Oceania Care Company Limited - Maureen Plowman Rest Home

Oceania Care Company Limited - Maureen Plowman Rest Home

Introduction

This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted by Health Audit (NZ) Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity:Oceania Care Company Limited

Premises audited:Maureen Plowman Home

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 19 November 2014End date: 19 November 2014

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:50

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

• consumer rights
• organisational management
• continuum of service delivery (the provision of services)
• safe and appropriate environment
• restraint minimisation and safe practice
• infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator / Description / Definition
Includes commendable elements above the required levels of performance / All standards applicable to this service fully attained with some standards exceeded
No short falls / Standards applicable to this service fully attained
Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity / Some standards applicable to this service partially attained and of low risk
A number of shortfalls that require specific action to address / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk
Major shortfalls, significant action is needed to achieve the required levels of performance / Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Maureen Plowman is part of the Oceania Group. This surveillance audit has been undertaken to establish compliance with the Health and Disability Services Standards and the District Health Board Contract. Maureen Plowman provides residential dementia and rest home level care for up to 55 residents with 50 residents occupying the service during the audit.

A business and care manager had been in the role for three weeks with a clinical manager who provides clinical oversight. Staffing was appropriate to support the needs of residents requiring dementia and rest home care. There was a quality and risk management programme in place.

Seven of eight improvements required at the last certification audit around open disclosure, document control processes, policy review, the quality and risk programme and most of the requirements related to care planning and medication processes have been addressed. One improvement continues to be required around documentation of interventions in care plans.

Improvements are required to staff training and separation of dirty and clean laundry.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. / Standards applicable to this service fully attained.

Staff were able to demonstrate an understanding of residents' rights and obligations. This knowledge was incorporated into their daily work duties and caring for the residents. Information regarding resident rights, access to advocacy services and how to lodge a complaint was available to residents and their family and complaints were investigated. Staff communicated with residents and family members following any incident.

The improvement required at the certification audit around open disclosure has been addressed.

Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. / Some standards applicable to this service partially attained and of low risk.

Maureen Plowman has implemented the Oceania quality and risk management system that supports the provision of clinical care and support. Policies were reviewed and business status reports allowed monitoring of service delivery. Benchmarking reports were produced that included clinical indicators, incidents/accidents, infections and complaints.

Staffing levels were adequate in the rest home and the dementia unit and rest home and interviews with residents and relatives demonstrated that they had adequate access to staff to support residents when needed. A new management team was on site that included the business and care manager and clinical manager. Both have extensive experience in leadership in aged care services.

The improvement required at the certification audit around document control and review of policies and quality data has been addressed.

Improvements are required to training for staff as per the training schedule.

Continuum of service delivery

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. / Some standards applicable to this service partially attained and of low risk.

Residents have an initial nursing assessment and care plan developed by the registered nurse on admission to the service. The person centred care plan was developed within the required timeframe. When there are changes in the resident`s needs, a short term care plan is implemented to reflect these changes.

An improvement from the previous audit in relation to assessment has been effectively closed out. There is an improvement required in relation to the interventions documented requiring more input from the multidisciplinary review evaluations.

Residents are reviewed by a general practitioner on admission to the service and at least three monthly. The provision of services is provided to meet the individual needs of the residents. Continuity of care is promoted. The families interviewed report consistency in delivery of care.

The service has a planned activities programme to meet the recreational needs of the residents with a focus on residents with impaired cognitive function. Residents are encouraged to maintain links with family and the community.

A safe medicine management administration system was observed at the time of audit. The service has documented evidence that staff responsible for medicine management are assessed as competent. Improvements from the previous audit have been closed out in relation to medicine management.

Residents` nutritional requirements are met by the service. Special diets are catered for and food is available twenty four hours a day. The four week summer/winter menu plans have been approved by the organisation`s registered dietitian.

Safe and appropriate environment

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. / Some standards applicable to this service partially attained and of low risk.

There is a current building warrant of fitness in place. There was a planned and reactive maintenance programme in place with issues addressed as these arise. Residents and family described the environment as meeting their needs.

Improvements are required to separation of the clean and dirty areas in the laundry.

Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. / Standards applicable to this service fully attained.

The service has clearly described restraint minimisation and safe practice policies and procedures which comply with the standard. There are currently four residents using enablers. Staff have received training in de-escalation techniques for managing challenging behaviour and education about the service policy, regulations and safe and effective alternatives to restraint. Staff interviewed understand that the use of enablers is a voluntary process along with approval and informed consent processes. Safety was promoted at all times.

Infection prevention and control

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. / Standards applicable to this service fully attained.

