Athenree Lifecare Limited

Current Status: 23 October 2014

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Provisional Auditconducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified.

General overview

Athenree Rest Home and Hospital provides residential care for up to 43 residents and occupancy on the first day of the audit was 40. The service provider is certified to provide geriatric hospital level care, rest home level care and dementia level care. The facility is currently operated by Athenree Rest Home and Hospital Limited. This provisional audit was undertaken to establish the extent to which the existing provider conformed to the requirements of the Health and Disability Services Standards and the District Health Board (DHB) funding contract prior to a change in ownership. This audit also established how well prepared the prospective provider was to providing a health and disability service. A representative for the prospective provider, Athenree Lifecare Limited, was interviewed during this audit. Residents and family members interviewed report they were satisfied with the care provided.

There were 20 areas identified during this audit that required improvement. The required improvements related to: management of continence; management of consent processes; appointment of a clinical manager; maintenance of the quality and risk management system; human resources management; activities provided in the dementia unit; medicine management; management of resident documentation including assessment details; availability of protective clothing; management of the environment including the external area in the dementia unit, storage of equipment and the designation of dual purpose rooms.

HealthCERT Aged Residential Care Audit Report

HealthCERT Aged Residential Care Audit Report (version 3.92)

Introduction

This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care 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 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

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: / Athenree Lifecare Limited
Certificate name: / Athenree Rest Home and Hospital
Designated Auditing Agency: / Health Audit NZ Ltd
Types of audit: / Provisional Audit Provisional Audit
Premises audited: / 7-11 Marina Way, Athenree, Waihi Beach
Services audited: / Hospital services – geriatric (excl psychogeriatric), Rest home care, Rest home care (dementia).
Dates of audit: / Start date: / 23 October 2014 / End date: / 24 October 2014

Proposed changes to current services (if any):

Total beds occupied across all premises included in the audit on the first day of the audit: / 40

Audit Team

Lead Auditor / XXXXXXXXX / Hours on site / 12 / Hours off site / 12
Other Auditors / XXXXXXXXX / Total hours on site / 12 / Total hours off site / 4
Technical Experts / Total hours on site / Total hours off site
Consumer Auditors / Total hours on site / Total hours off site
Peer Reviewer / XXXXXXXXX / Hours / 4

Sample Totals

Total audit hours on site / 24 / Total audit hours off site / 20 / Total audit hours / 44
Number of residents interviewed / 4 / Number of staff interviewed / 10 / Number of managers interviewed / 3
Number of residents’ records reviewed / 7 / Number of staff records reviewed / 7 / Total number of managers (headcount) / 3
Number of medication records reviewed / 14 / Total number of staff (headcount) / 40 / Number of relatives interviewed / 4
Number of residents’ records reviewed using tracer methodology / 3 / Number of GPs interviewed / 1

Declaration

I, XXXXXXXXX,Managing Director of Auckland 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 / Yes
b) / the DAA has in place effective arrangements to avoid or manage any conflicts of interest that may arise / Yes
c) / the DAA has developed the audit summary in this audit report in consultation with the provider / Yes
d) / this audit report has been approved by the lead auditor named above / Yes
e) / the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook / Yes
f) / if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider / Not Applicable
g) / the DAAhas provided all the information that is relevant to the audit / Yes
h) / the DAAhas finished editing the document. / Yes

Dated Wednesday, 5 November 2014

Executive Summary of Audit

General Overview

Athenree Rest Home and Hospital provides residential care for up to 43 residents and occupancy on the first day of the audit was 40. The service provider is certified to provide geriatric hospital level care, rest home level care and dementia level care. The facility is currently operated by Athenree Rest Home and Hospital Limited. This provisional audit was undertaken to establish the extent to which the existing provider conformed to the requirements of the Health and Disability Services Standards and the District Health Board (DHB) funding contract prior to a change in ownership. This audit also established how well prepared the prospective provider was to provide a health and disability service. A representative for the prospective provider, Athenree Lifecare Limited, was interviewed during this audit. Residents and family members interviewed report they were satisfied with the care provided.

