Charleston Residential Limited

Charleston Residential Limited

Introduction

This report records the results of a Surveillance 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 and Disability Auditing New Zealand 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:Charleston Residential Limited

Premises audited:Pururi Court Rest Home and Hospital

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

Dates of audit:Start date: 20 July 2015End date: 21 July 2015

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:68

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

Puriri Court provides rest home and hospital level care for up to 72 residents and on the day of audit there were 68 residents. The service is managed by a general manager with support from a clinical nurse manager. The residents and relatives interviewed during the audit spoke positively about the care and support provided by staff.

This unannounced surveillance audit was conducted against a sub-set of the relevant Health and Disability Standards and the contract with the District Health Board. The audit process included the review of policies and procedures, the review of residents and staff files, observations, and interviews with residents, family, management and staff.

The service had no findings at the previous certification audit and no improvements were identified at this surveillance audit.

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.

The service practices open disclosure and the general manager and clinical nurse manager operate an open door policy. Families are informed of changes in resident’s health status or incidents in a timely manner. Interpreters are available if needed. The right of the consumer to make a complaint is understood, respected, and upheld. Complaints processes are implemented and complaints and concerns are managed and documented.

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.

Governance is provided by the director of the business. The general manager ensures services are planned, coordinated, and appropriate to the needs of the residents. There is an established, documented, and maintained quality and risk management system in place that reflects continuous quality improvement principles. The service has a range of policies and procedures that are aligned with current good practice and service delivery and are regularly reviewed. Quality improvement data is collected, analysed, and evaluated and corrective action plans are utilised to make quality improvements within the service. Actual and potential risks are identified, documented and where appropriate communicated to residents, their family/whānau of choice, and staff. Incidents and accidents are managed according to policy. Human resource management is appropriate and education and training is provided. Staffing levels are adequate to meet residents’ needs.

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.

Service delivery is overseen by registered nurses every day across all areas. Each resident is comprehensively assessed and interventions are planned in consultation with the resident and their families where appropriate. Plans of care are developed by registered nurses in consultation with the resident’s general practitioner and other specialist staff. Each resident has an individual and group activities plan to maximise their health and independence. Residents were evaluated on a regular basis and at least six monthly. Residents were seen by the general practitioners at least three monthly. Where possible residents were taken to visit their general practitioner and accompanied by a registered nurse. The medicine management system was managed appropriately in line with required guidelines and legislation. The food service was provided by qualified staff and was appropriate to the needs of residents. Residents and family interviewed were satisfied with service delivery.

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 facility has a current building warrant of fitness.

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.

Restraint minimisation is practiced. The service has alternative systems available so that staff can use restraint as a last resort strategy. Care plans include reference to the use of restraint or enablers. There were 11 residents using 15 restraints on the day of audit and 6 residents voluntarily using an enabler.

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 infection prevention and control programme includes the surveillance programme, which is managed by a registered nurse onsite with management support and oversight. There are established systems in place, which are appropriate to the needs of residents and visitors to the premises.