There is a monthly surveillance programme, where infections are recorded, analysed and where trends are identified these are actioned. The infection surveillance results are benchmarked and results are fed back to staff at the staff meetings and displayed in the nurse station.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating / Continuous Improvement
(CI) / Fully Attained
(FA) / Partially Attained Negligible Risk
(PA Negligible) / Partially Attained Low Risk
(PA Low) / Partially Attained Moderate Risk
(PA Moderate) / Partially Attained High Risk
(PA High) / Partially Attained Critical Risk
(PA Critical)
Standards / 0 / 16 / 0 / 3 / 0 / 0 / 0
Criteria / 0 / 42 / 0 / 3 / 0 / 0 / 0
Attainment Rating / Unattained Negligible Risk
(UA Negligible) / Unattained Low Risk
(UA Low) / Unattained Moderate Risk
(UA Moderate) / Unattained High Risk
(UA High) / Unattained Critical Risk
(UA Critical)
Standards / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 0 / 0 / 0 / 0

Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome / Attainment Rating / Audit Evidence
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The organisation’s complaints policy and procedures is in line with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) and includes time-frames for responding to a complaint. Complaint’s forms are available in the dementia unit and rest home. There is also a ‘mail’ box and anyone can put a note in the box with follow up according to the complaints policy.
A complaints register is in place and the register includes the date the complaint was received; the source of the complaint; a description of the complaint; and the date the complaint was resolved. Evidence relating to each lodged complaint is held in the complaint’s folder. All complaints are included in the indicator /quality monitoring processes with results reviewed by head office staff.
Two complaints lodged in 2014 were selected for review. There is documented evidence of time-frames being met for responding to these complaints with documentation indicating that the complainants are happy with the outcome. The complaints are also part of the reporting process through review of indicators with benchmarking occurring.
Residents and family state that they would feel comfortable complaining.
The Oceania clinical and quality manager confirmed that there have not been any complaints with the Health and Disability Commission (HDC), Ministry of Health or District Health Board since the last audit.
The District Health Board contract requirements are met.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / Accident/incidents, the complaints procedure and the open disclosure procedure alert staff to their responsibility to notify family/enduring power of attorney of any accident/incident that occurs. These procedures guide staff on the process to ensure full and frank open disclosure is available.
Family are informed if the resident has an incident, accident, has a change in health or a change in needs, evidenced in 10 of 10 completed accident/incident forms and in the resident files.
Interviews with eight family members (three from the dementia unit and five rest home) confirm they are kept informed. Family also confirm that they are invited at least six monthly to the care planning meetings for their family member with this confirmed on the multi-disciplinary form.
Family interviewed confirm that they are invited to attend the resident meetings which are held at least two monthly. There have been two resident/family meetings since the new business and care manager has been in the service and these have been well attended.
Interpreter services are available when required from the District Health Board. There are no residents currently requiring interpreting services and all residents interviewed confirm that staff are approachable and communicate well. The information pack is available in large print and advised that this can be read to residents.
Staff have had training around communication in 2014 with a number of sessions offered during the year to accommodate staff.
Family contact is recorded in residents’ files – sighted in five of five resident files reviewed (three rest home and two dementia). The improvement required at the certification audit has been addressed.
The District Health Board contract requirements are met.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Maureen Plowman is part of the Oceania group with the executive management team including the chief executive officer, general manager, operations manager, regional operational managers and clinical and quality managers providing support to the service.
Communication between the clinical and quality manager and the business and care manager takes place on a monthly basis with more support provided as required (confirmed by the clinical and quality manager and business and care manager interviewed).
Oceania has a clear mission, values and goals. The vision is to be the provider of choice for senior New Zealanders of care and lifestyle options in a way that meets and exceeds the expectations of our residents, staff and stakeholders. The mission is ‘we provide excellent contemporary care that reflects our residents’ individuality and their right to choice, respect and dignity. We provide a positive and welcoming environment in which our residents are encouraged and supported to improve their quality of life’.
The facility can provide care for up to 55 residents with 15 residents in the dementia unit (a 17 bed unit) and 34 residents in the rest home (38 total beds available).
The business and care manager is responsible for the overall management of the facility. The business and care manager is an enrolled nurse, has 16 years’ experience in aged care including management roles and has been in the role for six weeks. The business and care manager is supported by a clinical manager who has two years prior experience as a clinical manager in another facility.
The District Health Board contract requirements are met.
Standard 1.2.3: Quality And Risk Management Systems
The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. / FA / Maureen Plowman uses the Oceania quality and risk management framework that is documented to guide practice. The business plan is documented and reported on through the business status reports. This includes financial monitoring, review of staff costs, progress against the healthy workplace action plan, review of complaints, incidents, relationships and market presence action plan and review of physical products.