

There shall be monitoring processes in place to ensure all assessments, consents, and application of ECT comply with the current national guidelines and legislation and service providers’ policies and procedures.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.7.3 (HDSS.2021:3.7.3)

People receiving services and whānau shall be given specific information on the benefits, risks, and known side effects of ECT. Information shall also include alternative treatment options.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.7.4 (HDSS.2021:3.7.4)

For Māori, service providers shall recognise the role of whānau and community in a person’s illness and treatment, and particular beliefs, such as the sacredness of the head, as essential.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Subsection 3.8: Obtaining and caring for gametes and embryos (HDSS.2021:3.8)

The people: I trust that mygametes and embryos will be safely and appropriately collected or created and stored.
Te Tiriti: My gametes and embryos will be collected or created and stored with regard to mana motuhake, tikanga, and kawa that are important to me.
As service providers: We ensure gametes and embryos are safely and appropriately collected or created and stored in a safe environment.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.8.1 (HDSS.2021:3.8.1)

Service providers shall implement policies and procedures to accurately identify people, gametes, embryos, and other biological samples.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.8.2 (HDSS.2021:3.8.2)

Service providers shall ensure safe preparation, performance, and discharge for obtaining and transferring gametes, embryos, and other biological samples. This covers procedures that fall under the day-stay label as well as those that do not, such as intrauterine and in-vitro insemination and embryo transfer.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.8.3 (HDSS.2021:3.8.3)

Service providers shall ensure a suitable environment for optimising embryo culture conditions.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Timeframe (days): Choose an item (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)

Criterion 3.8.4 (HDSS.2021:3.8.4)

Service providers shall ensure the safe storage, manipulation, and use of cryopreserved biological materials in accordance with New Zealand legislation and regulation and best practice.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 3.8.5 (HDSS.2021:3.8.5)

Service providers shall ensure there are contingency plans in place to minimise the risk of adverse outcomes following a disaster.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.8.6 (HDSS.2021:3.8.6)

Service providers shall ensure the design of facilities is appropriate for assisted reproductive treatment and the people who use it.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.8.7 (HDSS.2021:3.8.7)

On closure of a fertility service, there shall be ongoing safe storage and accessibility to gametes, embryos, tissues, and medical records.

Attainment and Risk: Not Audited

Evidence:

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Criterion 3.8.8 (HDSS.2021:3.8.8)

Service providers shall ensure the design of the facility and the delivery of service are culturally and clinically safe for Māori who visit and use the service.

Attainment and Risk: Not Audited

Evidence:

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Section 4: Person-centred and safe environment

Health and disability services are provided in a safe environment appropriate to the age and needs of the people receiving services that facilitates independence and meets the needs of people with disabilities.

Subsection 4.1: The facility (HDSS.2021:4.1)

The people: I feel the environment is designed in a way that is safe and is sensitive to my needs. I am able to enter, exit, and move around the environment freely and safely.
Te Tiriti: The environment and setting are designed to be Māori-centred and culturally safe for Māori and whānau.
As service providers: Our physical environment is safe, well maintained, tidy, and comfortable and accessible, and the people we deliver services to can move independently and freely throughout. The physical environment optimises people’s sense of belonging, independence, interaction, and function.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.1.1 (HDSS.2021:4.1.1)

Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 4.1.2 (HDSS.2021:4.1.2)

The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.1.3 (HDSS.2021:4.1.3)

There shall be adequate personal space that is safe and age appropriate, and has accessible areas to meet relaxation, activity, lounge, and dining needs.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.1.4 (HDSS.2021:4.1.4)

There shall be adequate numbers of toilet, showers, and bathing facilities that are accessible, conveniently located, and in close proximity to each service area to meet the needs of people receiving services. This excludes any toilets, showers, or bathing facilities designated for service providers or visitors using the facility.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.1.5 (HDSS.2021:4.1.5)

There shall be adequate space to allow people to move safely around their personal space and bed area.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.1.6 (HDSS.2021:4.1.6)

Each person’s room shall have at least one external window, providing natural light, and appropriate ventilation and heating.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.1.7 (HDSS.2021:4.1.7)

When services design new buildings there shall be consultation and co-design of the environments, to ensure that they reflect the aspirations and identity of Māori.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Subsection 4.2: Security of people and workforce (HDSS.2021:4.2)