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 / 0 / 0 / 0 / 0
Criteria / 0 / 39 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / Staff, residents and families interviewed were aware that residents, and where applicable, their representatives have the right to make a complaint. There is an established complaint management system in place. All consumer complaints are listed in a paper-based complaints register. Of the six complaints received, only three were determined to be justified following investigation and there have been no serious consumer complaints since the previous certification audit. The Health and Disability Commissioner (HDC) is currently in correspondence with the business regarding a complaint and the DHB is aware of the situation. The nationwide advocacy service has been involved. The service is awaiting the outcome and response from the HDC.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / The service has policies and procedures in place to ensure that residents and their relatives are communicated with effectively. Staff practice open disclosure and this was confirmed on interview with four relatives (two hospital and two rest home). Records are kept of discussions with families. Interpreter services are available if needed.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Puriri Court is certified to provide rest home and hospital level care to up to 72 residents. On the days of audit there were 68 residents – 28 rest home including one ACC and one respite resident; and 40 hospital residents including two younger persons and one respite. There were no residents under the medical component of the certificate.
Governance of the business is provided by the director. The director actively manages the business to ensure that services are provided in accordance with expectations as documented in the business, quality risk and management plan. The plan documents the mission, philosophy and objectives. The director reviews the plan every year in consultation with the general manager.
The director employs a general manager who has 30 years of aged care experience and has been in the role since February 2013. The general manager is supported by a clinical nurse manager who has been in the role since May 2014. The clinical manager is an experienced district nurse with expertise in wound care.
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 / The quality plan is included in the business, quality risk and management plan which is reviewed yearly to measure achievement. The service has in place a range of policies and procedures to support service delivery that are reviewed at least bi-annually if not earlier. The policies include reference to the InterRAI Long-Term Care Facilities Assessment System (InterRAI LTCF). Key components of service delivery are linked to the quality and risk management system including resident satisfaction, health and safety, the management of adverse events, restraint minimisation, and infection prevention and control. Data are evaluated and results used for quality improvement. There are a number of quality meetings held including a monthly continuous quality improvement (CQI) meeting, monthly staff meetings, monthly management meetings, monthly registered nurse (RN) meetings and two monthly resident meetings. Information on quality and risk management is conveyed to staff through handover sessions and the monthly staff meetings. Corrective actions are documented. Actual and potential risks are identified, documented and where appropriate communicated to residents, their family/whānau of choice, visitors, and those commonly associated with providing services. The service maintains a risk register and a hazard register. Risks are identified, monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk. Risks are actively managed.
Standard 1.2.4: Adverse Event Reporting
All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. / FA / There is an incidents and accidents policy that includes definitions. The policy outlines responsibilities including immediate action, reporting, monitoring and the need to identify corrective actions to minimise reoccurrence and debriefing of staff involved. Staff document all adverse events at the time of the event or shortly thereafter. Residents received appropriate clinical care from a registered nurse in a timely manner, as evidenced in the sample of incident reports reviewed. Events are reviewed and discussed by the clinical manager and the general manager as they happen. Any additional corrective actions required are then implemented. Incidents and accidents are investigated and a paper-based record of events is maintained. There is further discussion of incidents/accidents in monthly CQI and staff meetings. Management are aware of the need to notify relevant authorities in relation to essential notifications.
Standard 1.2.7: Human Resource Management
Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. / FA / Human resources policies are implemented to meet the requirements of legislation. Prospective employees undergo reference checking, and qualification checks. New employees complete an orientation programme. The service employs 10 RNs of whom four are InterRAI competent and three are in training, which enables the service to meet its InterRAI obligations. An annual in-service education programme is in place and a record of education attendance and achievement is maintained. Annual appraisals are conducted for employees. Caregivers are encouraged and supported to complete ACE training. RNs are supported to meet their professional development obligations including InterRAI training.
Standard 1.2.8: Service Provider Availability
Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. / FA / The service has a documented rationale for determining staffing levels and skill mix for safe service delivery. There is a roster that provides sufficient and appropriate coverage for the effective delivery of care and support. The general manager and clinical nurse manager work 40 hours per week and are supported by the compliance quality officer who is a RN and who works three days in the role on average. The clinical nurse manager and the compliance quality officer share on call duties around clinical matters. There are dedicated laundry staff employed during the day. Laundry is done by caregivers in the evenings only. Staff turnover has been stable. The service does not use agency staff.
Standard 1.3.12: Medicine Management
Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. / FA / The medication management policies comply with medication legislation and guidelines. Standing orders are not used. Medicines are appropriately stored and managed. Medication administration practice complies with the guidelines. Medicines are administered by RNs and senior caregivers. The service is piloting a system of routine dual administration to determine if two staff giving medicines will eliminate medication errors. There is a system of assuring medicines competency are in place. The facility uses a packaged medication management system for the packaging of most tablets. The RNs reconcile the delivery of medicines. Medication charts are written correctly by the medical practitioner and there was evidence of three monthly reviews by the GP. Medicine administration charts for 12 residents were sampled and these were correctly completed by staff. One resident was self-administering an inhaler as needed. The resident was cognitively able to manage the inhaler.
Standard 1.3.13: Nutrition, Safe Food, And Fluid Management