Aria Park Senior Living Limited

Introduction

This report records the results of a Certification 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 The DAA Group 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:Aria Park Senior Living Limited

Premises audited:Aria Park Retirement Village

Services audited:Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit:Start date: 15 April 2014End date: 16 April 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: 75

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

Aria Park Retirement Village provides rest home and hospital care for up to 130 with 86 beds certified as rest home level (including 10 dual purpose beds, RH & Hospital and 46 Serviced apartments). Aria Park is owned by Aria Park Senior Living Ltd, which is privately owned. There were seventy five residents in the rest home and hospital facility on the day of the audit. This certification audit was conducted against the Health and Disability Services Standards and the provider’s contract with the district health board.

The management team includes the owner/managing director, the facility manager, and two clinical managers who together are responsible for the overall management of the facility. They are supported by a senior manager from another care facility owned by the owners. Service provision is monitored. Staffing levels are appropriate for the services provided, are reviewed daily and take into consideration the needs of the residents. The service has an implemented quality and risk management system that is reviewed and refined to improve service delivery and minimise risk.

There are no areas requiring improvement.

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 demonstrated good knowledge and practice of respecting residents’ rights in their day to day interactions. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Families interviewed expressed satisfaction with staff who work in a caring and respectful manner.

There is one resident who identifies as Maori residing at the service at the time of audit. The service providers report there are no known barriers to Maori residents accessing the service. Services are planned to respect the individual culture, values and beliefs of the residents.

Written consents are obtained from the residents' family/whanau, enduring power of attorney (EPOA) or appointed guardians. Signed consent forms were sighted in all residents' files reviewed.

The organisation provides services that reflect current accepted good practice. This is evidenced in the guidelines for service delivery. The care staff have completed, or are enrolled in, national unit standards for the care of the elderly. There is regular in-service education and staff access external education that is focused on aged care and best practice.

Links with family and the community are encouraged and maintained.

There is a documented complaints management process for residents, family/whanau to provide feedback easily. Appropriate forms are available and accessible. Residents interviewed stated they are aware of how to make a complaint if necessary. Complaints are well managed by the facility manager with investigations and actions being completed professionally. Complaints are used to improve service delivery. The complaints register is current and up-to-date.

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. / Standards applicable to this service fully attained.

Aria Park Retirement Village has a documented quality and risk management system that supports the provision of clinical care and support for residents. The scope, vision, direction and objectives of the service are documented in the Aria Park Village Quality Improvement Risk and Management Action Plan which is implemented. The adverse event reporting system is a planned and coordinated process. The operations manager is responsible for the documentation control system for the organisation. The chief executive officer signs off any changes and/or new policies.

There are human resources policies implemented around recruitment, selection, orientation and staff training and development.

Staffing levels and skill mix of staff meet the changing needs of residents and is based on an appropriate staffing rationale.

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. / Standards applicable to this service fully attained.

Preadmission information clearly and accurately identifies the services offered. The service has policies and processes related to entry into the service.

Services are provided by suitably qualified and trained staff to meet the needs of residents. Residents have an initial nursing assessment and care plan developed by the registered nurse (RN) on admission to the service. The service meets the contractual times frames for the development of the long term care plan. When there are changes in the resident’s needs, a short term care plan is implemented to reflect these changes. The care plan evaluations are conducted at least six monthly on all aspects of the care plan. All residents are part on the interRAI assessment programme.

Residents are reviewed by a GP on admission to the service and at least three monthly, or more frequently to respond to any changing needs. The provision of services is provided to meet the individual needs of the residents. A team approach to care is provided ensuring continuity of services. Referrals to other health and disability services is planned and coordinated, based on the individual needs of the resident. The families interviewed report that interventions are consistently implemented as planned.

The service has a planned activities programme to meet the recreational needs of the residents. Residents are encouraged to maintain contacts with family and the community.

A safe medicine administration system was observed at the time of audit. Staff responsible for medicine management are assessed as competent to do so.