The people: I trust that if there is an emergency, my service provider will ensure I am safe.
Te Tiriti: Service providers provide quality information on emergency and security arrangements to Māori and whānau.
As service providers: We deliver care and support in a planned and safe way, including during an emergency or unexpected event.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.2.1 (HDSS.2021:4.2.1)

Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.2.2 (HDSS.2021:4.2.2)

Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.2.3 (HDSS.2021:4.2.3)

Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.2.4 (HDSS.2021:4.2.4)

Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.2.5 (HDSS.2021:4.2.5)

An appropriate call system shall be available to summon assistance when required.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.2.6 (HDSS.2021:4.2.6)

Service providers shall identify and implement appropriate security arrangements relevant to the people using services and the setting, including appropriate identification.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 4.2.7 (HDSS.2021:4.2.7)

Alternative essential energy and utility sources shall be available, in the event of the main supplies failing.

Attainment and Risk: Not Audited

Evidence:

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Criterion 4.2.8 (HDSS.2021:4.2.8)

Service providers will explain emergency and security arrangements to all people using the services.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Section 5: Infection prevention and antimicrobial stewardship

Health and disability service providers’ infection prevention (IP) and antimicrobial stewardship (AMS) strategies define a clear vision and purpose, with quality of care, welfare, and safety at the centre. The IP and AMS programmes are up to date and informed by evidence and are an expression of a strategy that seeks to maximise quality of care and minimise infection risk and adverse effects from antibiotic use, such as antimicrobial resistance.

Subsection 5.1: Governance (HDSS.2021:5.1)

The people: I trust the service provider shows competent leadership to manage my risk of infection and use antimicrobials appropriately.
Te Tiriti: Monitoring of equity for Māori is an important component of IP and AMS programme governance.
As service providers: Our governance is accountable for ensuring the IP and AMS needs of our service are being met, and we participate in national and regional IP and AMS programmes and respond to relevant issues of national and regional concern.

Attainment and Risk: Not Audited

Evidence:

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Criterion 5.1.1 (HDSS.2021:5.1.1)

The governance body shall identify the IP and AMS programmes as integral to service providers’ strategic plans (or equivalent) to improve quality and ensure the safety of people receiving services and health care and support workers.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.1.2 (HDSS.2021:5.1.2)

There shall be a formally agreed mechanism for accessing appropriate IP and AMS expertise that assists with defining the strategic direction and provides advice to the governance body.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.1.3 (HDSS.2021:5.1.3)

There shall be a documented pathway for IP and AMS issues to be reported to the governance body at defined intervals, which includes escalation of significant incidents.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.1.4 (HDSS.2021:5.1.4)

Significant IP events shall be managed using a stepwise approach to risk management and receive the appropriate level of organisational support.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Subsection 5.2: The infection prevention programme and implementation (HDSS.2021:5.2)

The people: I trust my provider is committed to implementing policies, systems, and processes to manage my risk of infection.
Te Tiriti: The infection prevention programme is culturally safe. Communication about the programme is easy to access and navigate and messages are clear and relevant.
As service providers: We develop and implement an infection prevention programme that is appropriate to the needs, size, and scope of our services.

Attainment and Risk: Not Audited

Evidence:

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Criterion 5.2.1 (HDSS.2021:5.2.1)

There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall:
(a) Be responsible for overseeing and coordinating implementation of the IP programme;
(b) Have clearly defined responsibility for IP decision making;
(c) Have documented reporting lines to the governance body or senior management;
(d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed;
(e) Receive continuing education in IP and AMS;
(f) Have access to shared clinical records and diagnostic results of people.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.2 (HDSS.2021:5.2.2)

Service providers shall have a clearly defined and documented IP programme that shall be:
(a) Developed by those with IP expertise;
(b) Approved by the governance body;
(c) Linked to the quality improvement programme; and
(d) Reviewed and reported on annually.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.3 (HDSS.2021:5.2.3)