Outcome 1.1: Consumer Rights

The service provider ensured information regarding the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code), including the facility's complaints process and the Nationwide Health and Disability Advocacy Service, was accessible and was brought to the attention of residents’ and their families on admission to the facility. Residents and family members interviewed confirmed that their rights were met during service delivery; communication is appropriate; and they had a clear understanding of their rights and the facility’s processes if these are not met.

Improvements were required with the management of continence as one of the practices observed was not best practice.

During interview residents and family confirmed that consent forms were provided to them prior to admission to ensure they had time for consultation and that they were fully informed. They also confirmed that time was provided if discussions and explanation were required. An area requiring improvement relating to signing of consent forms has been identified during this audit.

The facility manager was responsible for the management of complaints and a complaints register was maintained. The residents can use the complaints forms, raise issues at the residents' meetings, or they can raise complaints directly with the facility manager, the registered nurses, or with any member of staff.

Outcome 1.2: Organisational Management

Athenree Rest Home and Hospital Limited was the current governing body and were responsible for the service provided at Athenree Rest Home and Hospital (Athenree). Planning documents reviewed included a mission statement, values, goals, the scope of services and philosophy.

The facility was managed by the current owner who worked full time on site and is a registered nurse with a scope of practice for mental health services. The facility manager was supported by a deputy manager who is an enrolled nurse. Improvements are required as the care manager left in August 2014 and had not been replaced.

Athenree Lifecare Limited was proposing to purchase the facility and assume responsibility for the provision of services from 11 December 2014. The compliance manager for the prospective purchaser was interviewed and has been involved in the aged care sector for the last 10 years in various roles. The general manager for the prospective purchaser had extensive experience in owning and managing aged care facilities. A quality and risk management plan for the prospective purchaser was reviewed as was an organisational structure.Harbourside Investment Limited Management Services (HILMS) will provide external support for clinical, policy, compliance and finance. An organisational structure for the prospective provider was reviewed and demonstrated linkages between the two companies.

There waslimited evidence available indicating that a quality and risk management programme had been maintained and improvements are required. Other areas have been identified as requiring improvement relating to the quality and risk management programme including, but were not limited to, integration of quality management in to all aspects of service delivery; analysis of quality improvement data to identify trends and reporting of this data; maintenance of the internal audit programme; and development of corrective action plans to address identified shortfalls. Adverse events were documented on accident/incident forms and in to a hard backed notebook.

There were policies and procedures on human resources management although improvements with human resource management are required. The improvements include: ensuring the validation of practising certificates for all service providers who require them to practice; and completion of criminal vetting for all new staff and recording of references. In-service education was provided for staff at least monthly and staff were supported to complete the New Zealand Qualifications Authority Unit Standards to obtain aged care qualifications including dementia specific education modules. A review of staff records provides evidenced that orientations were being completed and individual education records were maintained.

There was a documented rationale for determining staffing levels and skill mix in order to provide safe service delivery. The minimum number of staff was provided during the night shift and consists of one registered nurse and two caregivers. One of the care givers was based in the dementia unit. The facility manager was on call after hours. Care staff interviewed reported there was adequate staff available and that they were able to get through their work.

Resident information was entered into a register in an accurate and timely manner. Residents' files were integrated and documentation was legible with the name and designation of the person making the entry identifiable.

Outcome 1.3: Continuum of Service Delivery

The residents` records reviewed provided evidence that they had been assessed appropriately prior to admission, however, this was not always documented clearly on the admission record and the residents` records were not always filed appropriately for accessibility. These two areas identified are areas of required improvement. The provider had implemented systems to assess, plan and evaluate care needs of the residents. The residents` needs, outcomes and/or goals had been identified and these were reviewed on a regular basis with family input. A team approach to care delivery and continuity of service delivery was encouraged.