Residents' nutritional requirements are met by the service with likes, dislikes and special diets catered for and food available 24 hours a day. The service has a four week, summer/winter rotating menu which is approved by a 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. / Standards applicable to this service fully attained.

All building and plant complies with legislation. The building warrant of fitness was displayed.

Documented processes for the management of waste and hazardous substances are in place. Staff receive training to ensure safety is not compromised. Compliance with appropriate legislative requirements are met.

Hazard reporting systems and a hazard register are available for all areas of service delivery in the rest home and hospital care settings. The health and safety programme is closely linked with the infection control and the organisation’s risk management system.

The environment is appropriate for the needs of residents with suitable rooms, fixtures, fittings, floor and wall surfaces. Residents’ rooms are of an appropriate size to allow for care to be provided safely.

Essential emergency and security systems are in place with regular fire drills completed. A new call system allows residents to access help when needed.

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 minimal recorded restraint or enablers in use. Enabler use is voluntary and the least restrictive option. The related policies and procedures comply with the Standards. Safety is promoted at all times.

Staff education covers all required aspects of restraint and enabler use along with alternatives to restraint and behavioural management. Staff were familiar with and understood restraint and enabler use processes as defined in policy.

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.

The service has an appropriate infection prevention and control management system implemented to reduce the risk of infections to staff, residents and visitors. The service’s infection prevention and control policies and procedures reflect current accepted good practice. Relevant education is provided for staff, and when appropriate, the residents. There is a monthly surveillance programme, where infections information is collated, analysed and trended with previous data. Where issues are identified actions are implemented to reduce infections. The infection surveillance results are reported at the staff meetings. An external contractor benchmarks all data with other facilities in the Aria Park Senior Living Limited group.

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 / 50 / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 101 / 0 / 0 / 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 1.1.1: Consumer Rights During Service Delivery
Consumers receive services in accordance with consumer rights legislation. / FA / The rights policy contains a list of consumer rights that are congruent with the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). The service policy states the Code is displayed and available to all residents and monitored to ensure the rights of residents are respected. The policy meets the intent of this standard. New residents and family are given a copy of the Code on admission and a copy is displayed on the wall in full view for residents, caregivers and visitors. On commencement of employment all staff receive induction training regarding residents' rights and their implementation.
The clinical staff interviewed demonstrated knowledge on the Code and its implementation in their day to day practice. At the time of audit staff were observed to be respecting the residents’ rights in a calm manner that de-escalates and redirects those residents with cognitive impairment.
Family and residents reported on interview that they understand the Code of Rights and are treated with respect and dignity.
Standard 1.1.10: Informed Consent
Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. / FA / A detailed informed consent policy is in place. The service ensures informed consent is part of all care plans and contact with families. Every resident has the choice to receive services, refuse services and withdraw consent for services. If a resident is cognitively aware they will decide on their own care and treatments unless they indicate that they want representation. Informed consent is closely linked with the Residents’ Code of Rights and Responsibilities.
The residents' files reviewed had consent forms signed by the resident, family and enduring power of attorney (EPOA). The caregivers interviewed demonstrated their ability to provide information that residents require in order for the residents to be actively involved in their care and decision-making. Staff interviewed acknowledge the resident's right to make choices based on information presented to them. Staff also acknowledged the resident's right to withdraw consent and/or refuse treatment, with the staff demonstrating good knowledge on management of the resident’s needs.
Residents are giving the opportunity to discuss advanced directives with the GP and complete the documentation if they choose.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / The advocacy policy documents that all residents receiving care within the organisation's facilities will have appropriate access to independent advice and support, including access to a cultural and spiritual advocate whenever required.
The families/whanau interviewed reported that they were provided with information regarding access to advocacy services. Family/whānau are encouraged to involve themselves as advocates when required, as evidenced in interviews with families. Contact details for the Nationwide Health and Disability Advocacy Service is listed in the resident information booklet and with the brochure available at the entrances to the service. Related education for staff was last conducted as part of the in-service education programme.