Service providers shall develop written IP policies with input from suitably qualified personnel, which comply with relevant legislation and accepted best practice. The suite of policies shall include:
(a) Hand hygiene and standard precautions;
(b) Aseptic technique;
(c) Transmission-based precautions;
(d) Prevention of sharps injuries;
(e) Prevention and management of communicable infectious diseases in service providers and users;
(f) Management of current and emerging multi-drug-resistant organisms;
(g) Outbreak management;
(h) Decontamination and reprocessing of reusable medical devices and equipment;
(i) Single-use items;
(j) Health care-associated infection (HAI) surveillance;
(k) The built environment.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.4 (HDSS.2021:5.2.4)

Service providers shall ensure that there is a pandemic or infectious disease response plan in place, that it is tested at regular intervals, and that there are sufficient IP resources including personal protective equipment (PPE) available or readily accessible to support this plan if it is activated.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.5 (HDSS.2021:5.2.5)

IP personnel shall have input into other related clinical policies that may impact on HAI risk.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.6 (HDSS.2021:5.2.6)

Infection prevention education shall be provided to health care and support workers and people receiving services by a person with expertise in IP. The education shall be:
(a) Included in health care and support worker orientation, with updates at defined intervals;
(b) Relevant to the service being provided.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.7 (HDSS.2021:5.2.7)

A person with IP expertise shall be involved in procurement processes for equipment, devices, and consumables used in the delivery of health care.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.8 (HDSS.2021:5.2.8)

Service providers will demonstrate a clear process for early consultation and involvement from the IP personnel or committee during the design of any new building or when significant changes are proposed to an existing facility.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.9 (HDSS.2021:5.2.9)

Service providers shall ensure that reusable medical devices and shared equipment is appropriately decontaminated and reprocessed appropriately based on recommendations from the manufacturer and best practice guidelines. There shall be written policies for both manual and automated decontamination of reusable medical devices.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.2.10 (HDSS.2021:5.2.10)

There shall be evidence of audit and corrective actions, if applicable, of the appropriate decontamination of reusable medical devices based on recommendations from the manufacturer and best practice standards.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.2.11 (HDSS.2021:5.2.11)

Single-use medical devices shall not be reused or remanufactured unless a formal risk assessment process has been followed and documented and approved by the governance body.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.2.12 (HDSS.2021:5.2.12)

Service providers shall provide educational resources that are available in te reo Māori and are accessible and understandable for Māori accessing services.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.2.13 (HDSS.2021:5.2.13)

IP personnel and committees shall participate in partnership with Māori for the protection of culturally safe practice in IP, and thus acknowledge the spirit of Te Tiriti.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Subsection 5.3: Antimicrobial stewardship (AMS) programme and implementation (HDSS.2021:5.3)

The people: I trust that my service provider is committed to responsible antimicrobial use.
Te Tiriti: The antimicrobial stewardship programme is culturally safe and easy to access, and messages are clear and relevant.
As service providers: We promote responsible antimicrobials prescribing and implement an AMS programme that is appropriate to the needs, size, and scope of our services.

Attainment and Risk: Not Audited

Evidence:

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Criterion 5.3.1 (HDSS.2021:5.3.1)

Service providers shall have a documented AMS programme that sets out to optimise antimicrobial use and minimising harm. This shall be:
(a) Appropriate for the size, scope, and complexity of the service;
(b) Approved by the governance body;
(c) Developed using evidence-based antimicrobial prescribing guidance and expertise (which includes restrictions and approval processes where necessary and access to laboratory diagnostic testing reports).

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.3.2 (HDSS.2021:5.3.2)

Service providers shall have policies and guidelines in place, appropriate to the size, scope, and complexity of the service, which will comply with evidence-informed practice.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.3.3 (HDSS.2021:5.3.3)

Service providers, shall evaluate the effectiveness of their AMS programme by:
(a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects;
(b) Identifying areas for improvement and evaluating the progress of AMS activities.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 5.4: Surveillance of health care-associated infection (HAI) (HDSS.2021:5.4)

The people: My health and progress are monitored as part of the surveillance programme.
Te Tiriti: Surveillance is culturally safe and monitored by ethnicity.
As service providers: We carry out surveillance of HAIs and multi-drug-resistant organisms in accordance with national and regional surveillance programmes, agreed objectives, priorities, and methods specified in the infection prevention programme, and with an equity focus.

