Avonlea Trust Board - Avonlea Hospital and Home

Avonlea Trust Board - Avonlea Hospital and Home

Introduction

This report records the results of aCertification Audit ofa 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 byHealth 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:Avonlea Trust Board

Premises audited:Avonlea Hospital and Home

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

Dates of audit:Start date: 23 November 2016End date: 24 November 2016

Proposed changes to current services (if any):Since the last audit the service has reconfigured the use of some rooms. The number of dual purpose beds (rest home or hospital level of care) has been increased from eight to 17, which has reduced the rest home only level of care rooms from 34 to 25. The change was assessed by the MoH as low risk and a partial provisional audit was not required.

Total beds occupied across all premises included in the audit on the first day of the audit:44

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

Avonlea Trust Board provides rest home and hospital level of care for up to 50 residents. There were 44 residents at the time of audit. Residents and families reported satisfaction and were positive about the care and services provided.

This audit was conducted against the relevant Health and Disability Services Standards and the service’s contract with the district health board (DHB). The audit process included an onsite audit and review of resident and staff records, observations and interviews. Interviews were conducted with residents, families, management, clinical and non-clinical staff and a general practitioner (GP).

There are three shortfalls identified related to the analysis of quality data, medication management and monitoring of food temperature. No other systemic issues or shortfalls were identified.

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.

Resident’s rights are protected. Staff demonstrated knowledge and understanding of the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code). Residents and families are informed of their rights. There are copies of the Code of Rights posters and information relating to the Nationwide Health and Disability Advocacy Service accessible throughout the service.

Residents receive clinical services that have regard for their dignity, privacy and independence. The residents' ethnic, cultural and spiritual values are assessed to ensure they receive services that respect their individual values and beliefs, including for those residents who identify as Maori. There are processes to access interpreting and translating services as required.

Evidence-based practice is supported and encouraged to ensure residents receive services of an appropriate standard. Residents have access to visitors of their choice and are supported to access community services.

Evidence was seen of informed consent and open disclosure in residents' files sampled. There were advance care plans and advance directives that record the residents wishes, with these respected by staff.

There is a documented complaints process that complies with the Code. There were no outstanding complaints.

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.

A business plan and quality and risk management plan is documented and includes the mission and goals of the service. There is a process in place for the regular reporting against these goals.

The organisation is managed by an experienced and suitably qualified facility manager, who is a registered nurse. The organisation is governed by a board of trustees. The service is also part of a wider community trust board along with other smaller rural providers across the Waikato.

Quality management data is collected and discussed at staff meetings and staff were able to describe this. There is an internal audit programme. Corrective action plans are in place where necessary. Adverse events are documented and there is evidence of improvements implemented based on the findings. Open disclosure is documented as part of adverse event reporting and service delivery.

There are policies on human resource management. Practising certificates are current for all staff that required them. Staff records have the required information, including staff education records. Staff report access to in-service and external training. An orientation programme is in place and completed.

There is a documented rationale for determining staffing levels and skill mix in order to provide safe service delivery. Care staff reported there are adequate staff available.

Residents’ information is complete and maintained in a secure manner.

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 medium or high risk and/or unattained and of low risk.

Residents receive appropriate services that meet their desired goals/outcomes. Residents are admitted with the use of standardised risk assessment tools. Long and short term care plans are developed and evaluated in a timely manner. Short term care plans are developed when acute conditions are identified and resident’s response to treatment is documented.

Planned activities are appropriate to the needs, age and culture of the residents who reported that the activities are enjoyable and meaningful to them.

A medicine management system is implemented. Staff have the required medication competencies. Medications are monitored and reviewed as required.

The individual foods, fluids and nutritional needs of the residents are met. Resident files evidenced that stable weights and interventions are in place when weight changes are identified.

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.

The building complies with legislation and has a current building warrant of fitness. A preventative maintenance programme includes equipment calibration and electrical checks. The environment is appropriate to the needs of the residents.