Activities were planned across the services provided. A variety of activities were provided to meet the skills, interests and to maintain independence with daily living. There were no activities planned for the dementia care residents over the twenty four hour period and this is an identified area of improvement.

Medication management was safely implemented. There was compliance with respective legislative requirements, regulations and guidelines. There is one area of required improvement in relation to evidencing pharmacy input in respect of reconciliation of medications and medication audits. There was clear evidence of three monthly medication reviews by the general practitioner and more often if required.

The foodservice was managed by experienced staff. The menus were displayed each day. The individual dietary needs, identified during the assessment process were addressed and choices provided. Special diets can be arranged and dietitian input was recorded. Meals are provided at appropriate times of the day.

Outcome 1.4: Safe and Appropriate Environment

Several areas of the physical environment looked tired and were identified as requiring refurbishment and maintenance. The furniture in the residents’ bedrooms and chairs in the lounge were damaged and need repair / replacement, the vinyl flooring was damaged in several areas and there was no documented maintenance programme. Improvements are also required with the storage of equipment as empty bedrooms, the billiard room lounge and hallways were being used to store equipment and items of clothing.

With one exception, all bedrooms provided single accommodation, had wash hand basins and were of varying sizes. All of the rest home and hospital bedrooms were being used as dual purpose rooms, however, only eight of these bedrooms had been designated for this purpose and improvements are required. There were an adequate number of toilet and shower facilities available throughout the facility. External areas were available for sitting and shading was provided in external areas, although improvements with the safety of the external area in the secure dementia unit are required. An appropriate call bell system was available and security systems were in place.

Visual inspection provided evidence of sluice facilities and safe storage of chemicals and equipment. Protective equipment and clothing was provided and was used by staff, however, improvements are required as disposable aprons were not provided in the sluice rooms and the laundry.

There were policies and procedures for waste management, cleaning and laundry, and emergency management and these were known by staff. All laundry was washed on site. Improvements are required as residents’ personal clothing, bedding and towels were not being separated prior to washing and appropriate monitoring systems were not in place to evaluate the effectiveness of the laundry services.

Outcome 2: Restraint Minimisation and Safe Practice

The approved restraints at the service were bed rails and lap belts. There were currently two residents assessed as requiring a restraint and six who required enablers as required for safety purposes. There was one environmental restraint at the front entrance to the facility that is monitored. The policies and procedures were implemented to ensure safe use of restraint and enablers. Restraint was actively minimised and used as a last resort only. Staff education was undertaken as part of new staff orientation and was ongoing. Acceptable restraint approval, assessment, evaluation, monitoring and review were provided.

Outcome 3: Infection Prevention and Control

The service had an infection prevention and control management system implemented which was appropriate for the size and nature of this aged residential care service. Surveillance was managed by the infection control officer and staff interviewed were fully informed and experienced about infection control. Two registered nurses had recently completed the six month course on infection prevention and control. Monthly surveillance occurred and results were feedback to staff at the staff monthly meetings.

Summary of Attainment

CI / FA / PA Negligible / PA Low / PA Moderate / PA High / PA Critical
Standards / 0 / 35 / 0 / 5 / 8 / 0 / 0
Criteria / 0 / 81 / 0 / 7 / 13 / 0 / 0
UA Negligible / UA Low / UA Moderate / UA High / UA Critical / Not Applicable / Pending / Not Audited
Standards / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2
Criteria / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0

Corrective Action Requests (CAR) Report

Code / Name / Description / Attainment / Finding / Corrective Action / Timeframe (Days)
HDS(C)S.2008 / Standard 1.1.8: Good Practice / Consumers receive services of an appropriate standard. / PA Moderate
HDS(C)S.2008 / Criterion 1.1.8.1 / The service provides an environment that encourages good practice, which should include evidence-based practice. / PA Moderate / The service provider is using clear plastic sheeting and draw sheets on some of the beds and is washing and drying the plastic with other laundry before reusing the plastic again on resident’s beds. / Provide confirmation that appropriate continence products are used to manage resident’s incontinence. / 30