Rotorua Continuing Care Trust

Current Status: 15 May 2014

The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted 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

Whare Aroha Home and Hospital is run by the Rotorua Continuing Care Trust. This certification audit was undertaken to establish compliance with the health and disability services standards and the district health board contract. Whare Aroha Home and Hospital provides rest home, hospital and specialised dementia care for up to 78 residents. Occupancy on the day of audit was 73. There have been no major changes to buildings, management, plant and equipment since the last audit.

Evidence gathered indicates the residents are treated with respect and dignity and have their rights upheld. An expected level of care and support was being provided with three low risk areas for improvement being identified. These related to general practitioner prescribing practice, provision of restraint/enabler training and ensuring care plans in the dementia suite are sufficient to manage behaviours over a 24 hour period.

Audit Summary as at 15 May 2014

Standards have been assessed and summarised below:

Key

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

Consumer Rights as at 15 May 2014

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.

Organisational Management as at 15 May 2014

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.

Continuum of Service Delivery as at 15 May 2014

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.

Safe and Appropriate Environment as at 15 May 2014

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.

Restraint Minimisation and Safe Practice as at 15 May 2014

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.

Infection Prevention and Control as at 15 May 2014

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.

Audit Results as at 15 May 2014

Consumer Rights

Whare Aroha Home and Hospital provides appropriate and accurate information about their services. Appropriate discussion is held with the resident and family/whanau on admission to explain and discuss all information given. The organisation is committed to open disclosure principles. Cultural and individual values and beliefs are identified on admission. Staff receive education to ensure services are delivered in a manner that recognises and meets the values, needs, and wishes of each resident. The informed consent information is provided and processes are followed. Residents and family interviewed confirm that they are fully informed about all aspects of service delivery.

There is an appropriate complaints process and the complaints register is maintained by the general manager. Advocacy and support services are available as required. The service is able to demonstrate appropriate interactions with family/whanau and community services. The Health and Disability Services Consumers` Rights (the Code) is clearly displayed in all service areas and pamphlets are readily accessible. Staff have received education on the Code and this is ongoing.

Organisational Management

Whare Aroha Home and Hospital is a charitable trust and governed by a board of directors. The purpose, values, scope, direction and goals of the organisation are displayed and reflected the services provided. Day to day operations are the responsibility of the general manager who has appropriate skills and experience.

The organisation has a quality and risk management system that is monitored and reviewed to generate improvements in practice. A number of quality improvement initiatives have been implemented. The required policies, procedures and work instructions are in place and accessible. Goals for quality are defined and achievement towards these are reported and communicated. The organisation also implements an internal monitoring programme and corrective actions are developed where a short fall is identified. Risks are identified and managed accordingly. The risk management and adverse event reporting system is well documented and monitored.

Human resource management and employment policies are in place. There is a system for validating professional qualifications. Staffing is appropriate to meet the needs of residents over the 24 hours with experienced advice and assistance available. Orientation/induction and training is in place, however training on restraint/enablers needs to be included into the training programme in a more consistent manner. Staff performance is monitored through annual performance appraisals.

Resident records are secure and well maintained.

Continuum of Service Delivery

The residents’ records provide evidence that all residents have been assessed appropriately prior to admission. The service has well implemented systems to assess, plan and evaluate care needs of the residents. The resident`s needs, outcomes and/or goals have been identified and these are reviewed on a regular basis with family input. A team approach to care and delivery and continuity of service delivery is encouraged.

Medication management is safely implemented and a visual inspection of the medication systems and the lunchtime medication round evidences nursing staff comply with respective legislative requirements, regulations and guidelines. There is evidence of the general practitioners reviewing medication three monthly or more often if required. There is one area of requiring improvement in relation to a general practitioner grouping the prescribed medications and signing with one signature not each medication individually.

Food services policies and procedures are appropriate for the service setting. The service is managed by an experienced cook. The menu plans have been reviewed by a dietitian. The menus are documented and displayed daily. The individual dietary needs during the assessment process for each resident on admission are addressed and choices provided. Meals are provided at appropriate times of the day.

The activities programme and the Eden Alternative ten principles are well implemented and enjoyed by the residents. Participation is encouraged but is voluntary. Activities are meaningful and the programme is developed and implemented to ensure interests of residents are included. Outings in the community are arranged and entertainers come into the service on a regular basis.