Each resident’s room has natural light, heating and ventilation. There are sufficient numbers of showers in each of the wings. Residents` rooms allow for care to be easily provided and for the safe use and manoeuvring of mobility aids.

Essential emergency and security systems are in place with regular fire drills completed. A call bell system allows residents to access help when needed and residents stated that they are responded to in a timely manner.

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.

Policies and procedures identify the safe use of restraints and enablers. Enablers are utilised as the least restrictive option that allows residents to maintain independence, comfort and safety. There are 17 residents using restraints and one resident is using an enabler. Risk management plans are in place to prevent restraint-related injuries. Staff training on restraints and enablers is conducted annually. Interviewed staff demonstrated adequate knowledge on restraints and enablers. The restraint register is current.

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.

Infection prevention and control policies and procedures include a comprehensive infection control programme. The infection control programme is reviewed annually. The type of surveillance is appropriate to the size and complexity of the service. Action plans are developed to reduce the infection rates in the service. All staff receive education regarding infection prevention and control.

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 / 47 / 0 / 2 / 1 / 0 / 0
Criteria / 0 / 97 / 0 / 2 / 1 / 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 assessedat 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 / Staff demonstrated their knowledge of the Code of Health and Disability Services Consumers' Rights (the Code). The Code is part of the staff orientation and ongoing education programme. Staff observed on the days of the audit demonstrated knowledge of the Code when interacting with residents. All residents and families reported that they have high praise for the manner in which the staff interact with them and no concerns requiring breaches of rights were expressed.
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 / Evidence was seen of the consent process for the collection and storage of health information, outings and indemnity, use of photographs for identification, sharing of information with an identified next of kin, and for general care and treatment. The resident’s right to withdraw consent and change their mind is noted. Information is provided on enduring power of attorney (EPOA) and ensuring, where applicable, this is activated.
There are guidelines in the policy for advance directives which meet legislative requirements. The consent can be reviewed and altered as the resident wishes. An advance directive and advance care plan are used to enable residents to choose and make decisions related to end of life care. The files sampled have signed advance directive forms for resuscitation and antimicrobial usage at end of life.
Residents and family/whanau (where appropriate) are included in care decisions.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Advocacy information is available in brochure format at the entrance to the facility. Residents and families are aware of their right to have support persons. Education from the Nationwide Health and Disability Advocacy Service is undertaken annually as part of the in-service education programme. The residents and family are invited to the resident’s meetings. Staff demonstrated knowledge of residents’ rights and advocacy services.
Standard 1.1.12: Links With Family/Whānau And Other Community Resources
Consumers are able to maintain links with their family/whānau and their community. / FA / Residents have access to visitors of their choice. There are no restrictions to visiting hours. A number resident’s access community support independently, with family or as part of the activities programme. Family members interviewed reported that they are encouraged and welcomed to visit the service at the times of their choice.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / Complaints information is provided to residents and families as part of the admission process with at least annual updates for residents/families with visits from the advocate. There are complaints forms available throughout the service. The residents and families reported that they feel free to make a complaint if they need to. The residents and families report that issues are addressed almost immediately if they have any concerns.
The complaints register contains the complaints, dates and actions taken. There are no outstanding complaints. The complaints sampled reflected timeframes within right 10 of the Code.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / Residents and families are provided with information on the Code on entry to the service. Opportunities for discussion and clarification relating to the Code are provided to residents and their families either individually or as part of the resident’s meetings. There is a local visit by the Nationwide Health and Disability Advocacy Service at least once a year. The advocate is available to provide the residents, families and the service advice and support as required.
All residents and families reported no concerns requiring breaches of rights were expressed.
Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect
Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. / FA / All rooms are single occupancy to maintain the residents’ personal visual and auditory privacy. If personal discussions and GP examinations are required, these are conducted in the residents own room. Residents who have greater mobility access the GP in the community. Doors were observed to be closed during the delivery of personal care.