Attainment and Risk: Not Audited

Evidence:

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Criterion 5.4.1 (HDSS.2021:5.4.1)

Surveillance activities shall be appropriate for the service provider and take into account the following:
(a) Size and complexity of the service;
(b) Type of services provided;
(c) Acuity, risk factors, and needs of the people receiving services;
(d) Health and safety risk to, and of, the workforce;
(e) Systemic risk to the health and disability system as a whole.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 5.4.2 (HDSS.2021:5.4.2)

Service providers, through their IP role or personnel, shall determine the type of surveillance required and the frequency with which it is undertaken, taking into account the size and setting of the service and national and regional surveillance programmes and guidelines.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.4.3 (HDSS.2021:5.4.3)

Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.4.4 (HDSS.2021:5.4.4)

Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.4.5 (HDSS.2021:5.4.5)

There shall be clear, culturally safe processes for communication between service providers and people receiving services who develop or experience a HAI.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 5.5: Environment (HDSS.2021:5.5)

The people: I trust health care and support workers to maintain a hygienic environment. My feedback is sought on cleanliness within the environment.
Te Tiriti: Māori are assured that culturally safe and appropriate decisions are made in relation to infection prevention and environment. Communication about the environment is culturally safe and easily accessible.
As service providers: We deliver services in a clean, hygienic environment that facilitates the prevention of infection and transmission of antimicrobialresistant organisms.

Attainment and Risk: Not Audited

Evidence:

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Criterion 5.5.1 (HDSS.2021:5.5.1)

Service providers shall ensure safe and appropriate storage and disposal of waste and infectious or hazardous substances that complies with current legislation and local authority requirements. This shall be reflected in a written policy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.5.2 (HDSS.2021:5.5.2)

Service providers shall ensure that people, visitors and the workforce (both paid and unpaid) are protected from harm when handling waste or hazardous substances.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.5.3 (HDSS.2021:5.5.3)

Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include:
(a) Methods, frequency, and materials used for cleaning processes;
(b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team;
(c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemicals. This shall be reflected in a written policy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.5.4 (HDSS.2021:5.5.4)

Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include:
(a) Methods, frequency, and materials used for laundry processes;
(b) Laundry processes being monitored for effectiveness;
(c) A clear separation between handling and storage of clean and dirty laundry;
(d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a written policy.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 5.5.5 (HDSS.2021:5.5.5)

Service providers shall ensure that the IP role has – or IP personnel have – oversight of the facility testing and monitoring programme for the built environment.

Attainment and Risk: Not Audited

Evidence:

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Section 6: Restraint and seclusion

Services shall aim for a restraint and seclusion free environment, in which people’s dignity and mana are maintained.

Subsection 6.1: A process of restraint (HDSS.2021:6.1)

The people: I trust the service provider is committed to improving policies, systems, and processes to ensure I am free from restrictions.
Te Tiriti: Service providers work in partnership with Māori to ensure services are mana enhancing and use least restrictive practices.
As service providers: We demonstrate the rationale for the use of restraint in the context of aiming for elimination.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.1.1 (HDSS.2021:6.1.1)

Governance bodies shall demonstrate commitment toward eliminating restraint.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.1.2 (HDSS.2021:6.1.2)

Service providers shall demonstrate a commitment to ensuring the voice of people with lived experience, Māori and whānau, is evident on the restraint oversight groups.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.1.3 (HDSS.2021:6.1.3)

There shall be an executive leader who is responsible for ensuring the commitment to restraint minimisation and elimination is implemented and maintained.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.1.4 (HDSS.2021:6.1.4)

Executive leaders shall report restraint used at defined intervals and aggregated restraint data, including the type and frequency of restraint, to governance bodies. Data analysis shall support the implementation of an agreed strategy to ensure the health and safety of people and health care and support workers.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.1.5 (HDSS.2021:6.1.5)

Service providers shall implement policies and procedures underpinned by best practice that shall include:
(a) The process of holistic assessment of the person’s care or support plan. The policy or procedure shall inform the delivery of services to avoid the use of restraint;
(b) The process of approval and review of de-escalation methods, the types of restraint used, and the duration of restraint used by the service provider;
(c) Restraint elimination and use of alternative interventions shall be incorporated into relevant policies, including those on procurement processes, clinical trials, and use of equipment.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.1.6 (HDSS.2021:6.1.6)

Health care and support workers shall be trained in least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and de-escalation techniques within a culture of continuous learning.