Safe and Appropriate Environment

The facility is appropriate to the needs of the residents and fit for purpose. The building is separated into three areas which include the rest home, hospital and secure dementia suite. The building, facilities, furnishings and equipment are well maintained and suitable for the care and support of the residents. Applicable building regulations and fire safety requirements are met.

Well-furnished lounges, dining areas and safe external areas are accessible to all residents. The facility has plenty of natural light and is maintained at a comfortable temperature. All bedrooms are of sufficient size to allow for personal possessions and to accommodate mobility aids, equipment and staff caring for the resident. Additional thought has gone into ensuring the dementia suite supports a safe and stimulating environment for the residents in line with the Eden philosophy.

Toilet, shower and bathing facilities are sufficient in numbers and adequately equipped and furnished. The temperature of hot water is monitored to ensure resident safety.

Laundry and cleaning services are sufficient and monitored for effectiveness. Both meet safety and infection control requirements. The collection, storage and disposal of waste is in accord with local body requirements.

Processes are in place to maintain the safety and security of residents over the 24 hours and during an emergency. The call system is working effectively and there are adequate numbers of staff trained in first aid and emergency situations on duty at all times. The organisation has appropriate stores and equipment in the event of a civil defence emergency or a pandemic.

Restraint Minimisation and Safe Practice

The service has clearly described restraint minimisation and safe practice policies and procedures which comply with the standard. The policy clearly defines restraint and enabler use. Only enablers are used presently and the restraint register sighted is current and up to date. Staff are educated about the service policy. Staff interviewed understand that the use of enablers is a voluntary process along with approval and informed consent processes. Safety is promoted at all times.

Infection Prevention and Control

The infection control programme is clearly documented and is suitable for the facility. The infection control programme is reviewed on an annual basis. The nurse coordinator is responsible for the facilitation and implementation of the infection control programme and staff are aware of their responsibilities, including reporting residents suspected of having an infection.

Infection prevention and control policies and procedures are sufficient and aligned with current accepted practice. Staff interviewed confirm access to the required procedures and resources. Training on infection prevention and control is provided in an ongoing manner.

Infection control surveillance is occurring for residents who develop infections. The surveillance programme is appropriate to the service setting. Any trends are communicated at staff meetings, management and board reports. The use of antibiotics is monitored to ensure appropriateness.

HealthCERT Aged Residential Care Audit Report (version 4.0)

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: / Rotorua Continuing Care Trust
Certificate name: / Rotorua Continuing Care Trust
Designated Auditing Agency: / Health Audit (NZ) Limited
Types of audit: / Certification Audit
Premises audited: / Whare Aroha Home & Hospital
Services audited: / Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care); Residential disability services - Physical; Dementia care
Dates of audit: / Start date: / 15 May 2014 / End date: / 16 May 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: / 73

Audit Team

Lead Auditor / XXXXX / Hours on site / 16 / Hours off site / 12
Other Auditors / XXXXX / Total hours on site / 16 / Total hours off site / 8
Technical Experts / Total hours on site / Total hours off site
Consumer Auditors / Total hours on site / Total hours off site
Peer Reviewer / XXXXX / Hours / 3.5

Sample Totals

Total audit hours on site / 32 / Total audit hours off site / 23.5 / Total audit hours / 55.5
Number of residents interviewed / 6 / Number of staff interviewed / 10 / Number of managers interviewed / 4
Number of residents’ records reviewed / 10 / Number of staff records reviewed / 10 / Total number of managers (headcount) / 4
Number of medication records reviewed / 22 / Total number of staff (headcount) / 81 / Number of relatives interviewed / 2
Number of residents’ records reviewed using tracer methodology / 3 / Number of GPs interviewed / 1

Declaration

I, XXXXXXXX, Director of Auckland hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of Health Audit (NZ) Limited, an auditing agency designated under section 32 of the Act.

I confirm that:

a) / I am a delegated authority of Health Audit (NZ) Limited / Yes
b) / Health Audit (NZ) Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise / Yes
c) / Health Audit (NZ) Limited 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) / Health Audit (NZ) Limited has provided all the information that is relevant to the audit / Yes
h) / Health Audit (NZ) Limited has finished editing the document. / Yes

Dated Friday, 30 May 2014