Attainment and Risk: Not Audited

Evidence:

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Subsection 6.2: Safe restraint (HDSS.2021:6.2)

The people: I have options that enable my freedom and ensure my care and support adapts when my needs change, and I trust that the least restrictive options are used first.
Te Tiriti: Service providers work in partnership with Māori to ensure that any form of restraint is always the last resort.
As service providers: We consider least restrictive practices, implement de-escalation techniques and alternative interventions, and only use approved restraint as the last resort.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.2.1 (HDSS.2021:6.2.1)

The decision to approve restraint for a person receiving services shall be made:
(a) As a last resort, after all other interventions or de-escalation strategies have been tried or implemented;
(b) After adequate time has been given for cultural assessment;
(c) Following assessment, planning, and preparation, which includes available resources able to be put in place;
(d) By the most appropriate health professional;
(e) When the environment is appropriate and safe.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.2.2 (HDSS.2021:6.2.2)

The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.2.3 (HDSS.2021:6.2.3)

Monitoring restraint shall include people’s cultural, physical, psychological, and psychosocial needs, and shall address wairuatanga.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.2.4 (HDSS.2021:6.2.4)

Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include:
(a) The type of restraint used;
(b) Details of the reasons for initiating the restraint;
(c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint;
(d) If required, details of any advocacy and support offered, provided, or facilitated; NOTE – An advocate may be: whānau, friend, Māori services, Pacific services, interpreter, personal or family advisor, or independent advocate.
(e) The outcome of the restraint;
(f) Any impact, injury, and trauma on the person as a result of the use of restraint;
(g) Observations and monitoring of the person during the restraint;
(h) Comments resulting from the evaluation of the restraint;
(i) If relevant to the service: a record of the person-centred debrief, including a debrief
by someone with lived experience (if appropriate and agreed to by the person). This shall document any support offered after the restraint, particularly where trauma has occurred (for example, psychological or cultural trauma).

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.2.5 (HDSS.2021:6.2.5)

A person-centred debrief shall follow every episode of emergency restraint. Participation in this debrief shall be determined by the person when they feel ready.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.2.6 (HDSS.2021:6.2.6)

Service providers shall consider who is the most appropriate member of the workforce to debrief the person.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.2.7 (HDSS.2021:6.2.7)

Each episode of restraint shall be evaluated, and service providers shall consider:
(a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used;
(b) The type of restraint used;
(c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed;
(d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting from the person-centred and whānaucentred approach/reflections debrief;
(e) The impact the restraint had on others (for example, health care and support workers, whānau, and other people);
(f) The duration of the restraint episode and whether this was the least amount of time required;
(g) Evidence that other de-escalation options were explored;
(h) Whether appropriate advocacy or support was provided or facilitated;
(i) Whether the observations and monitoring were adequate and maintained the safety of the person;
(j) Future options to avoid the use of restraint;
(k) Suggested changes or additions to de-escalation education for health care and support workers;
(l) The outcomes of the person-centred debrief;
(m) Review or modification required to the person’s care or support plan in collaboration with the person and whānau;
(n) A review of health care and support workers’ requirements (for example, whether there was adequate senior staffing, whether there were patterns in staffing that indicated a specific health care and support workers issue, and whether health care and support workers were culturally competent).

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.2.8 (HDSS.2021:6.2.8)

Health care and support workers shall have the opportunity to be involved in a timely debrief following seclusion or restraint events.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Subsection 6.3: Quality review of restraint (HDSS.2021:6.3)

The people: I feel safe to share my experiences of restraint so I can influence least restrictive practice.
Te Tiriti: Monitoring and quality review focus on a commitment to reducing inequities in the rate of restrictive practices experienced by Māori and implementing solutions.
As service providers: We maintain or are working towards a restraint-free environment by collecting, monitoring, and reviewing data and implementing improvement activities.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.3.1 (HDSS.2021:6.3.1)

Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including:
(a) That a human rights-based approach underpins the review process;
(b) The extent of restraint, the types of restraint being used, and any trends;
(c) Mitigating and managing the risk to people and health care and support workers;
(d) Progress towards eliminating restraint and development of alternatives to using restraint;
(e) Adverse outcomes;
(f) Compliance with policies and procedures, and whether changes are required;
(g) Whether the approved restraint is necessary; safe; of an appropriate duration; and in accordance with the person’s and health care and support workers’ feedback and current evidenced-based best practice;
(h) If the person’s care or support plans identified alternative techniques to restraint;
(i) The person and whānau, perspectives are documented as part of the comprehensive review;
(j) Consideration of the role of whānau at the onset and evaluation of restraint;
(k) Data collection and analysis (including identifying changes to care or support plans and documenting and analysing learnings from each event);
(l) Service provider initiatives and approaches support a restraint-free environment;
(m) The outcome of the review is reported to the governance body.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Subsection 6.4: Seclusion (HDSS.2021:6.4)

The people: I trust that service providers do all that they can to enable health care and support workers to explore all other options so that I am not secluded.
Te Tiriti: Service providers take a person- and whānau-centred approach, to ensure there is no seclusion.
As service providers: We no longer consider seclusion a therapeutic intervention, and it only occurs when our environment is not conducive to the elimination of seclusion.

Attainment and Risk: Not Audited

Evidence:

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Criterion 6.4.1 (HDSS.2021:6.4.1)

Service providers shall work towards being seclusion free.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.4.2 (HDSS.2021:6.4.2)

Seclusion data shall be provided to governing bodies on a monthly basis, and strategies to support the elimination of seclusion shall be agreed and implemented.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.4.3 (HDSS.2021:6.4.3)

Service providers have policies and procedures that are based on national guidelines and aligned to the current legislation.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.4.4 (HDSS.2021:6.4.4)

Seclusion shall only take place in a designated and approved room.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.4.5 (HDSS.2021:6.4.5)

A person- and whānau-centred debrief shall follow every seclusion event, according to best practice. A person- and whānau-centred approach involves reflections of the event (including opportunities to input strategies to prevent seclusion being used again). Service providers shall apply what they have learnt from events and make changes to current safety care or support plans to add what is required to avoid seclusion.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.4.6 (HDSS.2021:6.4.6)

Each seclusion event shall be evaluated as soon as reasonably possible after the event. The evaluation is undertaken by registered health professionals from at least two different disciplines and a Māori or Pacific cultural advisor and lived experience advisor, where available, and shall consider:
(a) Whether the person’s care or support plan and advance directives and preferences, where in place, were followed;
(b) The impact the seclusion had on the person, other people using the service, and health care and support workers;
(c) The duration of the seclusion event and whether this was the least amount of time required;
(d) What alternative interventions were considered, why any were not used, and therefore why seclusion was the option of last resort;
(e) Whether appropriate advocacy or support was sought, provided, or facilitated;
(f) Whether the observations and monitoring were adequate and maintained the safety of the person;
(g) Future options to eliminate seclusion;
(h) Any suggested changes or additions to seclusion education for health care and support workers;
(i) The outcomes of the person- and whānau-centred debrief;
(j) Review or modification required to the person’s care or support plan in collaboration with the person.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.4.7 (HDSS.2021:6.4.7)

Service providers shall conduct comprehensive reviews at least six-monthly of all seclusion events, to determine how the service is working towards or maintaining zero seclusion, to determine:
(a) That a human rights-based approach underpins the review process;
(b) The number of people secluded, the number of episodes of seclusion, their duration, demographics, and any trends;
(c) Mitigating and managing the risk to the person, other people in the environment, and health care and support workers;
(d) Progress towards eliminating seclusion, and development of the many alternatives to using seclusion;
(e) Adverse outcomes;
(f) Compliance with policies and procedures, and whether changes are required;
(g) Whether there are additional education or training needs, or changes required to existing seclusion-elimination education;
(h) Service provider initiatives, and approaches that support and will achieve zero seclusion. The outcome of the review shall be reported to the governance body.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Criterion 6.4.8 (HDSS.2021:6.4.8)

Health care and support workers have the opportunity to be involved in a wider debrief or discussion following significant incidents supporting wellbeing to maximise learning from the evaluation of the seclusion event and to ensure safety for all in an environment of zero seclusion.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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Criterion 6.4.9 (HDSS.2021:6.4.9)

Night safety orders shall be recognised as a restrictive practice.

Attainment and Risk: Not Audited

Evidence:

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Finding:

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Corrective Action:

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